降低感染率的圍手術(shù)期策略課程

1、The Journal of Bone and Joint Surgery (American). 2010； 92:232-239.Perioperative Strategies for Decreasing InfectionA Comprehensive Evidence-Based Approach降低感染率的圍手術(shù)期策略：綜合性循證醫(yī)學(xué)路徑Joseph A. Bosco, III, MD1, James D. Slover, MD, MSI and Janet P. Haas, RN, PhD2Department of Orthopaedic Surgery, NYU Hospi

2、tal for J oint Diseases, New York University Langone Medical Cent er, 301 East 17th Street, New York, NY 10003. E-mail ad dress for J. A. Bosco III： Joseph. bosconyumc. org. E-mai 1 address for J. D. Slover： James. slovernyumc. orgInfection Prevention and Control, Westchester Medical Center, 100 Woo

3、ds Road, Macy Pavilion SW246, Valhalla, NY 10595. E-mail address： Haasjwcmc. comAn Instructional Course Lecture, American Academy of Or thopaedic SurgeonsIntroduction引言creased risk of infection with spine surgery. Patients considering or planning surgical weight-loss treatments, such as gastric bypa

4、ss surgery, probably should be adv ised to pursue these procedures first to reduce the ris k of infection at the sites of hardware or prostheses a s a benefit from weight loss. Working with patients and the appropriate consultants to optimize these factorsprior to surgery may improve patient outcome

5、s by loweri ng the risk of infection with high-risk joint-replaceme nt and spine procedures.吸煙和肥胖會(huì)增加脊柱手術(shù)感染的風(fēng)險(xiǎn)【13。盡管這些因素通 常難以操縱，但仍然應(yīng)該告知患者，戒煙以及減輕體重關(guān)于降低 脊柱手術(shù)感染的風(fēng)險(xiǎn)具有重要意義。假如患者正在考慮或打算通 過手術(shù)來減輕體重，如胃旁路手術(shù)，那么應(yīng)該建議患者先做減肥 手術(shù)，因?yàn)槿绱岁P(guān)于置入內(nèi)固定物或假體的部位能夠減少感染的 風(fēng)險(xiǎn)。與患者充分溝通，提出合理化的建議，在手術(shù)前盡量?jī)?yōu)化 這些因素，對(duì)這些關(guān)節(jié)置換和脊柱手術(shù)的高風(fēng)險(xiǎn)人群而言，能夠 改善臨床結(jié)

6、果，降低感染的風(fēng)險(xiǎn)。Another important preoperative consideration is preoper ative bathing. Preoperative bathing has been used to re duce the bacterial load of the skin prior to surgery be cause skin preparation immediately before surgery does not completely sterilize the skin. In addition, direct contaminatio

7、n can occur at the time of surgery. A recen t Cochrane review was performed to assess the informati on in the literature regarding preoperative bathing wit h antiseptics for the prevention of surgical site infec tionl4. Chlorhexidine gluconate is the most commonly us ed antiseptic for preoperative b

8、athing. The Cochrane re view revealed evidence that the bacterial load of resid ent skin flora is reduced by use of chlorhexidine gluco nate preparations for preoperative bathing. Repeated, c onsecutive treatments reduce this load progressively ov er time. However, concerns about the development of

9、res istant organisms and hypersensitivity remain. Therefore, the authors of the review concluded that there is no c lear evidence that preoperative bathing with chlorhexid ine gluconate is superior to preoperative bathing with other products, such as bar soap, for reducing the inci dence of surgical

10、 site infection.手術(shù)前另一個(gè)重要的考前須知便是術(shù)前洗澡。由于術(shù)前即刻的皮 膚消毒并不能完全殺滅所有細(xì)菌，因而通常都通過術(shù)前洗澡以減 少皮膚的細(xì)菌接種量。此外，假如術(shù)前不洗澡，手術(shù)時(shí)也可能發(fā) 生直接的污染。最近的一項(xiàng)Cochrane綜述對(duì)術(shù)前應(yīng)用消毒劑洗 澡預(yù)防手術(shù)部位感染的相關(guān)信息進(jìn)行了評(píng)價(jià)【14】。洗必泰葡萄 糖酸鹽是術(shù)前洗澡時(shí)應(yīng)用最多的消毒劑。Cochrane綜述的相關(guān) 證據(jù)顯示術(shù)前洗澡時(shí)應(yīng)用洗必泰葡萄糖酸鹽進(jìn)行消毒可使體表 常居菌的細(xì)菌接種量明顯減少。隨著時(shí)刻的延長(zhǎng)，反復(fù)、持續(xù)地 洗浴可使該接種量進(jìn)行性地下降。然而，如此做也有產(chǎn)生耐藥菌 及出現(xiàn)過敏反響的風(fēng)險(xiǎn)。因此，上文作

