Antibiotics (Properties, Administration, Interactions) - M.P. Cherenko 1999

Antisepsis, asepsis

HISTORY OF ORIGIN AND DEVELOPMENT

Throughout the centuries-long development of surgery, scientists have long distinguished two main periods: the pre-antiseptic and the antiseptic eras. The first era spans several millennia, stretching from antiquity to the second half of the 19th century, while the second has lasted just over a century, beginning in 1867. Although the first era yielded certain achievements—predominantly empirical and technical, some of which survive in modified forms to this day—it was characterized by interventions limited solely to the body surface. Moreover, from 50 to 80% of operated patients, even in the first half of the 19th century, died postoperatively from complications, predominantly of a purulent nature (pyemia, Sepsis). Even minor incisions or venipunctures performed for bloodletting very frequently became complicated by severe infectious processes. The great surgeon Nikolai Pirogov witnessed twelve guardsmen (It is worth noting that guardsmen were physically healthy young men) die consecutively of pyemia following routine bloodletting.

The majority of wounded patients succumbed to infection, both with and without surgery, especially amputations, which served as the primary Treatment for open and closed limb fractures. Regarding this, Nikolai Pirogov sorrowfully stated that a wounded soldier whose fracture went unrecognized and who consequently avoided amputation owed his life to our [medical] ignorance. Meanwhile, King Louis XIV of France remarked with bitter irony that 'surgeons' knives are more dangerous to his soldiers than enemy bullets.'

Although even in ancient times the most observant and perceptive physicians pointed out Structure/19.html">The Importance of cleanliness—washing hands, Skin, clothing, linen, premises, air, Water, and so forth—for wound healing and patient recovery in general, and even applied alcohol, vinegar, wine, tar, copper sulfate, and similar substances to treat wounds, suppuration of wounds (both accidental and surgical) was considered a natural, regular, and inevitable phenomenon until the second half of the 19th century. Only in isolated instances during the early 19th century was the cause of wound suppuration or puerperal fever attributed to hypothetical 'miasmas of living nature' transmitted from a sick person via hands, dressing Materials, instruments, and linen during medical Procedures and examinations.

Among those who recognized The Role of asepsis, special mention must be made of the Hungarian obstetrician-gynecologist Ignaz Semmelweis (1818–1865; Fig. 11) and the great Russian surgeon whose fate was closely intertwined with Ukraine, Nikolai Pirogov (1810–1881). The observations of I. Semmelweis, who worked as an assistant in Prof. Klein's clinic in Vienna, led him to conclude that puerperal fever among women in his clinic was caused by cadaveric poisons transferred to the birth canal by medical students coming straight from the anatomical theater to examine patients with unwashed hands. Semmelweis reached this Conclusion by comparing outcomes in Klein's clinic with those in a neighboring hospital where students did not train, and where maternal mortality was significantly lower. Another crucial observation was made by Semmelweis in his own clinic. Twelve postpartum women lay in adjacent beds in the front row at the same time. After being examined by students who began their rounds with the very first patient, all the women except the first subsequently died of pyemia. It was established that the first woman suffered from purulent vaginitis. Analyzing these facts, Semmelweis concluded that the students, starting their examinations with this infected patient, carried the lethal infection to the others. Based on these observations, he introduced mandatory handwashing for obstetricians using a calcium hypochlorite solution before examining patients. This reduced maternal mortality in the clinic from 18.3% to 1.3%. Emboldened by these results and driven by his passionate nature, Semmelweis wrote letters to obstetricians-gynecologists across Europe, insisting that they introduce mandatory handwashing with chlorinated lime before examining the birth canal, branding the neglect of this measure a crime. At a time when microbes were entirely unknown, his ideas were so far ahead of their time that they were misunderstood and mocked, driving him first to madness and ultimately to death from sepsis resulting from a felon. Only later did Semmelweis's theory gain universal recognition, and in 1906, funded by physicians worldwide, a monument was erected to him in Budapest bearing the inscription 'Savior of Mothers.'

