4.1 Introduction

Infection of the surgical field is currently the second most frequent cause of nosocomial infections. The word “nosocomial” comes from the Greek noso 'illness' and komenion, meaning “care of.” We might say that it is an illness caused by care, or rather one that arises from care.

Infection of the surgical field represents between 15 and 18% of infections in hospitalized patients. If we consider only surgical postoperative patients, it represents 38% of nosocomial infections. Sixty seven percent of cases involve infections of the surgical wound, and 33% affect an organ or cavity.

The transmission of infections requires three factors: a source of infectious microorganisms, a susceptible host, and a transport mechanism for the microorganism.

The sources of microbic agents in the surgical field are numerous. They are classified as endogenous and exogenous. Exogenous sources are those such as the surgical inventory or instrumentation, fungible material (gases, sutures, etc.), the surgical environment (furniture, floor, air), and medical personnel (hands, skin, mucous membranes, and clothing).

Endogenous sources are the patient's skin, contaminated or infected tissues, and remote infections.

Most surgical infections have an endogenous source, arising from the patient's own flora, such as the skin or places that are normally contaminated.

Almost all surgical infections are acquired during intervention, that is the etiological agents come to the patient from a specific source during the operation. Leaving aside the instrumentation and surgical material, which is assumed to be properly sterilized, we must emphasize the following sources of infection:

1. The environment. Contamination of air in the operating room because of technical problems, faults in air filtration, or lack of positive pressure in the operating room with respect to the corridors.
2. Medical personnel. The presence of people in the operating room produces secondary contamination of the air. Aerial dissemination of bacteria is facilitated by verbal communication during the operation, which can lead to cases of infection. A potential reservoir of infections via personnel are the hands. The use of gloves is an effective preventive measure.
3. The patient. The patient is the principal reservoir for the development of a surgical infection, through lack of hygiene, inadequate handling, and other circumstances, microorganisms reach the area of the surgical wound.

4.2 Measures for controlling infection

4.2.1 Objective

To prevent contamination of the operating room in order to diminish the risk of infection related to perioperative care.

Activities

• Maintain adequate operating-room dimensions of 6x6 meters and a height of 3 meters. Doors must be sliding, not jamb-type, to avoid the dispersal of dust particles.
• Doors must be of the sliding type.
• Maintain an ambient temperature between 18 and 20° C, with a humidity between 50 and 60%. Temperature- and humidity-monitoring systems must be available in every operating room.
• Ensure that the ventilation system is correct and is provided with filters to reduce particulates.
• Establish well defined walking areas.
• Ensure that operating-room air is measured periodically and ventilation-system filters are changed.
• Leave instruments and apparatus needed for the surgical procedure in the operating room.
• Surfaces must be easily cleaned.
• Avoid the presence of unnecessary people and movement in the operating room.
• Leave “dirty” procedures for the end of the day.
• Rigorous application of hygienic protocols.

4.2.2 Objective

To maintain the sterile field throughout preoperative care to reduce postoperative infections.

Activities

• Introduce sterile material into the sterile field through sterile procedures.
• Dispose of contaminated objects immediately.
• Maintain a safe space between sterile and contaminated objects.
• Create a sterile field as near as possible to the time it is used.
• Maintain and continually monitor the sterile field.
• Remove everything whose sterility is in doubt.
• Eliminate or resterilize material that has been opened and not used before using it for another patient.
• Pour sterile liquids from a sufficient height to avoid accidental contact between the nonsterile container and the receiving container.
• Consider only the top of the operating table to be sterile. Objects found under the table are considered contaminated.

4.2.3 Objective

To ensure proper sterilization of critical material (everything that comes in contact with sterile tissues or the vascular system, whether temporarily or permanently).

Activities

• Subject all material to rigorous cleaning in advance. Reducing dirt and organic material is essential for correct sterilization. Most disinfectants are not effective in the presence of organic material.
• Whenever possible, use material only once; this way we ensure maximum sterility, although it is important to mention that single-use material should under no circumstances be reused, except that which is not used but has lost its sterile conditions and which the manufacturer assumes can be resterilized.
• Always verify that material is correctly sterilized following directions, and observe expiration dates.

4.2.4 Objective

To prep the patient before the surgical procedure, to reduce the frequency of postsurgical infections.

Activities

• Reduce the hospital stay to the shortest possible time.
• Perform a thorough and careful shower with antiseptic soap the night before and on the day of the procedure, lathering gently with plenty of soap and rinsing thoroughly with water.
• Paint the operative area before going to the operating room, painting in a circular motion from the center to the edge. Once in the operating room, final antisepsis will be performed. It is important to observe the application time of the antiseptic, which coincides with the time it takes to dry.
• Ensure that the patient is not wearing jewelry on entering the operating room.
• Mark off with sterile tape to protect the clean field from the parts that have not been prepared.
• Regarding the removal of hair from the puncture or incision area, it has been shown that shaving with a conventional razor is associated with an increased risk of surgical infection. This is owing to colonization by microorganisms in the small cuts produced by shaving. It is preferable not to shave, or at least to do so moments before the procedure (two hours before at most). Another option is the use of depilatory creams or special machines that only cut the hair. The area to be shaved will be limited as much as possible.