11、者的結(jié)論認(rèn)為，為了減少 手術(shù)部位感染的發(fā)生率，在術(shù)前洗澡時(shí)，并沒有明確的證據(jù)證實(shí) 應(yīng)用洗必泰葡萄糖酸鹽優(yōu)于其他的產(chǎn)品，如肥皂等。Hair removal has been used traditionally to keep hair f rom contaminating the wound. More recently, hair remova 1 has allowed surgeons to apply occlusive dressings to the skin perioperatively to keep skin flora from direct ly contaminat

12、ing the wound. Three methods used for hair removal include traditional razors, clippers, and hair-removal creams or depilatories. Hairless surgical site s can make the surgery and application of dressings and protective draping easier, but the use of razors to sh ave the surgical site increases the

13、risk of introducing primary infections through microscopic injuries to the skin. The Centers for Disease Control and Prevention(CDC) recommend that hair removal be minimized and that, when it is necessary, electric clippers or depilatories be used rather than razorsl5. A Cochrane review of th e lite

14、rature on hair removal prior to surgery supportedthe CDC recommendations and added that hair removal can be done on the day of the surgeryl6.以往術(shù)前通常都要求去除毛發(fā)以幸免污染創(chuàng)口，而最近那么傾向于 讓外科大夫在術(shù)前應(yīng)用密閉的敷料覆蓋皮膚，從而防止皮膚菌群 直接污染創(chuàng)口。傳統(tǒng)的去毛方式要緊有三種：剃毛、剪毛和脫毛 膏或脫毛藥物。手術(shù)部位去毛后通?？墒故中g(shù)操作更為方便，并 使貼膜和防護(hù)膜的應(yīng)用也更為簡(jiǎn)便，但應(yīng)用剃刀刮除手術(shù)部位的 毛發(fā)會(huì)對(duì)皮膚產(chǎn)生微小的損傷

15、，通過這些損傷局部原發(fā)感染的風(fēng) 險(xiǎn)會(huì)明顯增加。疾病預(yù)防和操縱中心(CDC)建議，應(yīng)盡量幸免 去毛，假如實(shí)在必要，也應(yīng)該應(yīng)用電動(dòng)剪毛刀或脫毛劑，而應(yīng)幸 免應(yīng)用剃毛刀【15。有學(xué)者對(duì)術(shù)前去毛相關(guān)的文獻(xiàn)進(jìn)行了 Coc hrane綜述，其結(jié)論與CDC所推舉的方案一致，此外，去毛應(yīng)該 手術(shù)當(dāng)天進(jìn)行16 oDental care is another preoperative issue to be discuss ed with high-risk orthopaedic patients. All patients, b ut particularly those at high risk for i

16、nfection, shoul d be encouraged to maintain good dental health before a nd after surgery. Bacteremia from a dental infection ca n cause acute hematogenous infection at the site of a t otal joint replacement. Evidence shows that the most cr itical period is the first two years after surgeryl7. T he A

17、merican Academy of Orthopaedic Surgeons (AAOS) in c onjunction with the American Dental Association (ADA) d eveloped guidelines for antibiotic prophylaxis for pati ents with a total joint replacement who require dental proceduresl8. Patients are identified as being at high or low risk depending on t

18、heir medical comorbidities. D ental procedures are categorized as high or low risk de pending on the risk of bacteremia. All patients should receive antibiotic prophylaxis for high-risk dental pro cedures for two years after the joint replacement, and high-risk patients should receive prophylaxis fo

