Oral and Maxillofacial Surgery for the Clinician. 2020 Jun 24 : 173–194. Guest Editor (s): Krishnamurthy Bonanthaya,1 Elavenil Panneerselvam,2 Suvy Manuel,3 Vinay V. Kumar,4 and Anshul Rai5 1Bhagwan Mahaveer Jain hospital, Bangalore, India 2Associate Professor, SRM Dental College, Ramapuram, Chennai, Tamil Nadu India 3Ananthapuri
Hospitals & Research Institute, Kerala Institute of Medical Sciences, Trivandrum, Kerala India 4Department of Maxillofacial Plastic Surgery, Uppsala University Hospital, Uppsala, Sweden 5Associate Professor, Department of Dentistry, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh India In the modern day’s Oral and Maxillofacial surgical practice, complex
surgical and aesthetical procedures are being carried out associated with an increased risk of infectious complications. Therefore, to ensure better outcomes of the surgical procedures, it is absolutely necessary that appropriate measures must be taken to decrease the incidence of associated infections. The practices to be carried out for infection control include proper scrubbing procedures for both patient and the operator, specific protocols to be followed by the operating personnel at the
time of procedures, proper handling of the instruments and maintaining an aseptic environment throughout the procedure. The main aim of this chapter is to provide information on the preoperative, operative and post-operative protocols that should be adhered to improve the safety of the patients undergoing surgical procedures. Keywords: Sterilization and Disinfection, Operating Room, Infection Control, Surgical Safety A study comprising data from 56 countries in 2004 stated that the annual major surgery volume was estimated to be 187–281 million operations, accounting for approximately one operation annually for every 25 human beings alive [1]. In subsequent studies, data were obtained from a total of 194 Member States of the World Health Organization for the years 2005–2012. According to these
studies, 312.9 million operations took place in 2012, showing an increase from the 2004 estimate of 226.4 million operations. 6.3% and 23.1% of operations were carried out in very-low and low-expenditure countries representing only 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively [2]. The incidence of
postoperative infections reported among the developed countries like UK and USA was approximately 5% and 5–6%, whereas in developing countries like India it is much higher, accounting for approximately 10–25%. [3, 4]. The main problem encountered in the practice of surgical safety is
that existing safety practices are not adequate in some countries. Lack of resources is the main reason behind this, particularly in developing countries. Good infection prevention and control is essential to ensure the safety of the patient undergoing any surgical procedure in the operating theater. The surgical site infections (SSIs) constitute 20% of the total hospital-acquired infections [4].
These infections cause substantial patient mortality and morbidity and burden healthcare systems with massive costs. Since these infections are primarily acquired during the operative procedure when the wound is still open, stringent protocols need to be followed at this point to minimize their onset. To establish surgical protocols, it is important to understand the basic concepts of sterilization, asepsis, and infection
control. In this respect, the following terminologies are very commonly used: These agents are a by-product of certain microorganisms, which either have the capacity to destroy or inhibit the growth of other microorganisms at low concentrations. A substance (or drug) capable of killing microorganisms or inhibiting their growth, in particular, pathogenic
microorganisms. This is a general term used to encompass those drugs that specifically act on certain types of microorganisms, including antibacterial (antibiotics), antifungal, antiviral, and antiprotozoal agents. Any agent synthetically or naturally obtained that can destroy or attenuate the microorganisms. It is the process in which
microbial agents on a living surface are either killed or their growth is arrested. These are the substances applied on the living tissues to reduce the possibility of infection, sepsis, and putrefaction by inhibiting the activity or growth of the microorganisms. The state of being free from living pathogenic organisms. Free of or using methods to keep free from microorganisms. It is defined as the processing and packaging of a sterile product into sterilized containers followed by proper sealing with a sterilized closure in a manner to control microbiological recontamination. It is an antimicrobial agent that has
the capacity to destroy both nonpathogenic and pathogenic organisms but may not destroy bacteria in spore form. It is an antimicrobial agent that inhibits the growth of microorganisms but is not capable of killing them. The occurrence of viable microorganisms on a surface or object before the sterilization procedure.