4.2.5 Objective

To prepare surgical-area personnel to reduce the risk of perioperative infections.

Activities

• Wear uniforms that are only for the surgical area. Preferably cotton, which is comfortable and allows the skin to breathe.
• Use footwear that is only for the surgical area and change it if leaving, or better use leggings that are discarded when leaving the surgical area.
• Wear a cap to avoid shedding and falling of hair into the surgical field.
• Use masks to avoid expelling microorganism-laden drops from the nose and orofacial cavity into the field. If eye-protecting masks are available, they should be used as a standard precaution. If not, another system of eye protection should be used.
• Use gowns throughout the entire procedure. Gowns are to be considered sterile from the thorax to the waist in front and from the hands to above the elbows.
• Use sterile gloves and change them if their integrity is lost. Also change them in long procedures, as their porosity diminishes [sic] with time.
• Use nonsterile gloves before any contact with blood, secretions, or contaminated substances. They should be changed between patients after washing the hands, and also in different procedures with the same patient.

4.2.6 Objective

To perform proper hygienic hand-washing to eliminate dirt and transient microbes from the skin.

Activities

• Perform hygienic hand-washing at the beginning and end of the work day.
• Before and after eating.
• After using the toilet facilities.
• Before and after contact with patients, whether gloves are used or not.
• Always remove all objects on the hands, including watches and jewelry.
• Keep fingernails short and do not use nail polish. Cuticles should be in good condition.
• Always remove all objects on the hands, including watches and jewelry.
• Keep fingernails short and do not use nail polish. Cuticles should be in good condition.

4.2.7 Objective

To perform good surgical hand-washing to eliminate transient and resident microbes from the skin and inhibit microbial growth.

Activities

• Perform surgical hand-washing before surgical procedures, aseptic techniques, or any invasive procedure in sterile cavities. Also, and more specifically, before any operation on immunocompromised people.
• Wash the arms and forearms with antiseptic soap. It is important to scrub both the palm and the back of the hand, as well as the spaces between the fingers, not forgetting the wrists and forearms. Soaping will proceed from distal to proximal. Use a system of counting time or brush-strokes.
• Rinse thoroughly, keeping the hands up and away from the body. In this position, dry with a sterile cloth.
• Use faucets with foot, knee, or elbow handles, to allow operation without using the hands again.

4.2.8 Objective

To care for the skin of medical personnel. The use of very irritating antiseptic soap can damage the skin of medical professionals. These injuries alter the skin's natural microbiota, replacing them with gram-negative bacteria that are highly pathogenic and resistant to antibiotics.

Activities

• Use hydrating creams after the work day.
• It is not advisable to use them during the work day, as they contain petroleum derivatives and can increase the porosity of gloves.

4.2.9 Objective

To perform proper handling of medical waste to reduce the risk to health and the environment.

Activities

• Classify and collect the waste produced by medical activities into the recommended groups:
• Medical waste that may be combined with municipal waste (type 1), not calling for any special administrative measures. Included in this group are paper, office supplies, and cardboard. It is collected in receptacles specifically designated for recycling.
• Nonspecific medical waste (type 2):
  Measures must be taken for manipulating, collecting, storing, transporting, handling, and disposal. This group includes single-use material contaminated with blood, secretions, and/or excretions. They are collected in containers and receptacles that are completely airtight, opaque, resistant to breakage, completely aseptic externally, with a volume no greater than 70 liters and a special easily opened hermetic seal, and not easily opened by accident.
• Specifically hazardous medical waste (type 3):
  The measures from the previous group must be taken, both in the area where they are produced and outside it, as it presents a danger to the health of workers and the public. This group includes medical waste capable of transmitting an infectious disease, anatomical waste, blood and its derivatives, needles and cutting and piercing materials, and finally live and attenuated vaccines. It is collected in containers and receptacles with the same characteristics as those in group 2, and single-use polyethylene or polystyrene containers so that it may be completely incinerated.
• Waste characterized by exceptional rules (type 4):
  This is waste whose handling is subject to special requirements from the hygienic and environmental point of view, both within and outside of the center where they are produced. It includes cytostatic waste, remnants of chemical substances (thermometers, solvents, photographic products), expired medications, radioactive waste, and metallic waste.

4.3 Special situations

Use extreme care with patients:

• In shock
• Malnourished
• Uncontrolled diabetics
• Anemic
• Uremic
• Cirrhotic
• Some neoplasias, such as leukemia, can reduce the patient's resistance sufficiently to increase the possibility of bacterial proliferation and infection
• Patients with other active infections at the time of the operation, significantly increasing the risk of infection
• Of advanced age
• Obese
• Hospitalized for an extended period
• Lengthy procedures
• Patients with debilitating lesions
• Iatrogenic factors

[From ARGIBAY PYTLIK Virginia, GÓMEZ FERNÁNDEZ Mónica, JIMÉNEZ PÉREZ Raquel, SANTOS VÉLEZ Salvador, SERRANO POYATO Carmen (eds.). Manual de Enfermería en Cardiología Intervencionista y Hemodinámica. Protocolos unificados, s.l. [Vigo], Asociación Española de Enfermería en Cardiología, 2007—transl. David M. Weeks]