Sterilization of surgical instruments is carried out by boiling, autoclaving and antiseptic substances. Non-cutting instruments are sterilized by boiling in a 1-2% solution of sodium bicarbonate, which prevents the oxidation of the metal and increases the boiling point. You can boil tools in distilled water. Instruments, washed with a brush and soap and dried after the previous operation, are lowered into water on a grid in special metal vessels - sterilizers, the sizes of which vary depending on the number and size of instruments. Boiling time for tools is 30 minutes. If the instruments were previously used for purulent surgery, and especially if they were contaminated with anaerobic microbes or Pseudomonas aeruginosa, the boiling time increases to 45 minutes. or even boil them three times for 60 minutes. with water change. Such instruments are immersed in a saturated solution for several hours before boiling. boric acid(if contaminated with Pseudomonas aeruginosa) or into a lysoform solution. Boiling of instruments intended for “clean” and for purulent operations is carried out in separate sterilizers. Instruments can be sterilized by placing them in bags or wrapped in sheets in an autoclave for 30 minutes. at a pressure of 2 am. Dry air sterilization is also used in drying cabinets at t° 180-200° for 40 minutes. In emergency cases, instruments may be sterilized by burning. Having placed them in a metal tray, they are doused with alcohol, which is set on fire. But such sterilization deteriorates the instruments, and the method is not reliable.
Cutting instruments become dull when boiled in water, so they are sterilized using a cold method. After washing with a brush and soap, they are immersed in 96% alcohol for 2 hours. Lower concentrations of alcohol cause rust. You can use solutions of the following composition: carbolic acid - 3 parts, caustic soda - 15 parts, - 20 parts, distilled water - 1000 parts; formalin - 20 parts, pure liquid phenol - 1.5 parts, sodium carbonate - 7.5 parts, distilled water - 500 parts. Sterilization in these solutions is less reliable and rust may form, so their use can only be recommended in the absence of alcohol. The exposure is the same as for sterilization with alcohol. Sterilize by boiling in distilled water for 30 minutes. Cylinders and pistons are boiled separately, wrapped in gauze. If the syringes are made of heat-resistant glass that can withstand temperatures above 200°, the best method is dry air sterilization at a temperature of 200° for 30 minutes. The needles are boiled with mandrels or filled with water using a syringe. Otherwise, air remains in their lumen, which prevents the flow of water (air heated to t° 100° does not ensure sterility). New needles are cleaned of grease and cleaned three times for 20 minutes. boil in a 2% sodium bicarbonate solution, changing the water each time. Then they are placed in gasoline for two hours and again boiled twice in a 2% solution of sodium bicarbonate. Store needles dry, with mandrins. Disassembled syringes and needles can be stored in 96% alcohol in special metal cases or in a glass container. Sharing the same syringe and needle on multiple people can lead to the transmission of epidemic hepatitis, even if the instruments are boiled before each injection. A reliable means of prevention is a centralized sterilization system, in which each syringe and needle, after a single use, is returned to the sterilization room for special treatment. The latter includes washing with a 10% solution of magnesium sulfate at a temperature of 45-50° (the needles are washed using a specially designated syringe) and immersion in the same solution for 15 minutes. This is followed by thorough rinsing with distilled water, boiling in it for 5 minutes and only then sterilization - dry air or in an autoclave (each syringe with needles is in a separate package).
From a functional point of view, surgical instruments are divided into conventional metal, cutting, plastic and rubber, and optical. The main regulatory document for the processing of medical instruments is: “Industry standard. Sterilization and disinfection of medical products. Methods, means, regimes ("I 42-21 - 2-85. Order M3 of the USSR dated June 10, 1985). Taking into account the unfavorable AIDS epidemiological situation, the OST was supplemented by the order of the State Medical Inspectorate and TsGSEN No. 222/80 dated June 27, 2000. SanPiN 2.1. 3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities” SanPiN 3.1.5.2826-10 “Prevention of HIV infection.
According to these documents, the following sequential stages of processing medical products are assumed: disinfection, pre-sterilization cleaning and sterilization.
