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Theatre Design Orthopaedic Exams
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Theatre Design Orthopaedic Exams
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Language: EN.
Segment:0 .
Sameer has lost his efforts recently in April, and he works in banga, and his talk, as I said, is about theater design. Without any further ado, I believe the Mike to Samir, please. Hello, everyone. My name is Samir Agarwal.
I'll be talking on theater design quite often. Topic what I have seen is it usually starts with a picture like this. Tell me what you see. First time when I was in one of her courses and I was shown this picture, I was quite disturbed what to talk, how much to talk, should they talk around, then basically what I realized was need to see the picture.
Take it as a prop. So basically, what you see is just a prop. Once you have. Seen the picture try to identify what the lead bit of the question is going to be. Usually no tricks, if they show you a theater, they want you to talk about the theater design. Right one of our we always think that if we see a question which we know a lot about, we should start talking immediately, give yourself about 5 seconds.
Plan your answer. That's very important, formulator reply, how you are going to approach this question, you know, everything about the topic. You want to show them that, you know, everything about the topic. So if you have a structure of your answer that is going to take you in a very strong position. And another a very small point, I think sometimes we miss.
Stop looking at the picture all through your talking, once you have seen the picture, once you know what you're going to talk about. You have taken your 5 seconds to look at the picture in the meantime, formulating your answers. Stop looking at the picture. Look at the examiner's. You are applying to the examiners, you're not replying to the picture.
That's really important. One thing I felt sometimes helps is if you lose your track, if you lose what you were talking about in Midway. Quick glance at the picture. You know, you have talked about lighting, you have talked about this, you have talked about that, oh, you are not talking about one particular thing. That picture can give you that clue, but don't stare at it.
Don't keep looking at it. So what is the purpose of a separate orthopedic theatre? It provides an ultra clean operating conditions. It maintains a very high level of sepsis. It provides adequate space for personal multiple trains, additional equipments like Sia and. The importance is the condition should be optimum for the patient, for the best results, and it should be comfortable through the OR personnel who are working there.
So basically, this is not directly related to the theater design, but this is the principle of theater design. So these are the things which need to be satisfied when you're designing a theater. Again, coming back to the structure of the replay. I tend to think of the bullet points as pigs. Each bullet point is a peg in my mind.
The think of a peg, hang on an explanation to that peg. Normally, if you look at the list, it's a very long list. Zones, temperature, humidity, light ventilation, so on, so forth. What happens is if you have a long list in your mind, you can't recall everything in the heat of the examination. You can still recall at least top three, four, five. If you can do that, if you start speaking on topic one, say subtopic one zones, now you remember your zones, you speak on your zones, you have done that for 15, 20, 30 seconds.
Go on to the next one and go on to the next one. You have already spoken to 2 and 1/2 minutes without being prompted. That's what we are trying to in. We are going to speak on a particular topic very sensibly containing facts, not talking anything which is not related and still have a minimum prompting. That is what is going to fetch the box.
So looking at this picture zones. We this is directly from RAM children's basic orthopedic sciences, nothing new in here. The theater zones are divided into four. The outside zone is anything outside the theater area, so which means all of the hospital, including the theater reception. The corridors inside the theater reception is the clean corridor.
The operating table and all the immediate adjoining areas are the aseptic zone. And then there is the disposal zone, which is supposed to be the unclean area directly related. So the best thing is during what you can mention is the disposal zone should be cordoned off or kept closed during the period of surgery. It should not be open.
Once you have mentioned the zones, the next thing we mention is about temperature. No why temperature regulation is important in the theater. One, it needs to provide a comfortable theater environment to the search surgeon and other personnel. Do we have. Hypothermia in patients directly related to increased incidence of infection, the contributing factors could be paralysis, IV fluids or large open wounds.
Now, these are two conflicting aims to be achieved ideal temperature for a surgeon is about 19 to 20 degrees. Anything warmer makes you feel very warm or stuffy. But if the patients are kept at this temperature, they become hypothermic. No, this is achieved by creating a microclimate around the patient using either a warmer. A blanket or what is commonly used in our theaters?
The bear. One of the problems of using these. Well, warming devices around the patient is it alters the airflow, particularly if you look at the warm air blower, which is used in the theater. It is usually placed within the zone of the laminar flow, and it disrupts the flow of air around the patient and can interfere with a smooth flow.
One of the important factor is it is important to maintain ideal temperature in order to species as. Not only the setting time of the segment, but also the mechanical properties of cement is dependent on the ambient temperature. When the cement is stored, prepared and applied. So if the theater temperature is too high, it impedes the mechanical properties of the cement.
Humidity, no humidity is. Percentage of moisture in the air, ideally is 40 to 60 degrees. A higher humidity accelerates the setting time of bone cement, thus reducing the working time there has been some reports in. Uh, well, it seems that a lower humidity increases the chances of electronic equipment failure.
Humidity is indirectly controlled mainly by the temperature and the ventilation regulation. But in an ideal operation theatre, there has to be a monitoring of the humidity. Lights, operating theater lights are very important. Gone are the days when surgeons would operate in candlelight or in the light of day, filled with a jar of fireflies.
Now we have dedicated operating lights. There are three very important key attributes to operating lights. Adjustability brightness and control. Adjustability of the light means essentially the light can be focused into the area of surgery. So suppose we are operating on a hand. You need a very small area of focus of the light, whereas if you are doing a hip out plaster, you need a larger area.
This adjustability of the light should be possible. The brightness should be enough. There should be a uniform illumination of 40,000 lights or more. And the brightness of the light could be controlled. One important aspect of modern theater lights is color rendition. The artificial lights do tend to change the color of the object they fall on, so the better the quality of the light, the more true is the color rendition of the issues, which helps identify the different issues.
