手术学-无菌术.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,无 菌 术,ANTISEPSIS,无菌术,无菌术的历史,无菌术的概述,抗菌,灭菌,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,古代手术场景,感染非常常见，以至于认为是不可避免的甚至是愈合过程中的必然过程,也有些措施，如火烧，油烫，油膏,The Agnew Clinic,The Agnew Clinic,distinguished surgeon,Dr.David Hayes Agnew,on the eve of his retirement from the University of Pennsylvania Medical School.The surgical team is set off from the attentive students by the illumination from an unseen source of daylight.A young member of the surgical team administers open drop ether vapors through a gauze cone to a limp female form.The surgical team labors as Dr.Agnew elaborates on his surgical technique for cancer of the breast.,The First Operation with Ether,The controversy over the invention of general anesthesia and the first public demonstration of diethyl ether at the Massachusetts General Hospital on October 16,1846 is matched by the uncertain origin of this recreation of the event by Robert Cutler Hinckley completed in Paris in 1892.,A photographer(daguerreotypist),Josiah Hawes,is said to have been so frightened that he was unable to record this momentous event.The First Operation with Ether is painted after the style of Thomas Eakins(1844-1916).The participants have been identified as:Gilbert Abbott,the patient;John Collins Warren,MD,the surgeon;William T.G.Morton,the anesthetist;and Henry J.Bigelow,MD,the junior surgeon.,Each one knew that he was a participant in medical history.The inscription on Mortons graveside monument pays tribute to him as the Inventor and Revealer of Anesthetic Inhalation.BEFORE WHOM In all time Surgery was Agony.BY WHOM Pain in Surgery was averted and annulled.SINCE WHOM Science has control of pain.The painting hangs in th,Billroth,The torch of modern surgery was lit by Christian Albert Theodor Billroth,MD(1829-1894)when he became chief of surgery at Allegemeines Krankenhause in Vienna.Billroth passed his techniques to many including William Stewart Halstead,MD(1852-1922)who in turn trained Harvey Williams Cushing,MD(1869-1939).Billroth reached his surgical fame during a,Belle,poque,of surgery due in no small part due to the introduction of ether and chloroform general anesthesia in the middle of the 19,th,century.The image painted in 1890 by Adalbert Franz Seligmann shows Billroth at the age of 60 demonstrating surgery in a brightly lit,operating theater to an admiring audience.Billroth,s eternal fame did not result from this operation for trigeminal neuralgia but from the complex abdominal surgery on the stomach and small bowel still referred to by his name.,The Operation,(1929),Christian Schad visited the operating rooms in Geneva and recorded his impressions in his painting titled,The Operation,(1929).Schad combines the precision of a medical illustrator with the shortened perspective and muted earth tones of the avant garde artists of his era.The carefully drawn surgical instruments and glistening red appendix(apparently normal)with adjacent caecum create a sense of realism and authenticity(Sachlichkeit).The surgical team consists of Dr.Haustein,his assistant and two nuns wearing brown rubber gloves.Although the nuns wear sectarian head covers,the scene describes a time before the widespread acceptance of surgical caps and masks.The facial expressions of the surgical team are without emotion.The patient,s eyelids are slightly closed as he rests comfortably under what is probably spinal anesthesia,无菌术的认识历程,Heppocrates(,公元前,460-377),：古希腊,化脓性伤口，非化脓性伤口，术前清洁。