Disinfection is carried out in order to protect medical staff from infection when processing instruments after surgery. Physical methods Disinfection (boiling, steam and air) is practically not used in hospital settings due to bulkiness, lack of effectiveness or rapid wear of instruments. The following agents are used as chemical methods: a) 3% chloramine solution - 60 min; b) 6% hydrogen peroxide solution - 60 min; c) 6% hydrogen peroxide solution + 0.5% detergent solution - 60 min; d) 4% formaldehyde solution (for formaldehyde) - 60 min; e) 4% hydrogen peroxide solution - 90 min; f) drug "Sidex" - 15 min. All instruments are filled with one of these solutions until they are completely immersed. After disinfection they are washed running water.
Pre-sterilization cleaning is carried out to remove protein, fat and mechanical contaminants, as well as medicines. During pre-sterilization cleaning, the following steps are performed sequentially: a) soaking for 15 minutes in a washing solution, which includes hydrogen peroxide 3% - 156 ml, detergent - 5 g and water to a volume of 1 l; b) individual washing of each product in the washing complex for 30 seconds; c) rinsing with running water after using detergents - at least 3 minutes; d) rinsing with distilled water to wash off salts; e) drying the instruments until the moisture completely disappears.
Actually sterilization. The previously used boiling retains its value only for disinfection or sterilization of personal instruments. If the previous stages are carried out when sterilizing any instruments, regardless of their type, then during direct sterilization they are used differentially various methods depending on the type of instrument being sterilized.
Conventional metal instruments are sterilized in a dry-heat oven or in a steam sterilizer (autoclave).
Sterilization of instruments in a dry-heat oven is carried out with hot air for 1 hour at a temperature of 180 C without packaging (open method). To control the quality of sterilization in a dry-heat oven, the following test indicators are used: hydroquinone (the indicator turns black) and thiourea ( yellow indicator turns orange).
Sterilization in a steam sterilizer occurs as a result of exposure to water vapor. It consists of two metal chambers, nested one inside the other and hermetically sealed with a front cover. Steam from the steam generator enters the outer chamber, from it into the inner chamber and then into the condenser. If the outlet valve of the inner chamber is closed, then the steam pressure in the inner chamber begins to increase (maximum - up to 2 atm.). At the same time, the steam temperature rises to 132°C at 2 atm. Conventional metal surgical instruments are sterilized under pressure of 2 atm. within 20 min. Modern steam sterilizers should be of the pass-through type, that is, have two front covers on opposite sides of the device, and these covers should be located in different rooms for complete isolation of sterile and non-sterile material. In addition, steam sterilizers must be equipped with generators that create a pulsating vacuum to remove air from the sterilizer, which acts as a heat insulator and prevents effective sterilization. Instruments to be sterilized in a steam sterilizer are placed in Schimelbusch boxes or boxes with a special bacterial filter, as well as in special bags for sterilization. Sterile instruments from a closed Schimelbusch box can be used for 3 days, from a closed box equipped with a filter - for 20 days. After opening containers or packages, their contents must be used within 1 day, subject to all aseptic rules.
Sterilization bags come in several types: a) crepe paper, which is wrapped in the form of an envelope (if there is no damage to the integrity of the packaging, it maintains the sterility of the contents for 3 days); b) paper packaging with a strip of hot-melt adhesive and a [class] sterilization indicator (unopened packaging retains the sterility of the contents for 60 days); c) combined packaging, in which one side is made of laminated paper and the other is made of polyethylene film, has a strip of hot-melt adhesive and a class I sterilization indicator (unopened packaging retains the sterility of the contents for 1 year). Packaging bags for sterilization are produced by European companies Rexam (England), SPS - lab. (France), Steriking (Finland), etc. Sterilization open method should not be carried out in a steam sterilizer!
There are chemical (cold) methods for sterilizing instruments: 6% hydrogen peroxide solution at a temperature of 18°C for 6 hours, paraform or 16 “/formaldehyde solution in sealed chambers for 48 hours, 0.5% aqueous-alcohol solution chlorhexidine for 5 minutes, sterilization in special chambers with ethylene oxide PO), as well as radiation sterilization.