One important aspect is the peripheral lights in the theater should be bright enough to avoid a very sharp contrast between the light and the dark areas. So if we're working in the canopy area and the outside lights are very dark, it provides undue strain on the AIIS. So if the theater is uniformly lit, it helps our AIIS.
Ventilation, very important concept. Take some time to elaborate on this. Because this is where quite a significant number of points and important factors are one of the most important things to say is the Communist. Contamination comes from airborne particles, and the source of these particles is the personal indicator.
It is shed from the body. It has been found that 90% comes below the neck. The ventilation is responsible for controlling the temperature, the humidity and the level of airborne contamination. It is. In the guidelines to do an air quality monitor, monitoring in cases of ultra clean theater, it should be done at least every three months.
That and it is done by calculating the bacteria carrying particle per cubic meter at this point, if you remember, you can mention about microbiological strip sampler that essentially draws air over culture plates in a specified quantity. And then these culture plates are incubated for 48 hours, and the Colony Forming units are calculated. So in a normal operation theatre, the CFA units per cubic meter is about 30 five, whereas to define a theater as an ultra clean theatre, which is the aim of all orthopedic theatres, especially where arthroplasty are performed, it should be less than 10 CFU in the centre, which means in the area just around the operating theater.
Now, this is a picture of a plate in which 1,000 liters of air sample in an empty theater. And this is what happens when a person walks by. So this just denotes how much of the contamination comes from the personnel who are in the theater. Well, the various ventilation methods are being designed and developed and researched to reduce this.
Well, the concept here is plenum. What do we mean by plenum circulation or plenum ventilation? It is a system of mechanical ventilation in which fresh air is forced into the spaces to be ventilated from a chamber at a pressure slightly higher than the atmospheric pressure. So essentially, what it means is you have an area of high pressure, which is your operating room, and all the adjoining areas are at a slightly lower pressure.
So the flow of the air is unidirectional from the operating theater to the areas outside. This positive pressure gradient is always maintained in the theater. If you look at the picture, which I have it. Actually shows in these blue figures, blue figures, the partial pressure of the air in that particular area, and if you look at it, operating room has a high pressure area.
The disposal area has got a minus. So it essentially does not allow any air from the disposal area to come into the operating room. Now, this positive pressure, gredyd is affected by opening of the doors. And when the and it also depends on the size of the load, which are open, so when bigger doors are open, the pressure gradient drops. And it can allow some mixing of the air.
Laminar flow. We all know what laminar flow is. The definition of laminar flow, an entire body of air within a designated space, moving with a uniform velocity in a single direction along parallel flow lines. I need to remember that we need to remember a few key words here.
Entire body of air is 1 designated spaces to uniform velocity, three single direction, full and parallel flow lines. Five break it up. Remember it? This is important. You may be asked a direct question what is laminar flow? So I to my belief, I think you need to get these buzzwords in the definition once you have done that.
You probably the examiner knows what you're talking about. No, the laminar flow, again, this picture is just a graphic representation of what exactly laminar flow means, and the green area is the true laminar flow. And you can see when it hits the personal or objects around it, it changes into different colors. That is when the turbulence comes in. And as it goes towards the periphery, the turbulence increases so much that it totally loses the laminar flow quality of the air.
Now, what does this do to the air quality will come later? No, the three types of laminar flow mentioned is horizontal, laminar flow, vertical laminar flow or the X. The third one is X flow or exponential flow or the hover enclosure. At this point, you can mention a room in room concept that usually not the entire operation theater has a laminar flow system.
It is a part of the operation theatre, which is just adjoining. The operation table has the laminar flow, which is the center of the theater. Now coming to each one in slight more detail, horizontal laminar flow. As the name suggests, you have the Hepa filters placed onto one wall of the operation theater.
The floor is horizontal from one wall to the other. The important paper here is celebrated in 1982 said that horizontal air flow reduced infection rates in the r, but it increased the infection rates in the TKR. The explanation has given in Ramachandran says that it is probably something to do with the placement of personnel in the theater in the line of the flow. Again, if you look back to the picture, which I've shown before as you introduce people in the part of the laminar flow, it changes into turbulent flow and this probably has a bearing on it.
Anyhow, it's not commonly used in automatic operation theaters. This is a common type of. A laminar flow used it is ceiling mounted system, vertical, laminar flow, partial enclosure. What we mean by partial enclosure is essentially that. Part of the.
Room has got this laminar flow system, and this laminar flow system is segregated by partial height walls on all the four sides. So the air within the enclosure remains laminar or non turbulent. But when we introduce human personnel within that, the air which hits these personal flows back towards the patient.
And this also brings outside air, which is known as the air entrainment. It's basically the viscous flow of the air, which comes along. I don't know. Am I being clear on this? If anybody has a question, put it up, I'll try to explain it further. But it's essentially that this type of vertical laminar flow has the inherent problem of air entrainment, which brings in unclean air from the outside of the enclosure into the enclosure.
The next was the axilo or the Herbert enclosure. Now, if everybody has seen a trumpet, so the airflow is in the shape of an inverted trumpet, a trumpet. So essentially what it means is the air flows from the center and it is centrifugal in the flow. So the air doesn't float towards the patient, but it all, it's always flowing away from the patient.
Essentially, what it achieves is if you have. The patient in the center, the wound open, which is in or around the center of the operating enclosure. The air keeps flowing away from the patient and we try to reduce the airborne contamination into the wounds, which is essentially the aim of all of this exercise. Recent evidence at best, there is conflicting evidence.
If you look into the literature. There is literature both supporting as well as refuting the evidence of decreased incidence of surgical site infection with the use of ultra clean, laminar flow theaters. No if you look closely into this data, it is not exactly Black and white. Most of these areas are still gray.
So my exam answer would be it is desirable to use an ultra clean operation theater with a laminar flow for all my major surgeries, particularly out of plastic surgeries, unless more definitive evidence comes into light. One important point here, which I found was it is not a replacement to strict adherence to aseptic technique, prophylactic antibiotic surgical discipline, meticulous tissue handling and prevention of hypothermia.