A standardized test preparation of bacterial spores used to demonstrate effective sterilizing conditions by providing a defined resistance to a specific sterilization process. These are agents or devices used to monitor or confirm the attainment of one or more of the parameters required for a satisfactory sterilization process or used in a specific
test of the sterilization equipment. It is an agent, chemical in nature with properties that kills all forms of microbial agents, including spores. It is the process of removing all forms of foreign materials (from objects using detergents & water, soaps, and enzymes) by employing the mechanical action of washing or scrubbing the object. ContaminationIt is the process of entry of microbial agents into tissues or any aseptic environment. CrossinfectionThe spread of infection from one person, object or place to another. DecontaminationThe process by which a person or a surface is made free from all the agents that contaminate the surface and lead to the spread of infections. [5] DetergentIt is a chemical agent with cleansing actions in dilute solutions, which, on combining with impurities and dirt, make them more soluble. DiseaseDisruption of the normal performance of the vital functions of a plant or animal by an infection. DisinfectantThis is an agent, usually a chemical, applied on inanimate objects that destroys microorganism in the vegetative form but not the spores. Chemical disinfectant agents are categorized into low level, intermediate, and high level (depending on the product claims and regulatory requirements in different parts of the world).
DisinfectionAntimicrobial process to remove, destroy, or deactivate microorganisms on surfaces or in liquids. Disinfection is often considered as a reduction of the numbers and types of viable microorganisms (or “bioburden”) but may not be assumed to render the surface or liquid free from viable microbial contamination (in contrast to sterilization). Droplet NucleiThese are those particles of 1–10 μm that are implicated in the spread of airborne infections. Exogenous InfectionThe infecting microorganism comes from an external source. FomitesAny inanimate object that is capable of absorbing or transmitting infectious microorganisms from one person to the other. FumigationThe process of disinfecting or purifying an area or object with the fumes of certain chemical agents. GermicideAgents that are designed to kill and destroy pathogenic organisms on the surface of different things. InfectionIt is the process of invasion of the tissues by microorganisms and their multiplication in the body of the host to produce disease. Microorganisms or MicrobeMicroscopic organisms, which may exist in its single-celled form or in a colony of cells. Minimum Effective Concentration (MEC)The lowest concentration of a chemical or product, used in a specified process that achieves a claimed activity. Minimum Recommended Concentration (MRC)The lowest concentration of a chemical or product specified by the equipment manufacturer to be used in a process. NosocomialThis comes from two Greek words, i.e., “nosus” meaning “disease” and “komeion” meaning “to take care of.” Also known as “hospital-acquired infections.” These are the infections originating or taking place in a hospital. Operating Room (OR)The operating room or operating theater is a facility within a hospital where surgical procedures are carried out in an aseptic environment. PathogenA pathogen is a tiny living organism, such as a bacterium or virus that is capable of producing disease in an individual. ResistanceIt is the natural ability of the agent to oppose the effects of any harmful agents. SoilNatural or artificial contamination on a device or surface following its use or simulated use. Sterile Barrier SystemPackaging that prevents the ingress of microorganisms following a sterilization process, thereby preserving the sterile state. SterilizerEquipment designed to achieve sterilization. Sterilizing AgentPhysical or chemical agent (or combination of agents) that has sufficient microbicidal activity to achieve sterility under defined conditions. SepticContaminated or infected. SporesThese are the reproductive forms of some microorganisms that can survive harsh environmental factors and have the capability of developing into new viable microbes. SterilizationSterilization is a process that destroys or removes all microbial life completely, including spores by means of certain chemical or physical processes. SterileFree from living microorganisms. SterilizeTotal destruction of all living forms. VectorIt is an organism that does not cause disease itself but which spreads infection by conveying pathogens from one host to another. VirulenceIt is a pathogen’s ability to infect, sustain, or spread infection in a living a host. Historical background of present day protocols is enumerated in Table 9.1. Table 9.1Historical background leading to proper sterilization and disinfection protocols