Cutting metal instruments (scalpels, surgical needles, scissors, etc.) are sterilized using cold methods so that they do not become dull when exposed to hot steam. Hydrogen peroxide or an alcohol solution of chlorhexidine are most often used for this purpose. Scissors can be sterilized in a dry-heat oven. Industrial radiation or ethylene oxide sterilization of scalpels and single-use atraumatic suture material is optimal.
Plastic, rubber and optical instruments. Sterilization of rubber and plastic products is possible using a thermal method in a steam sterilizer under a pressure of 1.1 atm. within 45 min. Currently, disposable gloves sterilized by industrial radiation are used, but in extreme conditions Rubber gloves can be sterilized by autoclaving. For the chemical sterilization method, formalin vapor, ethanol, ethylene oxide, etc. are used.
In addition to gas sterilization of optical instruments (endoscopes), a 0.5% alcohol solution of chlorhexidine, Pervomur or Sidex is used.
1.2.2. Sterilization of dressings and surgical linen. Dressings and linen include large and small gauze napkins, gauze swabs, other special gauze and cotton products, as well as sheets, diapers and gowns. A set of material for autoclaving is called a stack. Steam sterilization is carried out in Schimmelbusch boxes, metal boxes with filters, as well as in cotton sheets or diapers. The beaks are equipped with labels, which should contain information about the contents of the beak and whether it belongs to a particular operating room or dressing room. The process of preparing dressing material for surgery or dressing is divided into 3 stages.
I stage of pre-sterilization preparation of material. The gauze cloth is cut into pieces of various sizes depending on what is to be made - small napkins, large napkins, tampons, etc. The gauze should be soft and hygroscopic. The dressing material is folded so that the free edges are tucked inside the napkins or tampons.
Stage II - laying and preparing the material for sterilization. There are 3 main types of bix styling. Universal laying is usually used when working in dressing rooms and for small operations. In this case, the material is placed in boxes in sectors (small napkins in one sector, large napkins in the other, tampons in the third, etc.) so that sterility does not have to be violated when searching for one or another type of material. Targeted installation includes everything necessary to perform typical manipulations, procedures and minor operations (position for tracheostomy, for catheterization of the subclavian vein, for epidural anesthesia, etc.). They put everything in the bix necessary tools, dressings and linen. View laying is used when working in large operating units. At the same time, one type of dressing material or linen is placed in the bin (in one - dressing gowns, in another - sheets, in a third - napkins, etc.).
Currently, disposable surgical linen made of non-woven material (sheets, diaper gowns, caps and masks), as well as packages with gauze wipes for industrial radiation sterilization, are increasingly used.
III stage - sterilization. Sterilization of linen is carried out using the steam method under a pressure of 2 atm. at a temperature of 132°C for 20 minutes. Before loading into the autoclave, check whether the holes in the container are open. After sterilization of the hole in the bix, during the process of removing it from the autoclave, close it with a metal rotating tape on the body of the bix and mark the date of sterilization on it.
TREATMENT OF SURGEON'S HANDS
Cleaning (washing) the surgeon's hands is a very important procedure. There are certain rules for washing your hands. It is necessary to carry out sequentially: mechanical and chemical (degreasing) treatment, exposure to antiseptic agents and tanning (closing the pores to maintain the sterility of the skin surface).
Modern methods of hand treatment do not require special tanning (film-forming antiseptics or antiseptics with a tanning element are used).
Mechanical and chemical treatment
Mechanical and chemical treatment is carried out by washing hands under the tap with a brush and soap. Hands are washed thoroughly from the fingertips to the upper third of the forearm. In this case, a certain sequence of processing is observed, which is based on the principle “do not touch the treated areas of the hands for less than clear skin and objects."
Application modern methods allows hand washing simply with soap or liquid detergents(in the absence of household hand contamination).
The need to sterilize veterinary instruments is intuitively clear - it is designed to prevent the penetration of microorganisms into the wound being treated and, as a result, infection of the patient upon contact.
General information
Widely used in medical and veterinary practice different kinds sterilization, which are divided into:
- physical;
- chemical methods.