So these things use of an ultra clean operation theater is not a substitute, but it is just an adjunct to these techniques of preventing surgical site infection. Clothing and drapes. No surgical clothing, an ideal surgical clothing is prevent airborne bacterial dispersion. Effective barrier, even if wet, allow air and water vapor circulation for the comfort.
There is no ideal surgical clothing as yet. Uh, any particular material has got some benefits, so it has also got some disadvantages. One important buzzword here is moist bacterial breakthrough. It is the direct migration of bacteria through wet clothing. You need to bring in that term if you're discussing clothing or draping. So different types of clothing which are available in the theater at the moment.
Gotten the old ones, the reusable cotton gowns no longer used very frequently. Uh, these are comfortable to wear as they are open pore, but the polls are more than 80 microns. And they lead to my free migration of bacteria, which is not a desirable thing. They have mostly been done away with. Now, different types when I'll go to text, these are all mentioned in the general textbook, but basically the commonest type which are used are the disposable non-woven ones, which the open structure.
Basically, it is a non-woven open structure with different layers, so it essentially traps the bacteria or the particle. Carrying bacteria has some protection against the moist breakthrough, and it also allows air and water vapor circulation because of being an open structure. The only downside is these are single use disposable gowns. But then again, it may be an advantage also, because if it is a single use garment, it cannot.
Cause cross-infection. Body exhaust systems and use of surgical helmets. A definite evidence is they provide protection to the surgeon. No conclusive evidence as to a reduction in surgical site infection. Now, coming on to the two different types, the body exhaust system, which was by John Lee, that was a negative pressure system, so the pressure hose was connected to the helmet.
It used to create a negative pressure around the person. The gown and the helmet was on one single piece. And this? Was supposed to reduce the. Squabs or the shedding of particles from the surgeons or OR personnel skin. Leading to a reduction of infection, the newer ones, the surgical helmets with a full face shield.
These are a positive pressure system, essentially the taking ear from the top and the it down the person's face and along the body onto the ground. Now, there has. It has been proved that this is better in terms of protection to the surgeon. But as yet, no conclusive evidence whether it prevents surgical site infection. But again, as per the current trends, we would continue using it until there is evidence to refute it that it does any harm.
Coming on to skin preparation. Well, there are as many ways of preparing the skin as there are surgeons. The important thing here is what is the skin and sepsis skin anti sepsis is to reduce the bacterial and viral load. We cannot eliminate or sterilize the skin. We cannot 100% make it sterile, so we can only reduce the bacterial and viral load.
And antiseptics are disinfectants that are used on living tissue. The commonly used antiseptics are. Either force iodine containing compounds, potent broad spectrum, rapid acting bactericidal agents, they are active against spore fungi and viruses, but rapidly inactivated by blood feces or pus. Alcohol rapidly active against a broad spectrum of gram negative and gram positive bacteria that it is inactive against wider sense.
The action of alcohol. It doesn't have a residual action, so it works only as long as it is on the skin. Once it dries out, the bactericidal action is over chlorhexidine. It's this big compound with bactericidal and bacteria. And against bacteria, fungi, lipophilic viruses, activity is sustained in blood and presence of pus.
These are NICE guidelines. So alcohol based solution of chlorhexidine is the first choice. If it is not contraindicated or the surgical site is next to mucous membrane, if the surgical site is next to mucous membrane, an aqua solution of chlorhexidine, if chlorhexidine is contraindicated alcohol based protein iodine or if alcohol based solution or chlorhexidine are unsuitable echos solution of poverty and iodine.
Basically, you've got two choices. They or chlorhexidine. You've got two choices alcohol and equus if mucous membrane, no alcohol, if open wounds, no alcohol, only eco solutions, first choice alcohol based chlorhexidine stick to this simple principle should answer the question. Coming on two trips. The communist drapes are body drapes.
The non-woven disposable drapes, which we use day in, day out. I don't think the cotton drapes are used anywhere anymore. The controversy is about the use of seasonal drapes. NICE guidelines clearly says only idle for impregnated drapes to be used, and there is no evidence that it decreases the incidence of surgical site infection. This is a recent reference iPhone.
This is from jabalpur, b.c., one of the big names in infection, especially in other places. This was 2016 article reapplication of a skin preparation solution after draping and before the application of either for impregnated, incisive trade resulted in a significant reduction in the rate of SSI in patients undergoing elective joint replacement.
Use of masks. Do we use masks? Yes, all of us do. Is there in evidence? Probably not. There is no evidence to that. Masks reduce infection or fish, even facial contamination. A very interesting study I found was which says that a naked surgeon sheds minimum swans.
Which is similar to an unmasked surgeon, so basically a mass use of masks is common sense, and then the boy guidelines says that anyone, everyone in the theater during arthroplasty must wear a mask during the surgery. One important thing is masks get contaminated easily, so they should be replaced after each case. So you need to wear a new mask after every case.
Use of gloves. Use of double gloves without gloves changed frequently at the moment is best practice. The commonly used latex gloves provide excellent tactile feel and comfort. Latex allergy is not uncommon. And for people who are allergic to latex, the patients or the surgeon, the other options are polymer gloves like neoprene poly isoprene or polyurethane.
Some details are in the book, I think a mention of names that there are alternatives which have some advantages, as well as disadvantages. I just wanted to mention the Kevlar impregnated puncture resistant gloves, which are useful in certain cases in particular if there is a high suspicion of bloodborne virus diseases. Prophylactic antibiotics.
No, this was an MRC trial. If you look at it the first or the measures which really changed the incidence of surgical site infection, the first one is an antibiotic loaded cement and the second one is systemic antibiotics. And if you look at the magnitude of change, which is much higher than ulnar claw in theater plastic isolators, body exhausts suit so use of systemic antibiotics has brought about a major change in the incidence of surgical site infection.
