IV. Reference basis of action.

Preparation to sterilization of surgical tool.

Efficiency of any method of sterilization in a great deal relies on the cleanness of objects, that will be subject to sterilization. Create the presence of contaminations of organic and inorganic character (tailings of the factory greasing, convolute blood, exudates, wetting and others like that) round microorganisms protective shell, action of both thermal and chemical factors of sterilization is sharply lowered. That is why to the before sterilization cleaning such large significance is attached. Before the before sterilization cleaning there are instruments muddy by biological materials must disinfection to one of the following methods:

- Boiling in a 2% solution of sodium of hydrocarbonate during 30 minutes.

- In a dry heat closet at the temperature 120^oС during 45 minutes.

- Immersion in a 1% solution of chloramines on 60 minutes.

- Immersion in a 6% solution of hydrogen peroxide in a 1 hour.

- Immersion in a 0,1% solution of sulfochlorantin in 30 minutes.

- Immersion in a 0,2% solution of dezaktin in a 1 hour.

- Immersion in a 3% solution of Lysol in a 1 hour.

- Immersion in a 2,4% solution of pervomur on 15 minutes.

The before sterilization cleaning of instruments.

The before sterilization cleaning can be conducted hand-crafted or by means the special washing machines. The machine method of treatment is used in CSO or large operating blocks of hospitals. For the hand method of treatment it is necessary to prepare special washing solution which can be 2nd kinds:

а) On 1 l of solution - a 978 ml drinking-water, 17 ml pergidrolya technical are easily soiled A or B or hydrogen peroxide of medical (the concentration 27,5%), 5 g SMZ (“Lotus”, “Ayna” and others like that).

b) On 1 l of solution - a 995 ml drinking-water, a 5 g SMZ plumb “Biolot”.

A washing complex prepare in glass crockery or in the enameled pelves. The calculated quantity of water is poured at first, and then the necessary quantity of pergidrol and SMZ is added. For the receipt 10 l of solution take a 9550 ml water 400 ml pergidrol and 50 g SMZ. Complex solution can be used from the moment of purveyance for a day long, if the color of him did not change. Such solution can be warmed up to 6 times because in the process of heating concentration of peroxide of hydrogen does not change substantially.

The hand method of before sterilization treatment consists of a few stages:

Additionally: If an instrument is muddy strongly by a blood, he at once after the use is dipped in a 1% solution of sodium of benzoate at a room temperature on a 1 hour which is still and inhibitor of corrosion.

- Rinsing of instrument in running water during a 1 min.

- Immersion in washing solution at the temperature 50^oС on 15-17 min.

- Washing of every instrument in washing solution by a brush or wadding-gauze tampon during 0,5 - 1 min.

- Rinsing by running water during 5-10 min.

- Rinsing by the distilled water during a 1 min.

- Drying by hot air in a dry heat close at the temperature 85^oС, or on the table covered by a sheet.

After the conducted before sterilization cleaning it is necessary to check up its efficiency and ascertain that on instruments there were no tailings of blood and SMZ. The SMZ absence is checked up by means fenolftalein test: on a washed-up instrument 1-2 drops of a 1% alcoholic solution of phenolphthalein inflict by a pipette and look after, to appear whether rose colouring, that will testify to the SMZ presence. In this case it is necessary once again to rinse a tool in running and distilled water and again after drying to repeat the given test.

Cleaning quality from a blood is checked up by means one of tests:

The Benzidin test. A 1% solution of muriatic benzidin is prepared on the distilled water. 3 Drops of this solution and 3 drops of a 3% solution of hydrogen peroxide inflict on an instrument. The dark blue-green colouring appears at presence of tailings of blood.

The Ortotuloidin test. A 4% solution of ortolidin is taken on 96% ethanol in a quantity 5 ml and add to them a 5 ml 50% vinegar acid and so much distilled water. 2-3 drops of solution and 1-2 drops of a 20% hydrogen peroxide inflict on the controlled instrument. The dark blue-green colouring appears at presence of tailings of blood.

The Amidopirin test. A reagent is prepared, that amidopirin consists of the equal parts (on 3-5 ml) 5% of alcoholic solution, a 30% solution of vinegar acid and 3% solution of hydrogen peroxide. 2-3 drops of reagent inflict on the controlled instrument. Appearance of the dark blue-green colouring testifies to the presence of tailings of blood on an instrument.

If on instruments the tailings of blood were found, peredsterilizatsionnaya treatment must be repeated in full.