Surgical Site InfectionsApproximately 2–5% of all surgical patients tend to acquire surgical site infections (SSIs) [4]. In developed & high-income countries (HICs), SSIs are the second most common cause of healthcare-associated infections [6], whereas in Low- & Middle-Income Countries (LMICs) or underdeveloped & developing countries these infections are the most common ones. Thus, to reduce the risk of surgical site infections, a more systematic approach has to be adopted, based on proper knowledge regarding the status of the patient, type, & time of the operation, personnel involved and the health care facilities available during a surgical procedure. The main pathogenic source of surgical site infections is the endogenous flora (usually aerobic gram positive cocci) of the patient present in the skin, the mucous membranes, or the hollow viscera. The exogenous sources of infection include members of the surgical team, environment of the operating theater and tools, materials & instruments brought to the sterile zones during the surgical procedure. Various strategies employed to prevent or control the occurrence of surgical site infections include reducing the contamination by microorganisms on the sterile surgical instruments as well as the body of the patient, prophylactic preoperative antibiotic coverage, carrying out the surgical procedure carefully, proper handling of the operating room. Surgical SafetySurgical safety is of utmost importance in order to prevent major and life-threatening complications leading to undue loss of life and patient morbidity. Thus, a list of ten essential objectives with a surgical safety checklist have been elucidated by the WHO to be followed by all the personnel present in the operating room to reduce the risk of such complications [7] (Tables 9.2 and 9.3). Table 9.2WHO: Ten essential objectives for safe surgery
Table 9.3WHO’s Surgical Safety Checklist
Environmental Control and DesignOperating Room (OR)The operating room or operating theater is a facility within a hospital where surgical procedures are carried out in an aseptic environment. Since the operating theater is a highly sterile, aseptic, and restricted area in a hospital setting, it is mandatory for all the personnel concerned to have a proper understanding of the working of the operation theater abiding by certain laws, regulations, and professional guidelines. Integrated infection control in the operation theater is the key to decreasing morbidity and mortality among the patients undergoing surgery. Following essentials must be present in an operating room:
Different Zones of Operation Theater ComplexThere are four different zones observed in any operating room complex described on the basis of type of cleanliness present, presence or absence of microorganisms, and the different procedures to be carried out in each zone (Fig. 9.1). Different zones of operation theater complex
Important Points
Maintenance in the Operation Theater
Disinfection and SterilizationSterilization is the ultimate procedure in controlling the undesired activities of microorganisms that are outside of the human body. Its purpose in the operating field is to prevent the spread of infectious disease, and in surgery, it primarily relates to processing reusable instruments. Surgical instruments are an integral part of surgical field and, being reusable, have greater chances of spreading the microorganisms if any of the reprocessing steps fails. Steps of reprocessing include cleaning, repackaging, disinfection or sterilization, and reusing. Cleaning, being the first step in the cycle of reprocessing, is the major step in the removal of any organic matter present on the surface of the instruments. Any failure in the removal of the visible soil at the initial stage can create a discrepancy in the efficacy of the subsequent disinfection and sterilization procedures. Sterilization is more effective a process than disinfection. The process of disinfection is carried out with the use of various chemical agents. Chemical disinfecting agent necessarily does not kill all microorganisms or spores present on an inanimate object but instead reduces the number of microorganisms to a level that is not harmful to health. Depending on their potency against microbes, they are classified as High-, Intermediate-, or Low-level disinfectants. The type of the sterilization procedures to be carried out for an object depends upon the classification of the instruments based according to the Spaulding Classification of the medical devices, the type of material of which the object is made of, the microorganisms to be present on the object, and availability of the sterilization methods and equipment (Table 9.4). Table 9.4Spaulding Classification of Medical Devices And Level of Disinfection
The Instrument Processing (Decontamination Steps) (Fig. 9.2)Instrument processing steps
Processing of the clinical or surgical items is a two step procedure.
B. Disinfection and Sterlization
Operating Room Decorum
Hand hygiene by operation theater persons is the most efficient way to reduce the risk of spread of infections.