One of the important things to see here is the NICE guidelines. The nice guideline says that clean surgery involving placement of prosthesis or implants must receive prophylactic antibiotic no antibiotics for clean Non Prosthetic surgeries. Single dose administered intravenously at induction of anesthesia.
If the surgery is going to be under tourniquet, the timing has to be a little bit before the induction. It's imperative to give a repeat dose if duration of surgery is prolonged. More than half life of the antibiotic administered and antibiotic treatment needs to be given to patients who have dirty or infected wounds.
One important thing, which I could find was this reference, which says that the entrance to the criteria for prophylactic antibiotic has not been offered. So what happens is if this has been audited by and reported in this paper in 2018 that no more than 50% to 55% compliance was found even in centers in Europe.
And if they did an audit and then they proactively told the people who were involved in direct patient care that they are doing an audit and looking at the compliance rate, they found that the results improved. So what are the important bits is the use of prophylactic antibiotics, if done correctly, has a good impact on the results.
Not prevention of cross-infection between cases, the floor and the surface in contact with the patient needs to be decontaminated with detergents. Contamination with body, blood or bodily fluids. Detergents for small spills, clothing, releasing agents for larger spills, known case with or without MRSA. As is common sense placed last on the list, they are usually recovered in the theater to avoid cross contamination.
The equipment and staff in the theater during the case should be kept to a minimum to avoid contamination and terminal clean of all services fixtures. And equipments with detergent and cloning, releasing agents and the theater is ready to use again once all the surfaces touched by. Now, the surgical safety checklist, where WHO is not a part of theater design, but it has become a part of our daily routine, so I just brought it in.
If you feel you are running, you still have time on hand and you are running out of steam. You can follow and do this surgical safety checklist. Talk about it. Talk about before induction, before skin skin incision, before the patient leaves the theater. The data, which has been collected after the introduction of surgical safety checklist has actually confirmed one of the recent papers from USA has confirmed that there was 52% lower 30 day mortality.
Once the safe surgical safety checklist was implemented in the hospital. So it's quite encouraging data so can be brought in. To sum up, basically, you're answering a question in the exam sum up zones outside clean, aseptic disposal for zones temperature 19 to 20 degrees Celsius in the theater with patient warming humidity 40% to 60% Lighting 40,000 to 160 laps, ceiling mounted.
Not shadowless lights, ventilation, the types of ventilation Downs, non-woven use, the terms must break through body exhaust suits. Mask and gloves, w or double gloves. Drapes, non-woven discussable, incisional drapes and their control sea ice cream preparation. Chlorhexidine adding equals alcohol prophylactic antibiotics advocacy. How much do you need?
When do you need it? When to be administered? How to make sure that it has been administered. Prevention of cross-infection mentioned about infective cases. What to do. WHO checklist. I think that.
Thank you very much, Samir. That was very thorough. Yet you kept the time and I think it was well explained, very good examples. Before we move to the questions, I'll give another chance for people who want to be questions as part of the Viva. Please raise your hands. We've got already one volunteer.
Moving on to the questions and this is open to all the mentors. The first question, which is about the. Laminar flow, the power flow he was talking about the diagram, he says that the arrows show the air flowing onto the patient. However, you seem to have explained that it should be going away from the patient and could you go back to that point and explain it again?
Yeah so I have got this picture in front. The red arrows are the Clean Air shadows, which are the center shadows. The center arrows, the arrows, which are in the center of the diagram. These are the Hepa filter. These arrows denote the Hepa filter air, which come on directly to the patient. And all the air which comes, which is hitting the patient and then flows out.
That is what the idea of forward flow is. Now these are ideal situations. These pictorial diagram, these are ideal situations of how exactly the flow must behave. But in essence, actually what happens is there are so many things which affect the flow of air. One of the important things is we have ceiling mounted lights. Now the canopy of the light covers the laminar flow in an area, so the laminar flow gets obstructed by it and then reforms, but it does not stay as non turbulent as it should be.
Second thing is, when we operate on a patient, we don't operate standing upright like a statue, but we do tend to bend over the patient a little. Now, overhead with the hoods on does cause a turbulence in the air. So all these factors. Next question is why not use alcohol based on open wounds? And that is for smear and all the mentos?
Right why don't we use when we clean abscesses or open wounds, why don't we use alcohol or that we use axilo energy? So betadine or products today do things that I know about alcohol one, it is a very strong irritant to. It is a desiccant. So basically it will dry out the mucous membrane. It will dry out the tissue and it is an irritant to the mucous membrane.
So you can increase the damage to the mucous membrane or the open wound. That's what I would have a different view. Uh, there is another issue with alcohol. The main problem is Yes. Apart from being an irritant is that pooling on the wound and risk of burns. That's a very important. If you do alcohol with determination, you are going to get burned inside the wound, and that's a very important safety issue here.
So this is a bit this is 11th April 2019. They have published a new nice guideline. And I would recommend all of them, all of you who are appearing in exams this year to quickly glance through this and maybe go through the basic moot points, you don't have to read the whole guidelines. Basic moot points would be as submitters, as mentioned in his talk, like how to prepare your surgical side, what is a recent antibiotic prophylaxis guideline?
What is specific about arthroplasty in uk? Because we all go about our tuberosity and I don't think there is any major change, but best that you guys glanced through it before your exam. Yet whenever there is a new guidelines, new ghost guidelines, new issue in the media, it usually comes in strongly in the exam, logically because they want to create awareness. And they know that one way of making this awareness is to ask people and then they would panic and go and read about it until other people and other people will start reading about it.
So this is one way of doing it, so it's a very strong point. Good going back, can you? OK, we leave on so people can have time to read that. Any other questions from any attendants, please. Fine, I will stop the recording now.