19、r high- risk dental procedures for life. Antibiotic regimens ar e included in the recommendations (Table I).術(shù)前處理牙科的疾病關(guān)于高風(fēng)險(xiǎn)的骨科患者而言也是一個(gè)值得探討的問題。關(guān)于所有患者，而感染風(fēng)險(xiǎn)較高的患者尤其，應(yīng)鼓 舞其在手術(shù)前后保持良好的口腔衛(wèi)生。源自牙齒感染的菌血癥可 導(dǎo)致全關(guān)節(jié)置換部位的急性血源性感染。有證據(jù)說明，臨界期通 常為手術(shù)后的頭兩年17。美國(guó)骨科醫(yī)師學(xué)會(huì)（AAOS）聯(lián)合美 國(guó)牙科協(xié)會(huì)（ADA）對(duì)全關(guān)節(jié)置換的患者進(jìn)行牙科手術(shù)時(shí)預(yù)防性 應(yīng)用抗生素制定了指南【18】。按照內(nèi)

20、科合并癥的情況將患者分 為高或低風(fēng)險(xiǎn)人群；按照菌血癥的風(fēng)險(xiǎn)將牙科手術(shù)分為高風(fēng)險(xiǎn)或 低風(fēng)險(xiǎn)手術(shù)。關(guān)節(jié)置換術(shù)后2年內(nèi)的所有患者在進(jìn)行高風(fēng)險(xiǎn)的牙 科手術(shù)時(shí)，都應(yīng)該預(yù)防性地應(yīng)該抗生素，而關(guān)于高風(fēng)險(xiǎn)的患者而 言，關(guān)節(jié)置換術(shù)后的任何時(shí)刻行高風(fēng)險(xiǎn)牙科手術(shù)時(shí)都應(yīng)該預(yù)防性 應(yīng)用抗生素。其推舉的方案中也包括了抗生素的用法（表1）。TABLE I Antibiotic Prophylaxis for Dental ProceduresMedicationMedicationDosageTimingCephalexinCephradineAmoxicillin2 g orally2 g orally2 g orall

21、y1 hr prior to procedu1 hr prior to procedu1 hr prior to表1牙科手術(shù)預(yù)防性應(yīng)用抗生素藥物藥物劑最用法給藥時(shí)間頭抱氨卡頭抱拉定阿莫西林2g I I 服2g 口服2g 2服術(shù)前1小時(shí)術(shù)前1小時(shí)硬冽死Antibiotics抗生素Perioperative prophylactic antibiotics are effective in reducing the rate of surgical site infections in high- risk orthopaedic cases. In a 2002 metaanalysis of

22、spin e fusion surgery, Barkerl9 reported that use of antibio tic therapy for such procedures is beneficial even when the infection rates without antibiotics are low. Simil ar studies have demonstrated the efficacy of preoperati ve antibiotics in general orthopaedic surgery and befor e total joint re

23、placement20,21.對(duì)高風(fēng)險(xiǎn)的骨科患者而言，圍手術(shù)期預(yù)防性應(yīng)用抗生素可有效地 降低手術(shù)部位的感染率。在2002年一項(xiàng)關(guān)于脊柱融合手術(shù)的me ta分析中，Barker 19指出，在如此的手術(shù)中應(yīng)用抗生素是 有益的，即使在不用抗生素時(shí)感染率也較低的情況下依舊如此。 其他類似的研究也證實(shí)，在一般的骨科手術(shù)和全關(guān)節(jié)置換手術(shù)之 前應(yīng)用抗生素都有著良好的效果20,21。The choice of antibiotic for patients with a low risk o f methicillin-resistant Staphylococcus aureus colonizat ion

24、 is either cefazolin (1 to 2 g administered intraven ously) or cefuroxime (1. 5 g administered intravenously).These doses must be adjusted for children. For patient s with a beta-lactam allergy, clindamycin (600 mg admin istered intravenously) or vancomycin (1. 0 g administere d intravenously) shoul

25、d be used in lieu of cephalospori ns. Patients who are colonized with methici11 inuresista nt Staphylococcus aureus are at high risk for colonizat ion (e. g. , nursing home residents), or have had a previ ous methicillin-resistant Staphylococcus aureus infecti on have an increased risk for the devel

26、opment of an inf ection with methicillin-resistant Staphylococcus aureus 22,23. Prophylaxis with vancomycin (1. 0 g administered intravenously) should be considered for these patients2 4.關(guān)于耐甲氧西林金黃色葡萄球菌定植風(fēng)險(xiǎn)較低的患者選擇抗生 素時(shí)，頭匏嗖琳（1-2g靜脈內(nèi)給藥）或頭抱吠辛（1.5g靜脈內(nèi) 給藥）差不多上能夠考慮的，應(yīng)用于兒童時(shí)劑量應(yīng)作相應(yīng)的調(diào)整。 假如患者對(duì)B-內(nèi)酰胺類藥物過敏，可用克林霉素（