Stage II - piling and preparation to sterilization. Piling of instruments for sterilization will rely on the method of sterilization, that will be applied (autoclave, gas sterilization, paraformalin chamber, chemical sterilization by solutions and others like that). After the previous drying on air the instruments are laid for drying in a dry heat close which heat to 85°C at the unclosed doors. Then the doors of closet close and begin sterilization.

Stage ІІІ - sterilization. Sterilization of instruments, syringes, needles, glass crockery is conducted in dry heat closes-sterilizers. After pushing closet an a door to, a temperature is taken to 180°C, supporting her automatically. Sterilization proceeds during 60 min. After disconnection of the system of warming and decline of temperature up to 70-50°C open the doors of close and by a sterile instrument close the lids of metallic boxes with instruments.

Sterilization of instruments, that plastic details are contained, it is possible to do in a steam sterilizer (autoclave). The packed objects are inlaid in a sterilization chamber. If packing are fixed in drum their opening must be opened. Surgical instruments and syringes sterilize during 20 min at 2 atm and the temperature 132.9°C. Time of beginning of sterilization measure from a moment the achievement of the proper pressure. Rubber gloves, systems for blood transfusion, rubber drainpipes sterilize at 1.1 atm and temperature of 120°C during 45 min. After sterilization it is obturated in drum. Methods of sterilization in dry heat and steam sterilizers it is needed to consider as basic.

The method of sterilization by boiling is used in small medical establishments, where it is not to the centralized sterilization. Hospital or portable electric immersion heaters, in which it is possible to sterilize instruments, syringes, needles, objects from glass, rubber drainages, catheters, gloves, are used for this purpose. In an immersion heater the distilled water is poured. For the rise of temperature of boiling of water, destructions of shell of bacteria, as add anticorrosion mean a 20 g sodium hydrocarbon on 1 l water (a 2% solution). On the bottom of immersion heater a thin marble is laid from cotton wool and gauze in order that salts that falls out, as sediment on it, but not on instruments. Instruments in the taken apart kind place on the special nets and drop by hooks on the bottom of immersion heater so that the handles of hooks were snarugi and close an immersion heater by a lid. Time of sterilization - 40 min from the moment of effervescence of water. Upon termination of sterilization a net with instruments is caught by hooks, give to flow to water and carry on the special dinner-wagon, covered by the sterile sheet built in 4 layers. An operating sister lays out instruments on large operating table. Instruments, syringes and needles, muddy by a pus, excrement the masses, after the special previous treatment sterilize by boiling during 90 min in a separate immersion heater.

Sterilization of instruments and objects, that are not subject to heat treatment (endoscope, toracoscopy, laparoscopy, vehicles or blocks of vehicles for artificial circulation of blood, hemosorbtion), is carried out in the special gas sterilizer. Objects for sterilization are placed in an air-tight sterilization chamber, that fill with the oxide of etilen. Term of display - 16 hours at the temperature 18°C. Sterilization can be conducted also by the mixture of oxide of etilen and bromine methylene at the temperature of 55°C during 6 hours.

Sterilization of instruments and optical vehicles (laparoskop, torakoskop) can be conducted in spirit solution of chlorhexidin biglukonat and pervomur. Sterilization of vehicles and instruments by chemical facilities stands to conduct in metallic boxes with lids, that warns evaporation of preparation. In default of the special crockery sterilize in the enameled or glass crockery. Instruments are grouted so that he covered them and close by a lid. In the urgent case, when it is impossible to provide sterilization of instruments on one of the noted methods, use sterilization of instruments by burning. In a metallic tray pour a 15-20 ml alcohol, a few instruments place on a bottom and alcohol set on fire. The method of burning is not enough reliable, pogaro- and explosive (presence of oxygen, steam of narcotic matters in mid air of apartments). Therefore to him come running in the exceptional case, strictly toing the lines of fire-prevention safety. During sterilization of cutting instruments (scalpels, scissors) by ordinary methods they blunt, therefore their best to sterilize without heat treatment. After before sterilization preparation the instruments are dipped in 96% ethyl alcohol on 30 min or in triple solution on 3 hours. The short-term boiling of cutting instruments is assumed only. Scalpels are placed in a separate sterilizer, their blades turn a gauze and boil in the distilled water without addition of sodium of hydrocarbon during 10 min, then place in 96% ethyl alcohol on 30 min.

Stage IV - storage of sterile material. Sterile material is saved in the special apartment. Out storage in one apartment of unsterile and sterile materials. Sterility of material in drum (if they were not opened) is saved during 48 hours, and on condition of the additional piling of material in a cotton sack - 72 hours. During the centralized sterilization the syringes save sterility during 25 days.

Prophylaxis of implantation infection of wound.

