Question for you smarties...

[NatCh]

Following our surgical scrub, after which our hands and forearms are supposedly sterile, the last thing we do before entering the O.R. is to rinse with water. The water comes directly out of the tap, which came from the building's water pipes, preceded by the local plumbing and water source.

How clean is that water?

Do you guys know if anyone has ever researched that question?

Nat

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[Dr_Feelgood]

Following our surgical scrub, after which our hands and forearms are supposedly sterile, the last thing we do before entering the O.R. is to rinse with water. The water comes directly out of the tap, which came from the building's water pipes, preceded by the local plumbing and water source.

How clean is that water?

Do you guys know if anyone has ever researched that question?

Nat

I've got a few thoughts on the topic. There is a nice cochrane review on whether tap H2O is okay for wound cleansing. Most of that research if out of less developed countries and there was no evidence that isotonic saline, distilled H2O, or boil H2O were better than tap H2O for cleansing open fractures

But there is some evidence that the aqueous (waterless srub) alcohol maybe superior to traditional scrubbing techniques. (You can get that reference from an upcoming Pod Today article) I never thought about the fact that this difference maybe due to bacteria in the water, pipes, ect. But if it was I think we would see more Pseudomonas.

 

[iceman69]

Aqueous, waterless alcohol is an oxymoron. Aqueous implies that the solution has something dissolved in water. If you're talking about pure alcohol, that would be superior for wound cleansing, and scrubbing. However, most of the tap water in the circuit to the OR should have passed through a pourous filter that is designed to only permit water to pass through it. But, the end the pipe where it comes out is not very clean compared to the interior of the pipe. The facets in the OR are much cleaner than a lot of other things in the OR according to the ID doc I work with. In some ways using 70% EtOH to sterilize a surgeons hands/forearms will be more effective than scrubbing, and washing with soap, and rinsing, but that's hard on skin...

 

[NatCh]

Avagard alcohol rub gives me a metallic or synthetic taste in my mouth if I use it for more than a couple of cases in a day. I end up with a pretty nasty headache that lasts into the evening too, so I don't really enjoy using it. I've heard a few O.R. staff mention similar side effects.

The facets in the OR are much cleaner than a lot of other things in the OR

I would like to know how infectious the tourniquets are. Do they get cleaned ever? Does everyone remove them while still wearing bloody gloves from the case? Does everyone apply them to the subsequent patient bare-handed?

Most of that research if out of less developed countries and there was no evidence that isotonic saline, distilled H2O, or boil H2O were better than tap H2O for cleansing open fractures

One of my Partners goes abroad annually for medical mission, and I like his stories about the drastically different standards of hygiene. He imitates dropping an instrument or implant on the ground, then rubbing it "clean" on his scrub top and proceeding to use it in the case.

 

[Dr_Feelgood]

Aqueous, waterless alcohol is an oxymoron. Aqueous implies that the solution has something dissolved in water. If you're talking about pure alcohol, that would be superior for wound cleansing, and scrubbing. However, most of the tap water in the circuit to the OR should have passed through a pourous filter that is designed to only permit water to pass through it. But, the end the pipe where it comes out is not very clean compared to the interior of the pipe. The facets in the OR are much cleaner than a lot of other things in the OR according to the ID doc I work with. In some ways using 70% EtOH to sterilize a surgeons hands/forearms will be more effective than scrubbing, and washing with soap, and rinsing, but that's hard on skin...

The waterless is the technique not the solution. (I've corrected it to clarify my point). You are dead on with what happens to the skin with traditional techniques, it is hard on the skin. Researchers believe that is why the waterless technqiue is more effective. It increases compliance and decreases the breakdown of skin. You don't need you say some ways, according to EBM, it maybe in all ways. (Unless it gives you a headache )

 

[Dr_Feelgood]

Avagard alcohol rub gives me a metallic or synthetic taste in my mouth if I use it for more than a couple of cases in a day. I end up with a pretty nasty headache that lasts into the evening too, so I don't really enjoy using it. I've heard a few O.R. staff mention similar side effects.

I would like to know how infectious the tourniquets are. Do they get cleaned ever? Does everyone remove them while still wearing bloody gloves from the case? Does everyone apply them to the subsequent patient bare-handed?

One of my Partners goes abroad annually for medical mission, and I like his stories about the drastically different standards of hygiene. He imitates dropping an instrument or implant on the ground, then rubbing it "clean" on his scrub top and proceeding to use it in the case.

The thing that gives me a headache about the alcohol rubs is the perfume. I can't stand the smell. As for the tourniquet, you are dead on with that statement. There is a great project, culturing those nasty items. Should we be using disposable?

 

[SportPOD]

I would like to know how infectious the tourniquets are. Do they get cleaned ever? Does everyone remove them while still wearing bloody gloves from the case? Does everyone apply them to the subsequent patient bare-handed?

At one of the hospitals I work at, they use sterilezed throw away tourniquets for EACH case. I'm not sure how expensive it is, but that's one way around the iodine scrubbed tourniquets.

Whenever I take off the tourniquet, I use the clean gloves that I have on underneath the dirty ones (I double glove). That way, I don't get the blood, bone parts or various other substances on the tourniquet or the dressing for that matter.

Not sure if there have been any true studies, but I'm sure the manafacturer's of the waterless scrub have their two cents about it.

 

[krabmas]

I have seen anecdotal studies on the difference between washing hands between each patient and using foam alcohol rubs. The people that used the alcohol had less dry hands than the people who washed w/ soap and water.


There are 2 studies in JBJS from 2007 in May or June? They both look at alcohol vs betadine in one way or another but for prepping the patient's foot not the surgeon's hands. They also cultured the feet after and did not look at rates of post op infection which would have been clinically more relavant. THe end result was basically that scubbing with an alcohol solution was superior to betatine scrub or any sponge spreading method.

As for the water out of the tap. There are systems by companies like "milipoore" that have filters so that only de-ionized water is filtered thru. They are terribly expensive and once the filters are expired the water will not flow. It would take a ton of upkeep and lots of money to implement these filters.

In the end none of these are going to make the risk of infection 0%. Some of the infection rate is due to the patient's immune system and their compliance and as well to the surgeon's sterile technique.

 

[karntrev]

Just a note. I work in a microbiology lab where we test a lot of drinking water (city water) in which the samples are mainly taken from facets from around the distribution area. We do coliform testing and sometimes an aerobic plate count. On the aerobic plate count we use a media that is very non-selective and almost anything can grow on it. We rarely see anything grow on the plates and rarely see a coliform come back positive. Usually if drinking water lines are bad it is because they have a line break somewhere. Just because the plates come back clean doesn't mean that the water is sterile but it does tell us it is very clean.

I will agree that washing your hands a lot with just soap and water kills your hands. I wash 7-10 times a day. I wash so much that even applying lotion doesn't help.