,Pasteur(1865):,法国，认识到微生物致病,Lister(1867):,英国，采用石炭酸消毒,Bergmann(1877):,德国，采用蒸汽灭菌,手术室空气消毒，器械消毒，无菌手术单，手套等无菌术内容日益完善,Pasteur,Proof that microbes are reproduced from parent organisms,and do not result from spontaneous generation,came from careful experiments in makeshift laboratories of Frances famed chemist and biologist,Louis Pasteur(1822-1895),at the Ecole Normale,Paris.Behind him are portraies of his father and mother,which he painted during his youth.Mme.Pasteur waits patiently for him to complete an observation.On the table is a replica of the experiment of Lizaro Spalanzani.Pasteur is holding one of his Swan-necked flasks.,Joseph Lister(1827-1912),When Surgeon Joseph Lister(1827-1912)of Glascow Royal Infirmary removed dressings from James Greenlees compound fracture,he found the wound had healed without infection-something unheard of before.For six weeks,Lister had treated the boys wound with carbolic acid.Now Listerhad proof of success of his principle of antisepsis-which was to revolutionize methods of treatment and to open new vistas in practice of surgery,of medicine,and of environmental sanitation.,Antony von Leeuwenhoek,draper of seventeenth-century Delft,Holland,in his spare time retired to his closet to observe the wonders of the microscopic world through tiny lenses he laboriously ground and mounted.He was first to report having seen animalcules-protozoa and bacteria-and to confirm by direct observation circulation of the blood.Through 200 years elapsed before practical application of his discoveries contributed to medicine,his work laid the foundation of modern medicines tremendous century-long onslaught against disease caused by bacteria and other microbiologic entities-a world-wide campaign which has resulted in saving millions of lives,.,William S.Halsted,He graduated from the College of Physicians and Surgeons in 1877.In 1881 he discovered that blood could be aerated and reinfused.He developed conduction anesthesia(1885)by experimenting with injecting his own nerve trunks with cocaine,a substance to which he subsequently became addicted(though later cured).At Johns Hopkins University he established the first surgical school in the U.S.An early champion of aseptic procedures,Halsted introduced the use of thin rubber gloves in surgery(1890).He emphasized homeostasis during surgery,gentleness in handling living tissue,and precise realignment of severed tissues.He originated the practice of hospital surgical residencies.,现代手术,切口感染率已控制在可接受的合理水平，,I,类切口感染率不到,3%,无菌术，细致手术，抗生素的应用,现代手术室的条件，层流技术的采用,无菌术,无菌术的历史,无菌术的概述,抗菌,灭菌,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,意义,医疗、生活和工作环境充满微生物：医院是病原微生物集中而且易于生长的场所。