Nikolai Pirogov was the second to recognize that suppurations and pyemia were caused by 'contagious miasmas' transmitted from patient to patient via linen, air, dressings, and surgeons' hands, and that these miasmas were living and capable of reproduction. He predicted that 'the time is not far off when a detailed study of traumatic and hospital miasmas will inaugurate a new direction in surgery.' This quotation lacks only the terms 'microbe' and 'infection.'

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Fig. 11. I. Semmelweis (1818–1865)

To prevent suppurations in military hospitals, Nikolai Pirogov introduced a brilliant measure: triage—the segregation of patients with purulent wounds from 'clean' wounded soldiers—and recommended burning pus-soaked mattresses. He used tincture of iodine, silver nitrate, and calcium hypochlorite to treat purulent wounds. However, these brilliant hypotheses could not coalesce into a systematic approach to combating infection because the theoretical foundation—the actual cause of suppuration, namely microbes—was still unknown. Only after Louis Pasteur discovered that Fermentation and putrefaction are the results of microorganism activity and proved that spontaneous generation does not occur, did it become possible to substantiate the empirical insights of pioneering surgeons regarding THE ORIGIN OF purulent infection. This laid the foundation for the system that would later be known as antisepsis and asepsis, becoming the cornerstone of the magnificent edifice of Surgery. The first master builder of this system was the great English surgeon Joseph Lister (1827–1912).

Guided by Pasteur's theory that fermentation and putrefaction stem from The activity of microorganisms, Joseph Lister hypothesized that wound suppuration is likewise a manifestation of living tissue putrefaction caused by microbes entering the wound directly from the air or via contaminated objects touching the wound, including the surgeon's hands. Based on this hypothesis, he developed a treatment system for patients with open fractures, which involved using carbolic acid (a component of coal tar, already known at the time as an antiseptic compound) to destroy microbes in the wound, on hands, in the air, and on dressings, and sealing the wound with an airtight carbolized bandage. This bulky bandage consisted of multiple layers. The first layer was made of thin silk soaked in a 3% carbolic acid solution—a protective layer designed to shield the wound from the air. An additional eight layers of gauze impregnated with a mixture of carbolic acid, rosin (pine resin), and paraffin were placed over the protective layer. All these layers were secured with a bandage soaked in carbolic acid. Surgeons' hands and instruments were treated with a 3% carbolic acid solution. Carbolic acid was also sprayed into the air of the operating and dressing rooms using atomizers. At the time, air was considered the primary source of microorganisms, so Lister's entire system was primarily aimed at preventing airborne microbial contamination. The outcomes of treatment using Lister's method were encouraging: mortality decreased several-fold, and wound suppuration became much rarer. Lister dedicated his works 'On a New Method of Treating Compound Fractures and Abscesses, with Observations on the Conditions of Suppuration' and 'On the Antiseptic Principle in Practice of Surgery' to this method. The year the latter was published (1867) came to be regarded as the birth of antisepsis as a new working principle in surgery. Consequently, The history of surgical development was divided into pre-antiseptic and antiseptic periods.

Lister's method rapidly spread throughout Europe, including the Russian Empire (P. P. Pelekhin, E. A. Kiter, S. P. Kolomnin, N. V. Sklifosovsky, V. P. Karavaev, and others). Resistance from conservatively minded physicians was broken. The revolutionary role of Lister's antisepsis in surgery lay not only (and perhaps not even so much) in achieving unprecedented outcomes in wound healing, but in creating the conditions necessary for operations on Internal Organs, particularly within the Abdominal cavity. Prior to the Introduction of Lister's antiseptic method, these organs were inaccessible to surgeons due to a fatal complication—abdominal infection, or Peritonitis.