Segment:0 .
Sameer has lost his efforts recently in April, and he works in banga, and his talk, as I said, is about theater design. Without any further ado, I believe the Mike to Samir, please. Hello, everyone. My name is Samir Agarwal.
I'll be talking on theater design quite often. Topic what I have seen is it usually starts with a picture like this. Tell me what you see. First time when I was in one of her courses and I was shown this picture, I was quite disturbed what to talk, how much to talk, should they talk around, then basically what I realized was need to see the picture.
Take it as a prop. So basically, what you see is just a prop. Once you have. Seen the picture try to identify what the lead bit of the question is going to be. Usually no tricks, if they show you a theater, they want you to talk about the theater design. Right one of our we always think that if we see a question which we know a lot about, we should start talking immediately, give yourself about 5 seconds.
Plan your answer. That's very important, formulator reply, how you are going to approach this question, you know, everything about the topic. You want to show them that, you know, everything about the topic. So if you have a structure of your answer that is going to take you in a very strong position. And another a very small point, I think sometimes we miss.
Stop looking at the picture all through your talking, once you have seen the picture, once you know what you're going to talk about. You have taken your 5 seconds to look at the picture in the meantime, formulating your answers. Stop looking at the picture. Look at the examiner's. You are applying to the examiners, you're not replying to the picture.
That's really important. One thing I felt sometimes helps is if you lose your track, if you lose what you were talking about in Midway. Quick glance at the picture. You know, you have talked about lighting, you have talked about this, you have talked about that, oh, you are not talking about one particular thing. That picture can give you that clue, but don't stare at it.
Don't keep looking at it. So what is the purpose of a separate orthopedic theatre? It provides an ultra clean operating conditions. It maintains a very high level of sepsis. It provides adequate space for personal multiple trains, additional equipments like Sia and. The importance is the condition should be optimum for the patient, for the best results, and it should be comfortable through the OR personnel who are working there.
So basically, this is not directly related to the theater design, but this is the principle of theater design. So these are the things which need to be satisfied when you're designing a theater. Again, coming back to the structure of the replay. I tend to think of the bullet points as pigs. Each bullet point is a peg in my mind.
The think of a peg, hang on an explanation to that peg. Normally, if you look at the list, it's a very long list. Zones, temperature, humidity, light ventilation, so on, so forth. What happens is if you have a long list in your mind, you can't recall everything in the heat of the examination. You can still recall at least top three, four, five. If you can do that, if you start speaking on topic one, say subtopic one zones, now you remember your zones, you speak on your zones, you have done that for 15, 20, 30 seconds.
Go on to the next one and go on to the next one. You have already spoken to 2 and 1/2 minutes without being prompted. That's what we are trying to in. We are going to speak on a particular topic very sensibly containing facts, not talking anything which is not related and still have a minimum prompting. That is what is going to fetch the box.
So looking at this picture zones. We this is directly from RAM children's basic orthopedic sciences, nothing new in here. The theater zones are divided into four. The outside zone is anything outside the theater area, so which means all of the hospital, including the theater reception. The corridors inside the theater reception is the clean corridor.
The operating table and all the immediate adjoining areas are the aseptic zone. And then there is the disposal zone, which is supposed to be the unclean area directly related. So the best thing is during what you can mention is the disposal zone should be cordoned off or kept closed during the period of surgery. It should not be open.
Once you have mentioned the zones, the next thing we mention is about temperature. No why temperature regulation is important in the theater. One, it needs to provide a comfortable theater environment to the search surgeon and other personnel. Do we have. Hypothermia in patients directly related to increased incidence of infection, the contributing factors could be paralysis, IV fluids or large open wounds.
Now, these are two conflicting aims to be achieved ideal temperature for a surgeon is about 19 to 20 degrees. Anything warmer makes you feel very warm or stuffy. But if the patients are kept at this temperature, they become hypothermic. No, this is achieved by creating a microclimate around the patient using either a warmer. A blanket or what is commonly used in our theaters?
The bear. One of the problems of using these. Well, warming devices around the patient is it alters the airflow, particularly if you look at the warm air blower, which is used in the theater. It is usually placed within the zone of the laminar flow, and it disrupts the flow of air around the patient and can interfere with a smooth flow.
One of the important factor is it is important to maintain ideal temperature in order to species as. Not only the setting time of the segment, but also the mechanical properties of cement is dependent on the ambient temperature. When the cement is stored, prepared and applied. So if the theater temperature is too high, it impedes the mechanical properties of the cement.
Humidity, no humidity is. Percentage of moisture in the air, ideally is 40 to 60 degrees. A higher humidity accelerates the setting time of bone cement, thus reducing the working time there has been some reports in. Uh, well, it seems that a lower humidity increases the chances of electronic equipment failure.
Humidity is indirectly controlled mainly by the temperature and the ventilation regulation. But in an ideal operation theatre, there has to be a monitoring of the humidity. Lights, operating theater lights are very important. Gone are the days when surgeons would operate in candlelight or in the light of day, filled with a jar of fireflies.
Now we have dedicated operating lights. There are three very important key attributes to operating lights. Adjustability brightness and control. Adjustability of the light means essentially the light can be focused into the area of surgery. So suppose we are operating on a hand. You need a very small area of focus of the light, whereas if you are doing a hip out plaster, you need a larger area.
This adjustability of the light should be possible. The brightness should be enough. There should be a uniform illumination of 40,000 lights or more. And the brightness of the light could be controlled. One important aspect of modern theater lights is color rendition. The artificial lights do tend to change the color of the object they fall on, so the better the quality of the light, the more true is the color rendition of the issues, which helps identify the different issues.
One important aspect is the peripheral lights in the theater should be bright enough to avoid a very sharp contrast between the light and the dark areas. So if we're working in the canopy area and the outside lights are very dark, it provides undue strain on the AIIS. So if the theater is uniformly lit, it helps our AIIS.