The most value in the origin of implantation infection has stitch material. For connection of fabrics during the operation use a different origin of filament, metallic paper clips, handles, wire. Exists more than 40 types of stitch material. Have most distribution the silk, lavsan, Capron, catgut, metallic staples. Filaments are applied, that resolve, and filaments which do not resolve. By natural filaments, that resolve there are the filaments of catgut. He is made from the intestine of goats and sheep. Lengthening of terms of resolution of catgut is achieved impregnatsiey by his metals (chrome-plating, silvering). Except for it synthetic filaments are used, that resolve - filaments of dekson, vikril, okcilon, and others like that. To the natural filaments, that do not resolve, filaments from natural silk, slamming, horsehair belong, to synthetic - filaments from a Capron, lavsan of dakron, nylon, ftorlon, and others like that.

Future material must correspond to the following main requirements - must have a smooth, even surface and not to cause the additional damage fabric; have positive manipulative characteristic - a good slide in тканях; be rubber-band (sufficient stretch ability warns the compression and necrosis fabric under their growing edema); be strong in node; have an hygroscopic characteristic and not to swell; be biologically compatible with alive fabrics and not to render the allergic influence upon organism. Destruction of filaments must coincide with the terms of cicatrisation of wound.

Suppuration of wound takes place considerably rarer at the use of stitch materials, that own antimicrobial activity due to entered in their structure antimicrobial preparations (letilan-lavsan, ftorolon, acetate and others filaments that nitrofuran preparations, antibiotics and others like that, are contained). Synthetic filaments, that antiseptics contained, have all dignities of stitch materials and at the same time have antibacterial properties.

Stitch material can be sterilize by gamma-irradiation in factory terms. Hanks of silk, catgut, Capron in ampoules save at a room temperature and are used as far as a necessity. Sterilize metallic stitch material (wire, staples) in an autoclave or boiling, filaments from a lavsan, Capron – by boiling or in solution of pervomur.

Silk, Capron, lavsan, flax, slamming is sterilized on the Kocher method. The previous careful mechanical cleaning of stitch material is thus foreseen by hot water with soap. The hanks of filaments wash in soapy water during 10 min, twice changing water then wash from washing solution, dry out by a sterile towel and wind on the special glass spools which place in banks with a pritertoy cork and inundate by ether on 24 hours for deprivation of fat, whereupon shift in banks with 70% alcohol on the same term. Before application boil silk during 10-20 minutes in solution of sulema 1:1000 and place in the hermetically closed banks with 96% alcohol. In 2 days the bacteriological control is conducted; at the negative result of sowing material is ready to application. Synthetic filaments can be sterilized by boiling during 30 min.

Sterilization of catgut. Heat treatment of catgut is not used. In factory terms a catgut is sterilized by gamma-rays. The methods of sterilization of catgut by chemical methods foresee previous deprivation of fat, what the convolute rings of catgut are placed for in the hermetically closed banks with ether on 24 hours. During sterilization for Claudius unite from a jar the ether and rings to the catgut inundate by the water solution Lugol (iodine of clean 10 ml, iodide of potassium 20 ml, the distilled water to 1000 ml) on 10 days then replace the Lugol solution to fresh and again abandon in him a catgut on 10 days. After it replace the Lugol solution 96% alcohol. In 4-6 days, sowing is done on sterility.

The Hubarev method foresees sterilization of catgut by the spirit solution Lyugolya (clean iodine and iodide of potassium on 10 ml, 96% ethyl alcohol to 1000 ml). After deprivation of fat unite ether and grout a catgut Lugol on 10 days after replacement of solution to new, a catgut is abandoned in the last still on 10 days. After the bacteriological control, at favourable results, the use of material is allowed.

The Sitkovsky method. After deprivation of fat in sterile terms the standard filaments of catgut are cut on 3 parts on 1-2,5 m long, wipe by solution of sulema 1: 1000 and displace in rings which place in a 2% aquatic solution of iodide of potassium: for filaments № 0 - on 30 seconds, for № 1 - on a 1 minute № 2 - 2 minutes № 3 - 3 minutes and etc. (time in minutes answers the number of filament). After the impregnation of filaments by the iodide of potassium of ring of catgut thread on thick filaments and suspend in the distance 7-8 sm from the bottom of glass jar, on the bottom of which a crystalline iodine is poured from computation: in a bank by a capacity 3 l - a 40 g iodine, by a capacity 5 l - a 60 g iodine. Banks are hermetically closed. Terms of display of catgut different depending on the thickness of filaments (№ 0 №1 are ready through 3 days № 2 № 3 № 4 - through 4 days № 5 № 6 - in 5 days). After the bacteriological control of filament suitable to the use.