From the outset, Lister's antiseptic method incorporated many elements of modern asepsis (disinfection of air, dressings, hands, and instruments). In other words, it was not limited strictly to disinfecting the wound itself, and therefore had a prophylactic orientation. All of this was achieved through the action of chemical substances—specifically, carbolic acid. However, over time, serious drawbacks to Lister's method became apparent: toxic effects on patients and physicians caused by carbolic acid (patient poisoning, dermatitis and Bronchitis in surgeons, etc.), as well as damage to living Tissues within the wound. Furthermore, its antimicrobial bactericidal effect proved insufficient; in many patients, Microbial growth AND pus accumulation were observed beneath the scab of dead tissue within the wound. To prevent these complications, other chemical compounds with known antimicrobial properties began replacing carbolic acid: mercuric chloride solutions (1:1000, 1:2000), potassium permanganate, salicylic acid, and boric acid. Yet these compounds proved either insufficiently bactericidal or even more toxic (such as mercuric chloride).

Other physical factors detrimental to microbes were also noted, notably the hygroscopic properties of gauze (M. Ya. Preobrazhensky) and the osmotic qualities of aqueous medicinal solutions. Critics of Lister's method argued that the actual absorptive action of the gauze dressing and aqueous carbolic acid solution held greater therapeutic value than the chemical action of the carbolic acid itself.

Research into the life cycles of MICROORGANISMS AND THE study of wound infection (by Louis Pasteur, Robert Koch, and others) established that pathogenic microflora could be destroyed more reliably through physical Methods—specifically high Temperature, such as hot steam or boiling—than through chemicals. Meanwhile, the renowned Russian scientist Ilya Mechnikov, while studying Immunity, concluded that the body's own defense reactions and tissue viability play the primary role in combating infection and microbial aggression, and that tissue damage is accompanied by a suppression of resistance to infection. These scientific breakthroughs served as a foundation for replacing Lister's chemical antisepsis with a method of preventing wound infection through physical sterilization techniques, particularly high temperatures, applied to any objects coming into contact with the wound during surgery. Unlike antisepsis, this approach was named asepsis. The credit for its creation belongs to Ernst von Bergmann and his pupil Carl Schimmelbusch. In 1890, at the 10th Congress of German Surgeons, Bergmann proclaimed asepsis as the primary weapon against surgical infection, dismissing antisepsis as lagging behind the current level of scientific development. Joseph Lister, who attended the congress, congratulated the creators of asepsis on their success in advancing the cause he had initiated.

However, abandoning antisepsis in the fight against wound infection proved not only premature but erroneous, because sterilizing the skin of the surgical field and surgeons' hands, as well as destroying microflora in traumatic wounds, was impossible without chemical antiseptics. Even the rubber gloves introduced by Jan Mikulicz-Radecki in 1897, which allowed hands to be made 'sterile' (as the gloves could be autoclaved), could not entirely replace chemical antiseptic agents. Consequently, alongside Physical Methods of infection Prevention, surgeons once again began utilizing chemical preparations, thereby returning to antisepsis. This revival was also facilitated by the creation of new chemical antiseptics far more effective than carbolic acid.

The limitations of pure asepsis became especially apparent during World War I in the treatment of casualties with gunshot wounds. Due to the high volume of patients with extensive devitalized tissues and severe microbial contamination, wounds were complicated by severe infections. In France, Alexis Carrel and Henry Dakin, and in Russia, Konstantin Sapezhko, recommended irrigating such wounds with chlorinated lime solutions, demonstrating the vital role of chemical antisepsis in the prevention and treatment of wound infection. Since then, these two modes of combating infection have merged into a single comprehensive system known today as the aseptic method. It is only for didactic purposes that we distinguish between antisepsis and asepsis. Throughout the 20th century, these methods have been enriched and developed through local mechanical interventions in wounds (surgical debridement), the introduction of various novel Physical and Chemical agents, biological products, as well as technical and organizational measures. Together, they form one of the principal pillars of surgery.

Antisepsis (from the Latin anti — against, sepsis — putrefaction) is a component of the unified aseptic method that currently ensures the prevention of wound infection during surgical operations and examinations. Antisepsis is a complex of agents and measures aimed at destroying microbes within the wound, surrounding tissues, and adjacent Body Cavities.