Ventilation, very important concept. Take some time to elaborate on this. Because this is where quite a significant number of points and important factors are one of the most important things to say is the Communist. Contamination comes from airborne particles, and the source of these particles is the personal indicator.
It is shed from the body. It has been found that 90% comes below the neck. The ventilation is responsible for controlling the temperature, the humidity and the level of airborne contamination. It is. In the guidelines to do an air quality monitor, monitoring in cases of ultra clean theater, it should be done at least every three months.
That and it is done by calculating the bacteria carrying particle per cubic meter at this point, if you remember, you can mention about microbiological strip sampler that essentially draws air over culture plates in a specified quantity. And then these culture plates are incubated for 48 hours, and the Colony Forming units are calculated. So in a normal operation theatre, the CFA units per cubic meter is about 30 five, whereas to define a theater as an ultra clean theatre, which is the aim of all orthopedic theatres, especially where arthroplasty are performed, it should be less than 10 CFU in the centre, which means in the area just around the operating theater.
Now, this is a picture of a plate in which 1,000 liters of air sample in an empty theater. And this is what happens when a person walks by. So this just denotes how much of the contamination comes from the personnel who are in the theater. Well, the various ventilation methods are being designed and developed and researched to reduce this.
Well, the concept here is plenum. What do we mean by plenum circulation or plenum ventilation? It is a system of mechanical ventilation in which fresh air is forced into the spaces to be ventilated from a chamber at a pressure slightly higher than the atmospheric pressure. So essentially, what it means is you have an area of high pressure, which is your operating room, and all the adjoining areas are at a slightly lower pressure.
So the flow of the air is unidirectional from the operating theater to the areas outside. This positive pressure gradient is always maintained in the theater. If you look at the picture, which I have it. Actually shows in these blue figures, blue figures, the partial pressure of the air in that particular area, and if you look at it, operating room has a high pressure area.
The disposal area has got a minus. So it essentially does not allow any air from the disposal area to come into the operating room. Now, this positive pressure, gredyd is affected by opening of the doors. And when the and it also depends on the size of the load, which are open, so when bigger doors are open, the pressure gradient drops. And it can allow some mixing of the air.
Laminar flow. We all know what laminar flow is. The definition of laminar flow, an entire body of air within a designated space, moving with a uniform velocity in a single direction along parallel flow lines. I need to remember that we need to remember a few key words here.
Entire body of air is 1 designated spaces to uniform velocity, three single direction, full and parallel flow lines. Five break it up. Remember it? This is important. You may be asked a direct question what is laminar flow? So I to my belief, I think you need to get these buzzwords in the definition once you have done that.
You probably the examiner knows what you're talking about. No, the laminar flow, again, this picture is just a graphic representation of what exactly laminar flow means, and the green area is the true laminar flow. And you can see when it hits the personal or objects around it, it changes into different colors. That is when the turbulence comes in. And as it goes towards the periphery, the turbulence increases so much that it totally loses the laminar flow quality of the air.
Now, what does this do to the air quality will come later? No, the three types of laminar flow mentioned is horizontal, laminar flow, vertical laminar flow or the X. The third one is X flow or exponential flow or the hover enclosure. At this point, you can mention a room in room concept that usually not the entire operation theater has a laminar flow system.
It is a part of the operation theatre, which is just adjoining. The operation table has the laminar flow, which is the center of the theater. Now coming to each one in slight more detail, horizontal laminar flow. As the name suggests, you have the Hepa filters placed onto one wall of the operation theater.
The floor is horizontal from one wall to the other. The important paper here is celebrated in 1982 said that horizontal air flow reduced infection rates in the r, but it increased the infection rates in the TKR. The explanation has given in Ramachandran says that it is probably something to do with the placement of personnel in the theater in the line of the flow. Again, if you look back to the picture, which I've shown before as you introduce people in the part of the laminar flow, it changes into turbulent flow and this probably has a bearing on it.
Anyhow, it's not commonly used in automatic operation theaters. This is a common type of. A laminar flow used it is ceiling mounted system, vertical, laminar flow, partial enclosure. What we mean by partial enclosure is essentially that. Part of the.
Room has got this laminar flow system, and this laminar flow system is segregated by partial height walls on all the four sides. So the air within the enclosure remains laminar or non turbulent. But when we introduce human personnel within that, the air which hits these personal flows back towards the patient.
And this also brings outside air, which is known as the air entrainment. It's basically the viscous flow of the air, which comes along. I don't know. Am I being clear on this? If anybody has a question, put it up, I'll try to explain it further. But it's essentially that this type of vertical laminar flow has the inherent problem of air entrainment, which brings in unclean air from the outside of the enclosure into the enclosure.
The next was the axilo or the Herbert enclosure. Now, if everybody has seen a trumpet, so the airflow is in the shape of an inverted trumpet, a trumpet. So essentially what it means is the air flows from the center and it is centrifugal in the flow. So the air doesn't float towards the patient, but it all, it's always flowing away from the patient.
Essentially, what it achieves is if you have. The patient in the center, the wound open, which is in or around the center of the operating enclosure. The air keeps flowing away from the patient and we try to reduce the airborne contamination into the wounds, which is essentially the aim of all of this exercise. Recent evidence at best, there is conflicting evidence.
If you look into the literature. There is literature both supporting as well as refuting the evidence of decreased incidence of surgical site infection with the use of ultra clean, laminar flow theaters. No if you look closely into this data, it is not exactly Black and white. Most of these areas are still gray.
So my exam answer would be it is desirable to use an ultra clean operation theater with a laminar flow for all my major surgeries, particularly out of plastic surgeries, unless more definitive evidence comes into light. One important point here, which I found was it is not a replacement to strict adherence to aseptic technique, prophylactic antibiotic surgical discipline, meticulous tissue handling and prevention of hypothermia.