Classic representatives of the first group include heat sterilization methods such as boiling, pasteurization, steam treatment under pressure, dry heat, ultrasonic and radiation sterilization.
Chemical methods remove microorganisms various solutions: iodine, formalin, acids, etc.
Basic sterilization methods
Boiling method for a long time was and remains the most common. Its essence is to heat the instrument in a disinfection boiler in distilled water with a 2% sodium bicarbonate solution. Boiling is used to treat metal containers and non-sharp tools. Cutting products quickly deteriorate when boiled, which is why scalpels, scissors, etc. immerse in a boiler for about 2 minutes, after which they are immersed in alcohol for several hours. Currently, sterilization by boiling is rarely used in medicine, since some microorganisms die only at temperatures of 150-200 degrees - when treated with steam or calcined in a dry-heat oven.
Special steam sterilizers modern models fully automated. This allows each type of instrument (packed in special containers) to be processed according to a program specified by the manufacturer, which guarantees a high degree of asepsis. In addition to instruments, steam can be used to sterilize reusable catheters, drainages, gloves, underwear, etc. At the end of steam sterilization, bacteriological control of sterility is carried out using special indicators.
The use of steam during sterilization is a risk factor for burns, which electric dry-heat ovens do not have. No moisture, also easy to process cutting tool without the risk of reducing its quality and service life. After laying the equipment being processed, it is heated to 140 degrees in 10-15 minutes and then, if necessary, to 200 degrees. Drying ovens can be various sizes and are located in close proximity to the operating room: the collection of the processed instrument is carried out exclusively in sterile clothing.
Gas sterilization is used to process polymer products and is based on the properties of ethylene oxide (and some other gases) to have a bactericidal effect on the instrument. Disadvantage - explosion hazard (you have to add to the composition carbon dioxide) and a long wait time until the gas is completely released from the internal structure.
Radiation sterilization is widespread when processing suture material, disposable syringes, catheters, etc. Ionizing radiation completely removes microorganisms, which, in combination with subsequent sterile packaging, allows instruments and devices sterilized by radiation to be stored for long months and even years.
Sterilization of surgical instruments is carried out in two stages.
First stage - pre-sterilization treatment, second- direct sterilization. The sequence of pre-sterilization preparation depends on the degree of bacterial contamination of instruments.
Pre-sterilization preparation includes: disinfection, washing and drying. Due to the high risk of spreading AIDS and performing operations on patients who have had hepatitis, the rules for pre-sterilization preparation have been changed and are equated to methods for processing instruments, providing a guarantee of destruction of the human immunodeficiency virus. Instruments after purulent operations for anaerobic infection, patients who underwent within 5 recent years hepatitis, as well as at risk of AIDS, are treated separately from others
Immediately after the operation, instruments are immersed in disinfectants (3% chloramine solution for 40-60 minutes or 6% hydrogen peroxide solution for 90 minutes, 0.5% polydes solution for 60 minutes, combined instrument disinfectant for 60 minutes). After disinfection, the instruments are transferred to a cleaning solution ( washing powder, hydrogen peroxide and water) at a temperature of 50 ° C for 20 minutes, then wash each instrument with a brush in disassembled form and rinse under running water. Currently, the “Stages and modes of pre-sterilization processing of products made from various materials” approved by the Ministry of Health of the Russian Federation in 1997 are used (Table 1).
Table 1.
Stages and modes of pre-sterilization cleaning of instruments combined with disinfection with nnkrasent 10A.
The quality of pre-sterilization treatment is checked by performing azopyram, phenolphthalein and benzindine tests for the presence of residual detergent components, blood and fat. At least 1% of the batch of instruments simultaneously subjected to processing are subject to control. In addition, quality control of pre-sterilization treatment is carried out by the Center for Hygiene and Epidemiology once a quarter. If the test is positive, the entire batch of instruments undergoes repeated pre-sterilization treatment.
The next stage is drying the instruments in a dry-heat oven at a temperature of 80 ° C for 20 minutes.
The choice of sterilization method depends on the type of surgical instruments to be sterilized.