27、600mg靜脈 內(nèi)給藥）或萬古霉素（1.0g靜脈內(nèi)給藥）代替頭抱菌素。如患 者居住在耐甲氧西林金黃色葡萄球菌較多的環(huán)境中，發(fā)生菌群定 植的風(fēng)險(xiǎn)往往較高（如敬老院的住戶），而曾經(jīng)感染上述耐甲氧 西林金黃色葡萄球菌的患者那么發(fā)生耐甲氧西林金黃色葡萄球菌 感染的風(fēng)險(xiǎn)會(huì)明顯增加22,23，對(duì)這些患者應(yīng)用考慮預(yù)防性 應(yīng)用萬古霉素（1.0g靜脈內(nèi)給藥）【24】oThe proper timing and duration of antibiotic prophylaxi s are imperative for safety and effectiveness. In gener al, antibiot

28、ic therapy should be started within one hou r prior to the surgical incision, and the drugs should be completely infused prior to tourniquet inflation. Th e exception to this recommendation is vancomycin, the a dministration of which may be started up to two hours p rior to the surgical incision. Th

29、is allows a slower inf usion and decreases the likelihood of red man syndrome.Red man syndrome occurs when hypersensitivity to vancomycin causes degranulation of mast cells and a release of histamine. The histamine leads to hypotension and fa cial flushing. Red man syndrome is prevented by the slo w

30、 administration of vancomycin over a period of one to two hours.預(yù)防性應(yīng)用抗生素注意合適的時(shí)機(jī)和持續(xù)時(shí)刻關(guān)于其平安性和 有效性差不多上特不關(guān)鍵的。通常應(yīng)在做手術(shù)切口之前的一個(gè)小 時(shí)內(nèi)應(yīng)用抗生素，同時(shí)止血帶充氣之前藥物必須輸注完畢。對(duì)這 一建議而言，萬古霉素是個(gè)例外，其開始給藥的時(shí)刻應(yīng)提早至做 手術(shù)切口之前兩個(gè)小時(shí)，如此能夠緩慢輸注，減少紅人綜合征的 發(fā)生率。萬古霉素過敏時(shí)可導(dǎo)致肥大細(xì)胞脫顆粒并釋放組胺從而 出現(xiàn)紅人綜合征，組胺可導(dǎo)致低血壓和顏面部發(fā)紅。應(yīng)用萬古霉 素時(shí)緩慢輸注，輸注時(shí)刻達(dá)1-2小時(shí)可防止發(fā)生紅人綜合征。Antibi

31、otic treatment should be stopped within twenty-fo ur hours after wound closure. Administration of prophyl actic antibiotics for longer than twenty-four hours has not been demonstrated to be effective and may actually lead to superinfection with drug-resistant organisms25. Repeat dosing with antibiot

32、ics is recommended during s urgical procedures that last for longer than four hoursSurgical site infections associated with orthopaedic su rgical procedures are devastating complications. They i ncrease morbidity, mortality, and cost and result in ou tcomes that are worse than those in uninfected ca

33、sesl. Decreasing the incidence of surgical site infections is not only of interest to patients and surgeons, it is aIso a major focus of several groups of interested parti es. These range from payers, including the Centers for Medicare and Medicaid Services (CMS, Baltimore, Marylan d), to institutio

34、ns represented by the Surgical Care Im provement Project (SCIP), a multiple-institution partne rship between major public and private health-care orga nizations, including the Joint Commission on Accreditat ion of Healthcare Organizations (Oakbrook Terrace, Illi nois). Decreasing the incidence of su

35、rgical site infect ions is, and will continue to be, a major focus in medi cine.關(guān)于骨科手術(shù)而言，手術(shù)部位的感染是一種毀滅性的并發(fā)癥，往 往會(huì)導(dǎo)致致殘率、致死率以及醫(yī)療費(fèi)用的增加，同時(shí)與沒有發(fā)生 感染的病例相比，最終的治療結(jié)果通常也會(huì)更差【1】。減少手or when there is 1500 mL of blood loss26.抗生素應(yīng)在創(chuàng)口閉合后的24小時(shí)之內(nèi)停藥。沒有證據(jù)說明預(yù)防 性應(yīng)用抗生素超過24小時(shí)是有效的，同時(shí)事實(shí)上還有可能導(dǎo)致 耐藥菌的二重感染【25】o而假如手術(shù)持續(xù)時(shí)刻較長(zhǎng)，超過4小 時(shí)或術(shù)中出