Modern antisepsis differs both qualitatively and quantitatively from Lister's original antisepsis, although their goal remains the same: to destroy pathogenic microbes that have entered the wound and surrounding tissues. Lister's antisepsis relied on a single antimicrobial arsenal consisting of a limited range of chemicals, of which carbolic acid was the most frequently used against putrefactive agents. Modern antisepsis, first of all, commands a significantly broader range of tools. Alongside chemical antiseptics, it employs mechanical, physical, and biological agents. Moreover, in preventing and treating wound infection, modern practice prioritizes mechanical methods—or a combination of them—over chemical ones.

The second distinctive feature of contemporary antisepsis is its biological compatibility and focus. Antiseptic agents must not only possess antimicrobial activity, bactericidal or bacteriostatic effects, but above all, they must be harmless to living tissues and the Organism as a whole. It is well established that living tissues and their normal physiological state are the primary factors in resisting infectious agents; therefore, the biological neutrality of antiseptics—and ideally, The stimulation of the protective properties of living tissues—is a defining characteristic of modern antisepsis. As historical experience has shown, Lister's antisepsis was short-lived precisely because its primary agent, carbolic acid, acted detrimentally not so much on microflora as on living tissues, causing tissue necrosis.

Chemical antisepsis. Chemical antisepsis refers to The Use of chemical substances for the prevention and control of infection. However, not all chemical substances used to combat infectious agents can be classified as antiseptics. Antiseptics strictly denote those substances and preparations utilized to disinfect The surface of The Human Body and open, purulent cavities that communicate with the external environment.

Chemical substances and compounds used for disinfection vary widely in composition and MECHANISM OF ACTION on microflora. Their antimicrobial action may involve dehydration, Swelling, or lysis of microbial Cells; disruption of cellular Respiration, protein, DNA, RNA, or membrane lipoprotein synthesis; and other effects that either destroy microbes or suppress their vital activity.

Chemical agents are utilized in the form of solutions, liniments, ointments, and powders, and very rarely as pure substance sticks (per se), an example being silver nitrate pencils ('infernal stone'). Chemical antiseptics are applied via wound irrigation (including continuous washing), dressings, and topical Applications. Disinfection is also achieved by immersing body parts with wounds or ulcers—such as hands, feet, Penis, or buttocks—into antiseptic solutions, or by dusting wounds and ulcers with antiseptic powders (all these forms constitute superficial antisepsis). The introduction of antiseptic solutions through natural or artificial openings (fistulas) into organ cavities (Urinary Bladder, Uterus, etc.) or tissues constitutes the second form of antisepsis: intracavitary antisepsis.

Depending on their intended purpose, antiseptics are divided into agents for scrubbing the surgeon's hands before surgery and prepping the operative field, and agents intended for direct irrigation, soaking of dressings, washing, applications, baths, and direct treatment of wounds (contaminated and infected), ulcers, burn surfaces, and cavities.

Among the numerous groups of chemical compounds, the most frequently employed antiseptics include halogens and halogen-containing agents, oxidizing agents, organic acids, Dyes, alcohols, certain heavy metal salts, nitrofuran derivatives, 8-hydroxyquinoline derivatives, ethonium, sulfonamides, phytoncides, and Antibiotics.

Halogens and halogen-containing agents. A 3–5% alcohol solution of iodine possesses a broad spectrum of bactericidal and sporicidal activity, alongside irritant effects (at 10% concentration, it exhibits tanning and cauterizing properties). It is used for disinfecting the surgical field and hands, as well as treating fresh microtraumas and small wounds to prevent infection. In children and adults with delicate, thin skin, a 1–3% alcohol solution of iodine is used. It should be kept in mind that hypersensitivity (and occasionally allergies) to iodine preparations is sometimes observed.

Iodophors—iodine-containing compounds—have found widespread clinical application. These include iodonate, an aqueous surfactant-iodine complex; iodinol (an iodine-polyvinyl alcohol compound); iodopyron, or povidone-iodine (a complex of atomic iodine with polyvinylpyrrolidone); and others. They are used at a 1% concentration for prepping the surgical site, as well as for treating purulent wounds, burn surfaces, and ulcers. All of these preparations exhibit high antimicrobial (and sporicidal) activity while causing minimal irritation compared to elemental iodine.