Classification of Surgical WoundsA widely used classification of surgical wounds is based on an estimate of likelihood of bacterial contamination of the operative site. In 1964 [9], National Academy of Sciences/National Research Council defined five general classes of operations:
Currently, this classification has been condensed into four groups for general use, without a subdivision of the clean category and in the modified form it is categorized into four categories [10] 1. Clean sites (wounds): • Elective (not urgent or emergency). • Primary closed. • No acute inflammation or transection of tracheobronchial, biliary, gastrointestinal, oropharyngeal tracts. • No technique breaks. 2. Clean-contaminated sites (wounds): • Emergency or urgent cases that are otherwise “clean.” • Elective procedures. • Reoperation via “clean incision” within 7 days. • Blunt trauma, intact skin, and negative exploration. 3. Contaminated sites (wounds): • Acute nonpurulent inflammation. • Major technique break or major spill from hollow organs. • Entrance of genitourinary or biliary tracts in presence of infected urine or bile, respectively. • Penetrating trauma less than 4 h old. • Chronic open wounds to be grafted or covered. 4. Dirty sites (wounds): • Purulence or abscess. • Preoperative perforation of tracheobronchial, biliary, gastrointestinal, oropharyngeal tracts. • Penetrating trauma more than 4 h old. Risk Factors Affecting the Rate of Postoperative Wound Infections“Cut Well, Sew Well, Heal Well” is an axiom favored by surgeons but is not always destined to be true. Altemeir and Culbertson (1965) [11] depicted that the risk of infection varies:
These factors interact in a complex way to fasten the development of infection. Since the days of Altemeier, clinical and epidemiologic studies have identified the risk factors that affect the rate of postoperative surgical site infection. This can be best explained by the classical epidemiological triangular model, i.e., model of interaction between agent host and environment resulting in disease (Fig. 9.10). Classical Epidemiological triangle The risk of postoperative wound infection also depends on the patient factors, pre and intraoperative factors (Table 9.5). Haley et al. (1985), in the Study of the Efficacy of Nosocomial Infection Control “(SENIC),“ [13] identified four independent and additive risk factors for postoperative wound infection. These factors are operation on the abdomen, operation lasting for more than 2 h, contaminated or dirty wounds (NRC CLASSIFICATION), and the presence of more than three discharge diagnoses. Table 9.5Factors that predispose a patient to infection
Factors Influencing the Development of Nosocomial InfectionsThe Microbial AgentHospital infections occur as a result of a variety of microorganisms. The microorganisms causing the disease may be divided into the following categories:
During the stay in a hospital, the patient comes in contact with various kinds of microbial agents (such as viruses, fungi, parasites, and bacteria), which are the main cause of the occurrence of infections in a patient. This exposure is not the only reason for the development of hospital-acquired infections. The other possible reasons are the host’s natural defense mechanisms (healthy/compromised/immunosuppressed), conditions present in a hospital environment, microbiology of the microbial agents (characteristic features), infective material present on the microbial agent, resistance to the antimicrobial agents, and other factors. The hospital-based infections may be a result of the spread of infection from one person to the other or by the residential flora of the patient or from any contaminated sources or from sources of the external origin (e.g., airborne diseases). Following are the factors that are the main sources of spread of hospital-based infections: Susceptibility of the PatientPatient factors that lead to the occurrence of infection are age, host’s immune response, presence of any disease, and interventions, which either help in diagnosing or treating any condition. Patients, either infant or older individuals, are at a higher risk of acquiring infections. Patients having a compromised immune system, undernourished, having some underlying chronic disease (AIDS, leukemia, malignant tumors, renal failure, diabetes mellitus, etc.), undergoing irradiation therapy, all at the highest risk of being infected by the hospital-based infections. Certain processes like catheterization, biopsy, intubations, etc. make the patient more vulnerable to these infections. Resistance of the BacteriaResistance of bacteria to antimicrobial agents is seen with the prolonged or prophylactic use of these agents. The microbial agents present normally in the human flora have both sensitive and resistant strains. Some antimicrobial agents have their action on sensitive strains by suppressing their activity, whereas the resistant strains are still active. These active resistant strains are the major cause of the development of resistance against the antimicrobial agents. Examples of resistant microbial agents are Multiresistant Klebsiella, strains of pneumococci, staphylococci, etc. In low-income or middle-income countries, this is the major problem faced due to unavailability and unaffordability of the better drugs. Month of OperationThe possible explanation for increased infection rates in summer is the relatively high environmental temperature leading to humid climate, resulting in excessive sweating. In addition, excessive sweating results in the displacement of bacteria lodged in skin appendages to the surface. Use of Electric CauteryThe use of electric cautery for cutting and coagulation during surgery causes more inflammation; more necrosis and abscess than the conventional use of scalpel and thus it increases the susceptibility of tissue for infection. Soballe et al [15], in their experimental study, found that electric cautery lowers the contamination threshold for infection of laparotomies and concluded that electric coagulation current should be used only when the need for meticulous hemostasis outweighs the considerably increases risk of infection. Duration of OperationThere is a direct correlation between the infection rate and time taken for the procedure. This may be the result of the more complicated operations being of longer duration, increased wound contamination from airborne bacteria, increased damage to the tissues due to large exposure of the wound, and increased manipulation; moreover, local resistance of tissue is reduced due to drying. Spread of InfectionThe microbial agents are spread by different ways in a health care setup. The different ways with which the agents can spread are contacting, droplets, airborne route, via vehicle, and vector-borne (Fig. 9.11). Sources of hospital-acquired infections Sources of the infectious agents are either external, i.e., from one person to the other, or from the hospital’s environment; or internal, i.e., within the patient himself.