So these things use of an ultra clean operation theater is not a substitute, but it is just an adjunct to these techniques of preventing surgical site infection. Clothing and drapes. No surgical clothing, an ideal surgical clothing is prevent airborne bacterial dispersion. Effective barrier, even if wet, allow air and water vapor circulation for the comfort.
There is no ideal surgical clothing as yet. Uh, any particular material has got some benefits, so it has also got some disadvantages. One important buzzword here is moist bacterial breakthrough. It is the direct migration of bacteria through wet clothing. You need to bring in that term if you're discussing clothing or draping. So different types of clothing which are available in the theater at the moment.
Gotten the old ones, the reusable cotton gowns no longer used very frequently. Uh, these are comfortable to wear as they are open pore, but the polls are more than 80 microns. And they lead to my free migration of bacteria, which is not a desirable thing. They have mostly been done away with. Now, different types when I'll go to text, these are all mentioned in the general textbook, but basically the commonest type which are used are the disposable non-woven ones, which the open structure.
Basically, it is a non-woven open structure with different layers, so it essentially traps the bacteria or the particle. Carrying bacteria has some protection against the moist breakthrough, and it also allows air and water vapor circulation because of being an open structure. The only downside is these are single use disposable gowns. But then again, it may be an advantage also, because if it is a single use garment, it cannot.
Cause cross-infection. Body exhaust systems and use of surgical helmets. A definite evidence is they provide protection to the surgeon. No conclusive evidence as to a reduction in surgical site infection. Now, coming on to the two different types, the body exhaust system, which was by John Lee, that was a negative pressure system, so the pressure hose was connected to the helmet.
It used to create a negative pressure around the person. The gown and the helmet was on one single piece. And this? Was supposed to reduce the. Squabs or the shedding of particles from the surgeons or OR personnel skin. Leading to a reduction of infection, the newer ones, the surgical helmets with a full face shield.
These are a positive pressure system, essentially the taking ear from the top and the it down the person's face and along the body onto the ground. Now, there has. It has been proved that this is better in terms of protection to the surgeon. But as yet, no conclusive evidence whether it prevents surgical site infection. But again, as per the current trends, we would continue using it until there is evidence to refute it that it does any harm.
Coming on to skin preparation. Well, there are as many ways of preparing the skin as there are surgeons. The important thing here is what is the skin and sepsis skin anti sepsis is to reduce the bacterial and viral load. We cannot eliminate or sterilize the skin. We cannot 100% make it sterile, so we can only reduce the bacterial and viral load.
And antiseptics are disinfectants that are used on living tissue. The commonly used antiseptics are. Either force iodine containing compounds, potent broad spectrum, rapid acting bactericidal agents, they are active against spore fungi and viruses, but rapidly inactivated by blood feces or pus. Alcohol rapidly active against a broad spectrum of gram negative and gram positive bacteria that it is inactive against wider sense.
The action of alcohol. It doesn't have a residual action, so it works only as long as it is on the skin. Once it dries out, the bactericidal action is over chlorhexidine. It's this big compound with bactericidal and bacteria. And against bacteria, fungi, lipophilic viruses, activity is sustained in blood and presence of pus.
These are NICE guidelines. So alcohol based solution of chlorhexidine is the first choice. If it is not contraindicated or the surgical site is next to mucous membrane, if the surgical site is next to mucous membrane, an aqua solution of chlorhexidine, if chlorhexidine is contraindicated alcohol based protein iodine or if alcohol based solution or chlorhexidine are unsuitable echos solution of poverty and iodine.
Basically, you've got two choices. They or chlorhexidine. You've got two choices alcohol and equus if mucous membrane, no alcohol, if open wounds, no alcohol, only eco solutions, first choice alcohol based chlorhexidine stick to this simple principle should answer the question. Coming on two trips. The communist drapes are body drapes.
The non-woven disposable drapes, which we use day in, day out. I don't think the cotton drapes are used anywhere anymore. The controversy is about the use of seasonal drapes. NICE guidelines clearly says only idle for impregnated drapes to be used, and there is no evidence that it decreases the incidence of surgical site infection. This is a recent reference iPhone.
This is from jabalpur, b.c., one of the big names in infection, especially in other places. This was 2016 article reapplication of a skin preparation solution after draping and before the application of either for impregnated, incisive trade resulted in a significant reduction in the rate of SSI in patients undergoing elective joint replacement.
Use of masks. Do we use masks? Yes, all of us do. Is there in evidence? Probably not. There is no evidence to that. Masks reduce infection or fish, even facial contamination. A very interesting study I found was which says that a naked surgeon sheds minimum swans.
Which is similar to an unmasked surgeon, so basically a mass use of masks is common sense, and then the boy guidelines says that anyone, everyone in the theater during arthroplasty must wear a mask during the surgery. One important thing is masks get contaminated easily, so they should be replaced after each case. So you need to wear a new mask after every case.
Use of gloves. Use of double gloves without gloves changed frequently at the moment is best practice. The commonly used latex gloves provide excellent tactile feel and comfort. Latex allergy is not uncommon. And for people who are allergic to latex, the patients or the surgeon, the other options are polymer gloves like neoprene poly isoprene or polyurethane.
Some details are in the book, I think a mention of names that there are alternatives which have some advantages, as well as disadvantages. I just wanted to mention the Kevlar impregnated puncture resistant gloves, which are useful in certain cases in particular if there is a high suspicion of bloodborne virus diseases. Prophylactic antibiotics.
No, this was an MRC trial. If you look at it the first or the measures which really changed the incidence of surgical site infection, the first one is an antibiotic loaded cement and the second one is systemic antibiotics. And if you look at the magnitude of change, which is much higher than ulnar claw in theater plastic isolators, body exhausts suit so use of systemic antibiotics has brought about a major change in the incidence of surgical site infection.