All general surgical instruments are conventionally divided into three groups:
Metal - cutting (scalpels, scissors, suture needles, amputation knives, etc.), non-cutting (syringes, injection needles, clamps, tweezers, hooks, probes, etc.);
Rubber and plastic (catheters, probes, drainages, etc.);
Optical - laparoscopes, gastroscopes, choledochoscopes, cystoscopes, colonoscopes, bronchoscopes, etc.
Sterilization of surgical metal instruments and products made of glass produced in the following ways.
Sterilization with dry hot air (aerosterilization) is carried out in dry-heat ovens (Fig. 3). Tools and syringes
Fig.3. Dry heat cabinet.
disassembled parts are placed in special metal mesh or packaged in kraft paper and sterilized at a temperature of 180-200 ° C for 1 hour. After sterilization, surgical instruments are transferred to an ultraviolet chamber to maintain sterility during their use (Fig. 4.). Products sterilized in kraft paper remain sterile for 3 days.
Fig.4. UFC 2.
For steam sterilization, instruments are placed in Schimmelbusch bottles, loaded into autoclaves and sterilized at a pressure of 1.1 atm - 60 minutes, 1.5 atm - 45 minutes, 2 atm - 30 minutes. Shelf life in containers with a filter is 3 days, without a filter - 24 hours.
Disposable instruments are sterilized in sealed bags using ionizing radiation (y-rays), ultraviolet rays and ultrasound. Currently, preference is given to sterilization with y-rays. For these purposes, the isotopes """Co and ""C are used. Sterilization must be carried out in compliance with safety measures in the factory. If the packages in which sterilization was carried out by y-rays are sealed, sterility is maintained for 5 years.
Boiling as a method of sterilization is currently not used and refers to disinfection. Disinfection of instruments by boiling is carried out in electric sterilizers of various designs and capacities, on grids immersed in distilled water with the addition of a 2% sodium bicarbonate solution for 30 minutes. Sterilization of cutting and piercing instruments is carried out in the factory using y-rays, gas method and cold chemically using antiseptics. In dressing rooms, cutting and stabbing instruments are sterilized in dry-heat ovens.
TO chemical methods Sterilization includes sterilization in the sterilization chambers of an air sterilizer (one- or two-chamber) with a capacity of 80 dm 3 or more with formalin vapor. Formalin is placed at the bottom of the chamber at the rate of 10 g per 10 dm 5 of the chamber, sterilization time is 16 hours. Instruments with an ebonite base, telescopes, all laparoscopic instruments, instruments with optics, especially precise and expensive instruments are sterilized using a chemical gas method. Before gas sterilization, laparoscopic instruments are disinfected in a 3% aldezone solution by rinsing in one container, then they are soaked in a second container for 1 hour and after the time is rinsed under running water to remove disinfectants.
To perform surgical interventions, there is a large number of different instruments (scalpels, scissors, needles and needle holders, clamps, hooks, retractors, probes, catheters, etc., including complex medical equipment). Instruments used during surgery, dressings and other manipulations require special pre-sterilization cleaning to remove protein, fat and other contaminants, as well as medications. Treatment is carried out especially carefully when instruments are contaminated with pus or intestinal contents. Such instruments must be disinfected with chemicals even before pre-sterilization cleaning: 6% hydrogen peroxide with a 0.5% solution of synthetic detergents (exposure 30 minutes), 0.1% peracetic acid (exposure 15 minutes), 2.4% permura solution (performic acid with hydrogen peroxide), triple solution (carbolic acid 3 g, sodium carbonate 15 g, formaldehyde 20 g, water 1 l) for 45 minutes.
Pre-sterilization cleaning consists of 6 stages: 1) rinsing with warm running water for 1 minute; 2) soaking for 15 minutes in a warm solution containing 1-2% hydrogen peroxide and 0.5% synthetic detergents, 3) treating instruments in a washing solution for 1 minute with a brush, brush, swab, paying attention to hard to reach places, the washing solution is changed to clean if signs of contamination or blood appear; 4) rinsing with running water for 5 minutes; 5) rinsing with distilled water for 1 minute; 6) hot air drying drying cabinet at a temperature of 80-85°.