36、血量大于1500ml,那么推舉在術(shù)中重復(fù)給藥一次【26】。We recommend that, in order to ensure the proper select ion and timing of antibiotic prophylaxis, the choice of antibiotics and duration of administration be incorpor ated into the surgical ntime-out.Rosenberg et al. reported that compliance with the proper timing and se

37、lect ion of antibiotics increased from 65% to 99% when the p rotocol was incorporated into the time-out27.在預(yù)防性應(yīng)用抗生素時(shí)為了確保合理選擇抗生素并確定適當(dāng)?shù)?給藥時(shí)機(jī)，我們推舉，將選擇抗生素和確定給藥持續(xù)時(shí)刻都?xì)w入 到手術(shù)的“time-out”（手術(shù)劃刀前暫停核對(duì)各項(xiàng)信息）方案中。 Rosenberg等曾報(bào)道，將相關(guān)的內(nèi)容并入到“time-out”方案中 之后，選擇抗生素以及用藥時(shí)刻的符合率由65%增加到99%27OSurgical Hand Antisepsis術(shù)者手部消毒The o

38、bjective of a preoperative hand scrub is to remove or kill as many bacteria as possible from the hands of the surgical team. Aqueous scrub solutions consisting of water-based solutions of either chlorhexidine glucon ate or povidone-iodine have been traditionally used.術(shù)前洗手的目的是為了盡可能多地去除或殺死手術(shù)人員手部的 細(xì)菌。通

39、常應(yīng)用的液態(tài)洗滌劑大多為洗必泰葡萄糖酸鹽或聚維酮 碘的水溶液。The authors of a recent Cochrane review28 found alcohol -based rubs containing ethanol, isopropanol, or n-propa nol to be as effective as aqueous solutions for prevent ing surgical site infections in patients29. Hajipour et al.30 reported that alcohol rubs were more ef

40、fective t han either chlorhexidine gluconate or iodine-based scru bs for reducing bacterial colony-forming units (CFUs) o n the hands of surgeons. Other investigators reported t hat the use of scrub brushes had no positive effect on asepsis and may actually increase the risk of infectionas a result

41、of skin damage31. On the basis of this evi dence, the recommended procedure for preoperative surgi cal hand antisepsis is that, preceding the first scrub of the day or when the hands are grossly contaminated, the surgical team should wash with soap and water, use a nail pick to clean under the nails

42、, and dry with pape r towels. They should then use an alcohol-based rub forthree minutes32. An alcohol-based rub should be used f or each subsequent case. The use of scrub brushes is no t recommended.有學(xué)者最近的一項(xiàng)Cochrane綜述【28】覺察，含有乙醇、異丙 醇或正丙醇的酒精擦劑與水溶液相比，關(guān)于預(yù)防患者手術(shù)部位的 感染具有類似的效果29 o Hajipour等30報(bào)道酒精擦劑 比洗必泰葡萄

43、糖酸鹽或含碘洗滌劑都更為有效，因?yàn)榍罢呖蓽p少 術(shù)者手上的細(xì)菌菌落形成單位（CFU）。另外還有學(xué)者報(bào)道應(yīng)用 毛刷關(guān)于手部消毒并沒有明顯的效果，同時(shí)事實(shí)上由于會(huì)損傷皮 膚反而會(huì)增加感染的風(fēng)險(xiǎn)31 o依照這些證據(jù)，術(shù)者術(shù)前手部 消毒推舉的方式為，在當(dāng)天初次刷洗之前或手部嚴(yán)峻污染時(shí)，手 術(shù)人員應(yīng)該用肥皂和水洗手，并用指甲簽將指甲下方的污物清理 潔凈，然后用紙巾擦干。然后，術(shù)者再用含酒精的擦劑涂抹3分 鐘【32】o后續(xù)的手術(shù)每次都應(yīng)該用含酒精的擦劑進(jìn)行涂抹，但不推舉應(yīng)用毛刷進(jìn)行刷洗。Surgical Site Preparation 手術(shù)部位的消毒Chlorhexidine gluconate-base