One of the important things to see here is the NICE guidelines. The nice guideline says that clean surgery involving placement of prosthesis or implants must receive prophylactic antibiotic no antibiotics for clean Non Prosthetic surgeries. Single dose administered intravenously at induction of anesthesia.
If the surgery is going to be under tourniquet, the timing has to be a little bit before the induction. It's imperative to give a repeat dose if duration of surgery is prolonged. More than half life of the antibiotic administered and antibiotic treatment needs to be given to patients who have dirty or infected wounds.
One important thing, which I could find was this reference, which says that the entrance to the criteria for prophylactic antibiotic has not been offered. So what happens is if this has been audited by and reported in this paper in 2018 that no more than 50% to 55% compliance was found even in centers in Europe.
And if they did an audit and then they proactively told the people who were involved in direct patient care that they are doing an audit and looking at the compliance rate, they found that the results improved. So what are the important bits is the use of prophylactic antibiotics, if done correctly, has a good impact on the results.
Not prevention of cross-infection between cases, the floor and the surface in contact with the patient needs to be decontaminated with detergents. Contamination with body, blood or bodily fluids. Detergents for small spills, clothing, releasing agents for larger spills, known case with or without MRSA. As is common sense placed last on the list, they are usually recovered in the theater to avoid cross contamination.
The equipment and staff in the theater during the case should be kept to a minimum to avoid contamination and terminal clean of all services fixtures. And equipments with detergent and cloning, releasing agents and the theater is ready to use again once all the surfaces touched by. Now, the surgical safety checklist, where WHO is not a part of theater design, but it has become a part of our daily routine, so I just brought it in.
If you feel you are running, you still have time on hand and you are running out of steam. You can follow and do this surgical safety checklist. Talk about it. Talk about before induction, before skin skin incision, before the patient leaves the theater. The data, which has been collected after the introduction of surgical safety checklist has actually confirmed one of the recent papers from USA has confirmed that there was 52% lower 30 day mortality.
Once the safe surgical safety checklist was implemented in the hospital. So it's quite encouraging data so can be brought in. To sum up, basically, you're answering a question in the exam sum up zones outside clean, aseptic disposal for zones temperature 19 to 20 degrees Celsius in the theater with patient warming humidity 40% to 60% Lighting 40,000 to 160 laps, ceiling mounted.
Not shadowless lights, ventilation, the types of ventilation Downs, non-woven use, the terms must break through body exhaust suits. Mask and gloves, w or double gloves. Drapes, non-woven discussable, incisional drapes and their control sea ice cream preparation. Chlorhexidine adding equals alcohol prophylactic antibiotics advocacy. How much do you need?
When do you need it? When to be administered? How to make sure that it has been administered. Prevention of cross-infection mentioned about infective cases. What to do. WHO checklist. I think that.
Thank you very much, Samir. That was very thorough. Yet you kept the time and I think it was well explained, very good examples. Before we move to the questions, I'll give another chance for people who want to be questions as part of the Viva. Please raise your hands. We've got already one volunteer.
Moving on to the questions and this is open to all the mentors. The first question, which is about the. Laminar flow, the power flow he was talking about the diagram, he says that the arrows show the air flowing onto the patient. However, you seem to have explained that it should be going away from the patient and could you go back to that point and explain it again?
Yeah so I have got this picture in front. The red arrows are the Clean Air shadows, which are the center shadows. The center arrows, the arrows, which are in the center of the diagram. These are the Hepa filter. These arrows denote the Hepa filter air, which come on directly to the patient. And all the air which comes, which is hitting the patient and then flows out.
That is what the idea of forward flow is. Now these are ideal situations. These pictorial diagram, these are ideal situations of how exactly the flow must behave. But in essence, actually what happens is there are so many things which affect the flow of air. One of the important things is we have ceiling mounted lights. Now the canopy of the light covers the laminar flow in an area, so the laminar flow gets obstructed by it and then reforms, but it does not stay as non turbulent as it should be.
Second thing is, when we operate on a patient, we don't operate standing upright like a statue, but we do tend to bend over the patient a little. Now, overhead with the hoods on does cause a turbulence in the air. So all these factors. Next question is why not use alcohol based on open wounds? And that is for smear and all the mentos?
Right why don't we use when we clean abscesses or open wounds, why don't we use alcohol or that we use axilo energy? So betadine or products today do things that I know about alcohol one, it is a very strong irritant to. It is a desiccant. So basically it will dry out the mucous membrane. It will dry out the tissue and it is an irritant to the mucous membrane.
So you can increase the damage to the mucous membrane or the open wound. That's what I would have a different view. Uh, there is another issue with alcohol. The main problem is Yes. Apart from being an irritant is that pooling on the wound and risk of burns. That's a very important. If you do alcohol with determination, you are going to get burned inside the wound, and that's a very important safety issue here.
So this is a bit this is 11th April 2019. They have published a new nice guideline. And I would recommend all of them, all of you who are appearing in exams this year to quickly glance through this and maybe go through the basic moot points, you don't have to read the whole guidelines. Basic moot points would be as submitters, as mentioned in his talk, like how to prepare your surgical side, what is a recent antibiotic prophylaxis guideline?
What is specific about arthroplasty in uk? Because we all go about our tuberosity and I don't think there is any major change, but best that you guys glanced through it before your exam. Yet whenever there is a new guidelines, new ghost guidelines, new issue in the media, it usually comes in strongly in the exam, logically because they want to create awareness. And they know that one way of making this awareness is to ask people and then they would panic and go and read about it until other people and other people will start reading about it.
So this is one way of doing it, so it's a very strong point. Good going back, can you? OK, we leave on so people can have time to read that. Any other questions from any attendants, please. Fine, I will stop the recording now.
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