Other halogen-based preparations (specifically, a 2–3–10% chloramine solution) are used for disinfecting instruments, gloves, and occasionally the skin. Due to its hemolytic effect, chloramine is not used for wound or ulcer care.

Chlorhexidine, a chlorine-containing antiseptic, has gained immense popularity in recent years. Its 0.5% alcohol solution is used to treat purulent wounds and Burns, ulcers, as well as for surgical site preparation and hand hygiene. Aqueous chlorhexidine solutions are less effective.

Oxidizing agents. The most common among these are hydrogen peroxide and potassium permanganate. Hydrogen peroxide (1–3% solution) is used to irrigate purulent wounds and body cavities. Although it is a mild antiseptic, it serves as a valuable donor and source of atomic oxygen, making it widely used in the management of anaerobic infections.

Due to its foaming action, it penetrates deep into wounds and cavities, flushing out pus, necrotic debris, and microorganisms.

Potassium permanganate is a very powerful oxidizing agent. Its solutions, ranging in concentration from 0.1–0.5% to 1–3%, are used to irrigate wounds, ulcers, cavities, burn surfaces, putrid wounds, and those complicated by anaerobic infections. Higher concentrations provide a cauterizing and coagulating effect; therefore, a 5% solution is applied to burn areas, primarily in open-wound management (e.g., on the face). A valuable property of potassium permanganate solutions is their deodorizing action (neutralizing the foul odor of putrid wounds), making them indispensable in the treatment of infected wounds and ulcers*. Combined use of hydrogen peroxide and potassium permanganate is significantly more effective.

Dyes. Brilliant green (a 1–2% alcohol solution) is used for staphylococcal skin infections (staphylococci are highly sensitive to this antiseptic), and less commonly for treating purulent wounds and burns. It is a component of several formulations, notably M.V. Novikov's compound, used for treating minor injuries.

Methylene blue is a mild antiseptic. Its 1–3% solution is used for purulent (staphylococcal and streptococcal) lesions of the skin and mucous membranes, particularly the Oral Cavity. Because of its high redox potential, it is used as an antidote in cyanide, carbon monoxide, and hydrogen sulfide poisoning.

Alcohols. The primary antiseptic in this group is ethyl alcohol, which is widely used for disinfecting the surgical site and the surgeon's hands, as well as in the early-stage treatment of soft tissue infections (infiltrates, felon, etc.). It is used in concentrations of 70%, 90%, and 95%. The antiseptic and bactericidal action of the drug is based on the dehydration of microbial cells and the dissolution of their lipid membranes.

The therapeutic effect of ethyl alcohol on inflammatory tissue infiltrates is primarily manifested by reduced edema and improved Blood supply. In sepsis, a 20–30% alcohol solution is sometimes administered parenterally as an energy substrate.

Acids and bases have limited application and generally possess weak antiseptic properties. Boric acid (2–3% solution) is used for wound complications caused by Pseudomonas aeruginosa; peracetic acid (Cozoxon-1) is used for prepping the surgical site and surgeons' hands; and methanoic (formic) acid mixed with hydrogen peroxide (C-4 formula) is used for scrubbing surgeons' hands (for 1.5 minutes), followed by drying and treating the hands with 95% ethyl alcohol for 3 minutes.

Among bases, a 0.5% ammonia solution was formerly widely used for scrubbing surgeons' hands via the Spasokukotsky-Kochergin method. This method is now rarely used, as simpler and more effective alternatives have emerged.

Over the past decade, nalidixic acid derivatives—the so-called quinolones, specifically ciprofloxacin—have gained widespread clinical popularity. They exhibit high antimicrobial activity, particularly against Gram-negative pathogenic microflora (Escherichia coli, Pseudomonas, etc.). However, drugs in this group are primarily used as systemic chemotherapeutic agents (enteral and parenteral).