44、d solutions have supplanted alcohol and iodine-based solutions for surgical site p reparation. Ostrander et al. 33 examined the residual am ounts of bacteria on feet prepared with a chlorhexidine gluconate, iodine/isopropyl alcohol, or chloroxylenol scrub. They found that chlorhexidine gluconate was

45、 supe rior to the other two preparation solutions in reducing or eliminating bacteria from the feet prior to surgery. Chlorhexidine gluconate skin preparation was superior to either 70% alcohol or iodine in decreasing infection associated with the placement of central venous cathet ers and the drawi

46、ng of blood for culture34,35. Thus, th e current evidence-based recommendations and best-pract ice guidelines call for the use of chlorhexidine glucon ate-based solutions for surgical site preparation and p lacement of central venous catheters.手術(shù)部位的消毒液，洗必泰葡萄糖酸鹽溶液差不多替代酒精和含 碘的溶液。Ostrander等【33】對(duì)洗必泰葡萄糖酸

47、鹽、碘/異丙 醇或氯二甲苯酚的擦劑消毒足部后，檢測(cè)剩余的細(xì)菌數(shù)量，結(jié)果 覺察在術(shù)后減少或消除足部細(xì)菌的功效上洗必泰葡萄糖酸鹽優(yōu) 于其他兩種消毒劑。而在置入中央靜脈導(dǎo)管和抽血樣做培養(yǎng)等操 作時(shí)，應(yīng)用洗必泰葡萄糖酸鹽進(jìn)行皮膚消毒，相比70%的酒精或 碘劑，均可減少感染的發(fā)生率34,35 o因此，在術(shù)區(qū)消毒以 及置入中央靜脈導(dǎo)管時(shí)，基于現(xiàn)有證據(jù)的建議和最正確操作指南都 提倡應(yīng)用洗必泰葡萄糖酸鹽溶液。Decreasing the Risk of Surgical Site Infection Related to the Operating-Room Environment降低手術(shù)部位感染相關(guān)的手術(shù)室

48、環(huán)境Although the arcane details of techniques used to steri lize surgical instruments are beyond the expected knowl edge of most orthopaedic surgeons, many of a surgeon1s actions can adversely affect sterilization and increase the risk of surgical site infections. Flash sterilizat ion is a procedure u

49、sed by operating-room staff to ster ilize instruments or implants with steam, on an as-need ed basis. Flash sterilization is not equivalent to ster ilization in central processing36,37. In central steril e processing, instruments are properly cleaned and all lumens are inspected； the instruments are

50、 then steriliz ed and allowed to dry completely, after which they are delivered in closed containers that ensure maintenance of sterility. Most importantly, the process is performe d by trained, focused professionals. The entire process takes three to four hours. Flash sterilization shouldbe used on

51、ly for dropped instruments or in an emergency situation. Preventable reasons for flash sterilization include an insufficient quantity of instruments, loane r instruments and/or instruments not delivered in time for proper processing, and inaccurate or incomplete sur gical booking requiring the emerg

52、ency, unplanned use of instruments and/or implants.盡管手術(shù)器械滅菌方法中專門多不為人知的操作細(xì)節(jié)并不是大 多數(shù)骨科大夫都期望掌握的知識(shí)，但外科大夫的專門多做法卻可 對(duì)滅菌過程產(chǎn)生負(fù)面的阻礙，并會(huì)增加手術(shù)部位感染的風(fēng)險(xiǎn)?？?速滅菌是手術(shù)室工作人員常用的一種對(duì)手術(shù)器械或內(nèi)置物的滅 菌方式，在一些必要的基座之上，應(yīng)用蒸汽?？焖贉缇⒉荒艿?同于中央滅菌過程136,37】。在中央滅菌處理中，手術(shù)器械先 用適當(dāng)?shù)姆椒ㄇ謇頋崈簦瑢?duì)所有內(nèi)腔都進(jìn)行完全的檢查，然后在 對(duì)器械進(jìn)行滅菌，并可使其完全干燥，最后手術(shù)器械在運(yùn)送過程 中必須保持密閉的包裝，以確保維持其