COVID 19 and Maxillofacial SurgeryThe occupational risk of acquiring viral diseases has been well known in Maxillofacial Surgery [16]. The WHO announced the Corona virus pandemic also known as COVID-19 as a public health emergency of international concern on January 30, 2020. Coronaviruses are RNA viruses infecting many species of animals including humans, name coronavirus was derived from corona meaning crown like because of the morphology observed for these viruses in the electron microscope. This family of viruses includes Middle East Respiratory Syndrome (MERS-CoV), Severe Acute Respiratory Syndrome (SARS-CoV), and novel Coronavirus (n CoV). Coronavirus is enveloped having round, spherical, or sometimes pleomorphic structure, with size ranging from 80 to 120 nm in diameter, containing a positive-strand RNA. The virus is made up of lipid bilayer envelop, membrane protein, and nucleocapsid, these structures also protect the virus when the virus is outside the host cell. The lipid bilayer forms the viral envelop which anchors the membrane protein, envelop protein, and the spike protein. The spike protein (S-protein) is responsible for the crown-like structure of the coronavirus as it forms the protrusions from the surface which bind to the host cells. Mode of Transmission of SARs-CoV 2Human to human transmission is due to respiratory droplet transmission and contact transmission. Spread occurs through coughing, sneezing, spitting, contacting the body fluids of the infected patient. The COVID-19 can remain infectious on inanimate surfaces from 2 h to 9 days, depending on the humidity, temperature, surface type, and viral load [17]. It has become an occupational threat to health care providers worldwide. Some of the known routes of spread of infection to health care providers are:
Aerosols generating procedures (AGP) create widespread environmental contamination and therefore pose a greater risk of transmission of infection to healthcare workers. Oral and maxillofacial surgeons are particularly vulnerable to this transmissible disease by way of the droplet or aerosol transmission due to the area of work and the type of instrumentation [18]. The incubation period is long and unpredictable ranging from 0 to 27 days with a mean of 6.4 days. Recent studies have shown that asymptomatic patients and those within the incubation period are also potential spreaders of the disease [19]. SymptomsSymptoms may range from mild symptoms to severe respiratory distress and some patients may be asymptomatic.