空气、地面、物品表面、墙面，患者和工作人员的体表。对外科手术是一大威胁,微生物导致的感染是最常见的疾病之一，一旦手术合并感染，痛苦甚至是死亡,无菌术是防止切口感染的基本措施,抗菌素不能代替无菌术,病原微生物,金黄色葡萄球菌,表皮葡萄球菌,肠道细菌，大肠杆菌，类杆菌，克雷百氏杆菌，铜绿假单胞杆菌，链球菌，肠球菌，厌氧球菌，等,感染的危害,局部组织破坏,全身中毒反应,干扰重要脏器功能,死亡,无菌术,在外科领域，针对切口感染致病微生物来源，及其感染途径所采取的一系列措施，称为无菌术。,由抗菌术，灭菌术，和一定的操作规程及管理制度组成。,反复反复,无菌观念是基础,无菌术是无菌观念具体的体现,非一朝一夕能够养成,从平时做起,无菌术,无菌术的历史,无菌术的概述,抗菌术和灭菌术,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,抗菌术,(Disinfection),又称消毒法，用化学方法消除或杀灭外科用品及体表、粘膜及表浅体腔的有害微生物。,有害微生物的数目减少到无害程度,不要求将所有的有害微生物消灭,所用的化学药物称为消毒剂,灭菌术,(Sterilizing),用物理或化学的方法杀灭一切活的微生物，包括致病菌，非致病菌。,微生物存活的概率减少到最低限度,对人体正常组织及受灭菌物品有一定不良损害，如改变药物成分，应用受到限制，,物理因子和药物，灭菌剂,灭菌方法,热力消毒,干热消毒（烧灼，干烤，红外线辐射灭菌）,湿热消毒（煮沸，低温蒸汽，高压蒸汽）,紫外线辐射消毒,:,空气消毒,电离辐射灭菌,超声波消毒,微波消毒,化学药品消毒法,醛类：甲醛，戊二醛，灭菌作用、,环氧乙烷：,含氯消毒剂：漂白粉,过氧化氢消毒剂：过氧乙酸,醇类：酒精,酚类：石炭酸，来苏尔,季铵盐类消毒剂：新洁而灭,碘类：碘酊，碘伏,70%,酒精,杀菌剂,皮肤、器械消毒,不适于手术器械消毒，不能杀灭芽孢,碘酊,碘和碘化钾的乙醇溶液,杀灭细菌，芽孢，病毒，原虫,2%,碘酊用于一般皮肤消毒,3.5-5%,碘酊用于手术野消毒,环氧乙烷,广谱杀菌剂，包括：细菌，芽孢，真菌，立克次氏体，病毒,穿透力强，对物品无腐蚀,熏蒸,2,小时,碘伏,紫黑色液体。是,碘,与表面活性剂的不定型结合物,0.30.5%,的碘伏用于手和外科皮肤消毒。广谱杀菌作用，可杀灭细菌繁殖体、芽孢、真菌和部分病毒,稀溶液毒性低，无腐蚀性。稀溶液不稳定，使用前配制，避免接触,银,、,铝,和二价,合金,戊二醛,广谱、高效、低毒消毒灭菌剂，它可以杀灭包括细菌芽胞、真菌孢子、分枝杆菌、病毒,(,包括甲肝、乙肝、艾滋病毒,),应用于医疗器械的冷灭菌和内窥镜的消毒,一般临床上应用,2%,戊二醛溶液在室温,25,下浸泡,30,分,60,分钟即达到消毒，,4,10,小时达到灭菌,无菌术,无菌术的历史,无菌术的概述,抗菌和灭菌术,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,手术室的消毒（非洁净手术室）,乳酸蒸熏法：每百立方米房间，用,12ml,乳酸，加清水,12ml,，放入蒸发器内，用酒精燃烧至乳酸烧干，房间封闭半小时，然后再开窗通风。（也有的采用甲醛蒸熏）,紫外线灯照射法：采用一定功率的移动式或固定式紫外灯照射，每天,2,次，每次,40,分钟。,臭氧消毒法：在手术室内安装臭氧发生器，手术完毕后，运行,30,分钟。,洁净层流手术室,原理：通过空调机组经粗、中、高效三级过滤器将手术室空气中细菌去除,采用空气洁净技术对微生物污染采取程度不同的控制，达到控制空间环境中空气洁净度适于各类手术之要求；并提供适宜的温、湿度。,高度洁净的空气（进入手术室的空气首先须经高效过滤器净化），能控制气流的流通方向（即采用层流超净装置），从洁净度高的手术区域流向洁净度低的区域，带走和排出气流中的尘埃颗粒（尘粒）和细菌,层流手术室是一个,“,正压,”,环境，,层流手术室洁净度,等 级,手术室 特别洁净 标准洁净 一般洁净 准洁净,洁净度级别,(,手术区,),100,级,1000,级,10000,级,300000,级,适用手术提示,关节置换手术、器官移植手术及脑外科、心脏外科和眼科等手术中的无菌手术,胸外科、整形外科、泌尿外科、肝胆胰外科、骨外科和普通外科中的一类切口无菌手术,普通外科,(,除去一类切口手术,),、妇产科等手,肛肠外科及污染,层流洁净手术室特点,低细菌数及低麻醉气体浓度,可提供舒适的气流,手术室正压气流防止外来污染的进入,室内空气清新、爽洁,一般情况下无需物理或化学方法进行消毒,院内感染率大大降低,噪音：成为层流手术室的一种噪音,造价较高，运行费用也较大，,无菌术,无菌术的历史,无菌术的概述,抗菌,灭菌,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,手术人员的术前准备,更换洗手衣裤和鞋，内衣的衣领和袖口卷入洗手衣内,带好无菌帽子和口罩，罩住鼻孔，盖住头发,修剪指甲,臂部有化脓性感染，不参加手术,手臂消毒法,肥皂刷手法：,用肥皂做一般的洗手。,用无菌毛刷蘸肥皂水刷洗手和臂，从手指尖到肘上,10cm,处，两臂交替刷洗，特别注意甲缘、甲沟、指蹼等处的刷洗。,手臂消毒法,肥皂刷手法,一次刷完后，手指朝上肘朝下，用清水冲洗手臂上的肥皂水。,反复刷洗,3,遍，共约,10,分钟。,手臂消毒法,肥皂刷手法,用无菌毛巾从手到肘部擦干手臂，擦过肘部的毛巾不可再擦手部。,用浸透碘伏的纱布涂擦手和前臂,1,遍，稍干后穿手术衣和戴手套。,穿,手术衣,戴手套,戴干手套：先穿手术衣，后戴手套。戴手套前，不能解除手套外面，戴好手套后不能接触皮肤,无菌术,无菌术的历史,无菌术的概述,抗菌,灭菌,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,手术野准备,备皮：,手术野消毒：,2.5-3%,碘酊,1,遍，酒精,2,遍,或碘伏：,2,遍,由内向外，由外向内,切口,15,公分区域,铺盖无菌巾单,手术巾：顺序，下对上我,中单，对齐中线，悬空，不污染,无菌术,无菌术的历史,无菌术的概述,抗菌,灭菌,手术室的消毒与清洁,手术人员的术前准备,病员的术野准备,手术进行中的无菌原则,手术进行中的无菌规则,手术衣的背部，肩部，脐部以下有菌区,未戴手套前，手不得接触手术衣和灭菌的手术物品,手术台边缘以下为有菌区,术中手套破，及时更换。,无菌单湿透需覆盖,术中未使用的器械，重新灭菌后才能用于他人，,手术进行中的无菌规则,术中污染的器械，需放于弯盘中，不能重新用于无菌区,术中人员换位方法,避免打喷嚏，咳嗽，不得已时，转头北向无菌区,参观者，勿太靠近手术人员，不要随意走动,手术行进中的无菌规则,手术切口的保护,胃肠道等空腔脏器切开前保护手术野和残面消毒,手术完毕后冲洗手术野和伤口,每个手术科室针对自身手术的特殊无菌要求，如口腔科耳鼻喉眼科的术野消毒，手术野的保护。,结 语,无菌术和无菌观念是每位医务工作者基本素质，而不仅仅是针对外科医生,致病微生物的污染是手术感染的主要原因，而无菌术是预防和减少这些感染的重要措施,抗菌素不能代替无菌术,