Thus, pre-sterilization cleaning of a used instrument takes about 25 minutes, not counting the time for drying, since if the instruments are sterilized immediately after cleaning, then there is no need to dry them. Scalpels are processed separately so as not to damage the blade. The quality of the treatment is checked for the presence of even traces of blood using a benzidine test, based on the oxidation of benzidine with hydrogen peroxide. If there are traces of blood on instruments or syringes, the colorless reagent takes on a blue-green color.
It is best to sterilize surgical instruments by autoclaving, placing them on trays, wrapped in a sheet, or packing them in two pouch-type bags with ties (minimum exposure 40 minutes at a pressure of 1.5 atmospheres). Can be sterilized in air dry heat sterilizers for 60 minutes, but instruments cannot be wrapped in cloth or paper, as they will char or burn at a temperature of 170°, which occurs in dry heat sterilizers. Therefore, the instruments are laid out in metal cases or boxes with open lids so that the temperature reaches the required 170-180°. For relatively quick and fairly simple sterilization of instruments, boiler sterilizers are used. The mesh with instruments is lowered into a sterilizer and boiled for 25-30 minutes in a 1-2% solution of sodium bicarbonate (soda) or simply in distilled water. Soda helps destroy microbial spores, fats and proteins, and prevents metal corrosion. If the instruments have not undergone pre-sterilization cleaning, then boiling is carried out 2-3 times for 45 minutes, changing the water or soda solution. Complete sterilization of the syringes is achieved after 45 minutes (the cylinders and pistons are wrapped in gauze, mandrels are inserted into the needles to avoid blockage of their lumen). In case of possible contamination of syringes with putrefactive and anaerobic microflora or hepatitis viruses (Botkin's disease or infectious jaundice), boiling 2-3 times in a separate sterilizer is necessary.
Sterilization of complex surgical equipment (optical systems, anesthesia machine parts, etc.), rubber products and synthetic materials possible with ethylene oxide or a mixture of it with methyl bromide at a rate of 1:2.5 in special gas sterilizers. Sterilization in steam-formalin chambers with formalin vapor is also used: formalin tablets are placed at the bottom of a tightly closed container or 25-30 ml of formalin (40% aqueous solution of formaldehyde) is poured into the chamber, and steam is supplied to the chamber. Sterilization is possible by washing in a solution of mercuric cyanide oxide (1:1000).
Surgical instruments can be processed by cold sterilization, which is carried out using phenol derivatives, formaldehyde, mercuric dichloride, alcohols, dyes, halogens and others chemical substances. High concentrations of these drugs have not only a bactericidal, but also a sporicidal effect. In particular, a triple solution is used (exposure 45 minutes, spores die after 1.5 hours); mercury preparation diocide in a solution of 1:1000 and 1:5000 (exposure 45 minutes); 1% solution of brilliant green (spores die after 30 minutes); gentian violet in an amount of 1 g and 2 g of formaldehyde, dissolved in 100 ml of 96% ethyl alcohol (spores are destroyed after 2-4 hours); 2.5% gobiton solution, where the active principle is 20% chlorhexidine gluconate (exposure 30 minutes). After using any of the above cold sterilization methods, the instruments are immersed in 70% or 96% ethyl alcohol to long-term storage in a sterile condition. Mercury oxycyanide (1:1000) is used to sterilize optical systems, synthetic and plastic products; the drug does not damage lenses and does not dissolve glue (exposure 20 minutes). Cutting and piercing instruments (scalpels, needles) are sterilized by immersion for 2 hours in 96% ethyl alcohol or triple solution.
In exceptional cases, without pre-sterilization treatment, instruments contaminated with pus are sterilized with Lysol (phenolic preparation), 35% solution of green potassium soap, 5% solution of chloramine B, 1% solution of sulfochloractin, 0.5% solution of chlorcin.
As a last resort, in exceptional cases, burning of instruments previously filled with 96% is used for sterilization. ethyl alcohol, as well as calcination in a flame. But these methods are unreliable when the instruments have a complex configuration or are large in size or volume.