53、無菌的狀態(tài)。最為重要的 是，這些操作都由通過專業(yè)訓(xùn)練的人員完成，整個(gè)過程需要3-4 小時(shí)。快速滅菌只有在術(shù)中器械掉落或緊急狀況下方可應(yīng)用。有 些因素是能夠幸免進(jìn)行快速滅菌的，包括手術(shù)器械數(shù)量缺乏，應(yīng) 用替代性器械和/或器械沒有按照合適的操作規(guī)程按時(shí)送達(dá)，手 術(shù)預(yù)約錯(cuò)誤或不完善需要緊急處理，非打算性地應(yīng)用手術(shù)器械和 /或內(nèi)置物等。To reduce the incidence of flash sterilization, we reco mmend an increase in physician awareness about the inad equacy of the technique

54、； improvement in the accuracy of surgical booking； mandating cooperation from vendors t o ensure timely delivery of equipment, including finane ial penalties for late delivery； purchase of more frequ ently flash-sterilized items； surgical scheduling to ac commodate and mitigate equipment shortages；

55、and, finall y, generation of incident reports when a flash-steriliz ed implant is used in a patient. Adopting these policie s and procedures leads to a decrease in the incidence of flash sterilization38.為了減少快速滅菌，我們建議增強(qiáng)對(duì)臨床醫(yī)師的宣傳和培訓(xùn)，使 其充分認(rèn)識(shí)到這一方法的缺乏；提高手術(shù)預(yù)約單的準(zhǔn)確性；要求 供貨商緊密配合，確保相關(guān)設(shè)備及時(shí)交付到位，關(guān)于延遲送達(dá)的 應(yīng)考慮適當(dāng)給予經(jīng)濟(jì)懲

56、辦；關(guān)于以往經(jīng)常進(jìn)行快速滅菌的器械適 當(dāng)增加購(gòu)買數(shù)量；通過調(diào)整手術(shù)安排以適應(yīng)和緩解設(shè)備上的不 足，最后，快速滅菌的內(nèi)置物應(yīng)用于患者后應(yīng)寫出相關(guān)的事件報(bào) 告。采納這些策略和規(guī)程可有效降低快速滅菌的使用率【38】。Powderless GlovesTraditionally, surgical gloves contained powder to aid in the manufacturing process and to make donning easier.The powder was either talc or lycopodium spores. Becau se of concer

57、ns about granuloma formation and adhesions associated with the use of these substances, cornstarchis now the powder of choice39. However, cornstarch is not benign. It causes foreign-body granuloma formation and delayed wound-healing and can decrease the amount o f bacteria required to cause a clinic

58、ally apparent infe ction40. Cornstarch also leads to increased latex sensi tivity in health-care workers. Type-I and type-IV hyper sensitivity reactions to latex protein in hospital staf f lead to increases in sick time and decreased job sati sfaction41. Powderless gloves decrease staff absenteeis m

59、 and eliminate the potential for foreign-body granulom a formation. These gloves cost 25% more than powdered g loves, but the added expense is mitigated by increased productivity of the operating-room staff41.無粉手套以往外科手套差不多上有粉的，如此在制造過程中便于操作，同 時(shí)也可使穿戴更為方便，粉末的成分為滑石粉或石松子。由于考 慮到應(yīng)用這些粉末可能會(huì)形成肉芽腫以及粘連，因此目前一般都

60、選用玉米淀粉【39。然而，玉米淀粉也不是沒有任何危險(xiǎn)的， 其可導(dǎo)致創(chuàng)口延遲愈合或形成異物性肉芽腫，同時(shí)它可使通常出 現(xiàn)感染相關(guān)臨床表現(xiàn)所需的細(xì)菌數(shù)量減少【40】o玉米淀粉還會(huì) 使醫(yī)務(wù)人員對(duì)橡膠的敏感度增加。醫(yī)院的工作人員對(duì)乳膠蛋白的 I型和IV型過敏反響會(huì)使不適時(shí)刻延長(zhǎng)，并使工作的中意度下 降【41】。無粉手套可減少工作人員的缺勤狀況，且可幸免向體 外形成肉芽腫的潛在可能。這些手套比有粉手套貴25%,但由此 增加的費(fèi)用會(huì)隨著手術(shù)室工作人職員作效率的提高而減少【41】。Antiseptic-Coated SuturesThe use of antiseptic-coated sutures ha