Radiographic Findings
Testing and Laboratory FindingsThe real time polymerase chain reaction (RT-PCR) of respiratory secretions from bronchoalveolar lavage, endotracheal aspirate, and nasopharyngeal or oropharyngeal swab is the definitive test. Other laboratory findings include lymphopenia, increased prothrombin time, and mildly raised CRP and ESR. General Preventive MeasuresCOVID 19 has shifted the focus on teleconsulting which includes tele screening, telemedicine, and triage. Telemedicine should be practiced whenever possible to decrease the footfall. Thorough history should be obtained from the patient regarding COVID 19 illness and elective procedures should be postponed and only emergent conditions should be taken up for surgery. Patient should be called on the basis of appointments, time between two appointments should be sufficient enough to perform all necessary sanitization measures and ensure minimal patient to patient overlap. In the waiting area, posters should be displayed to encourage hand hygiene and the wearing of masks and the area should be well ventilated. A minimum of 2 m distance should be maintained between the individuals. Extraoral radiographs should be preferred as an alternative to intraoral periapical radiographs. In the operatory there should be minimum personnel present, Air Conditioners should be avoided, doors and windows are advised to be kept open. The operating room should be spacious with adjoining two rooms for donning and doffing of the PPE’s. No touch sensor-based sanitizer dispenser should be installed at the entry and exit of OR [20]. All the surfaces of equipment like OR table, motor drills etc., should be covered with plastic sheets and sheets to be changed after every patient. OT’s should be equipped with HEPA filter (0.1 micron efficiency) and high frequency of air changes (ideally 25 per hour) should be ensured to reduce the viral load [20]. High-volume suctions should be used with one-third of suction jars prefilled with povidone-iodine solution. The Povidone Iodine solution has been shown to have significant viricidal activity up to 3 h and it has been advised to coat the oral cavity and nasal passages of both the patient and the operating team before the surgery [21, 22]. Fogger machines with 0.5% sodium hypochlorite can be used for sterilization of dental chairs, tables, doors, doorknob, etc. [20]. One-minute contact of the chemical ensures viral kill. Personal Protective Equipment
Specific Precautions to Be Taken During Surgery
As the COVID-19 situation is a dynamic evolving one and there is no definitive treatment available proper planning and implementation of infection control protocols are key to preventing transmission of the disease in the Maxillofacial settings. Control of Nosocomial InfectionsCDC elucidated certain guidelines to check the nosocomial infections in the Study on efficacy of nosocomial infection control (SENIC). These guidelines have decreased the emergence of hospital-acquired infections by a greater number. However, any breach in the infection control procedures can lead to spread of such infections. Certain conditions leading to improper infection control and spread of such infections are:
Prevention from Nosocomial InfectionsFollowing are the steps that can be taken by the staff in a hospital setup to prevent the spread of such infections:
ConclusionPreventing and controlling infections is the key factor in improving care and ensuring safety of both the patient and the health care worker. Infection control addresses factors related to the spread of infections within the operation theater complex (whether patient-to-patient, from patients to staff and from staff to patient, or among staff), including prevention (via hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, monitoring). Integrated infection control in the operation theater has various aspects, ranging from its designing ,environmental cleaning , management of biomedical waste and adherence to theatre attire. Use of Personal Protective Equipment (PPE) including gloves, gowns, face masks ,respirators and full face visors are essential to minimize risks of occupational infections. Whether in developed or developing country, where resources are limited, thorough knowledge about the principles of infection control and a little ingenuity will suffice to solve the problem of hospital-acquired infections. Surgical site infections are a result of microbial invasion in a sterile atmosphere. The main sources of microbial invasion in the operating theater include the atmosphere of the operating theater, the medical and the paramedical staff present at the time of the procedure, surgical instruments, and the patient at times also. Proper designing of operation theater, appropriate microbiological monitoring, proper sterilization, and strict adherence to barrier techniques form the basis to prevent infections in an operating environment. Contributor InformationKrishnamurthy Bonanthaya, Email: moc.liamg@ayahtnanobk. Elavenil Panneerselvam, Email: moc.liamg@sfmolinevale. Suvy Manuel, Email: moc.liamg@leunamyvus. Vinay V. Kumar, Email: moc.liamffider@ozeev. 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They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient.
What are the 5 standard precautions for infection control?Hand Hygiene. Hand hygiene is the most important measure to prevent the spread of infections among patients and DHCP. ... . Respiratory Hygiene/Cough Etiquette. ... . Sharps Safety. ... . Safe Injection Practices. ... . Sterilization and Disinfection of Patient-Care Items and Devices.. What are the infection control in OT?The practices to be carried out for infection control include proper scrubbing procedures for both patient and the operator, specific protocols to be followed by the operating personnel at the time of procedures, proper handling of the instruments and maintaining an aseptic environment throughout the procedure.
What are the 3 infection control procedures?Standard precautions consist of the following practices: hand hygiene before and after all patient contact. the use of personal protective equipment, which may include gloves, impermeable gowns, plastic aprons, masks, face shields and eye protection. the safe use and disposal of sharps.
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