Heavy metal salts. Silver salts, copper sulfate, zinc sulfate, bismuth subnitrate, and disinfectants (mercuric dichloride preparations, etc.) are used as antiseptics. The most commonly used antiseptics in this group are silver nitrate preparations: a 1–5% aqueous solution; the silver nitrate pencil (lunar caustic); a 1–3% protargol solution (containing 7.8–8.3% silver); and a 0.2–1% collargol solution. They are used to irrigate the urinary bladder, purulent wounds, and ulcers. For the prophylaxis of gonococcal ophthalmia neonatorum (blennorrhea), 1 drop of a 2% silver nitrate solution is instilled into the conjunctival sac. In recent years, silver sulfadiazine ointments (most commonly 1%) have been widely used for

treating burns, wounds, and ulcers. Among other agents in this group used for purulent wounds and ulcers accompanied by dermatitis, xeroform, dermatol (bismuth nitrate derivatives), and zinc sulfate pastes and ointments are preferred.

Nitrofuran derivatives. Antiseptics of the nitrofuran group, namely furacilin (1:5000–1:2500) and furagin (1:13,000), are used to treat local infectious processes (purulent wounds, burns, ulcers) by soaking dressings and irrigating wounds and cavities. These drugs have low toxicity and a broad spectrum of antimicrobial activity.

Other nitrofurans, such as furadantin and furazolidone, are administered enterally for urinary and gastrointestinal tract infections.

8-Hydroxyquinoline derivatives, particularly quinosol, are prescribed as aqueous solutions (1:1000, 1:2000) and ointments (5–10%) for the treatment, irrigation, and application of dressings to purulent wounds.

An aqueous solution of ethonium (0.5%) and its 1–2% ointments are used to treat infectious lesions of the skin, oral mucosa, and conjunctiva, as well as burn wounds.

Detergents. Various preparations (such as degmin and rocal) are used for surgical hand scrubbing, surgical site preparation, and instrument disinfection (rocal). In recent years, their scope of application has sharply narrowed.

Sulfonamides. Active against pathogens of purulent infections, drugs in this group—such as streptocide, ethazole, sulfacetamide sodium, and sulfapyridazine sodium—are used in the form of liniments, ointments, powders, and solutions to treat purulent wounds, prevent suppuration in fresh wounds, and for conjunctival sanitation.

The most effective agents in this group are 5% sulfamylon (mafenide acetate) and silver sulfadiazine-containing ointments, such as flamazine (1%) and dermazine. Sulfonamides are classified according to their elimination rate (the duration of maintaining a maximum concentration in the body) into short-acting, intermediate-acting, long-acting, and ultra-long-acting agents. They are primarily used as chemotherapeutic agents. The best-known include: phthalazol (short-acting); sulfamethoxazole and trimethoprim (intermediate-acting), and particularly their combination—bactrim or biseptol (which act rapidly and are widely used for lung and Kidney infections); sulfadimetoxin, sulfapyridazine sodium, and sulfalene (long- and ultra-long-acting, maintaining peak concentrations for 2–10 days), which are widely used for pulmonary and intestinal infections.

Antibiotics. A large group of biological antimicrobial agents is used primarily for Chemotherapy. However, some find topical application, mainly in the form of liniments (1–10%) and ointments (5–10%), predominantly on a water-soluble base (chloramphenicol, polymyxin, erythromycin, etc.), and less frequently as solutions (microcid, gramicidin, etc.) for treating purulent wounds, burns, and ulcers.

Along with topical application, antibiotics are also used for tissue infiltration around the inflammatory zone (antibiotic blockade), injection into abscess cavities after pus aspiration, and introduction into infection-involved Pleura, Peritoneum, joints, the spinal canal, etc.

For the treatment of wounds, burns, and ulcers, certain Enzymes (Lysozyme, proteases, etc.) are also used, alongside phytoncides—antimicrobial substances produced by various plants (such as St. John's wort, pot marigold, eucalyptus, etc.) that possess antimicrobial activity. Among these, the best-known phytoncide preparations are a 0.25% solution of imanin and novotimanin, calendula tincture, and chlorophyllipt solution (derived from eucalyptus, etc.). They are used for treating purulent wounds and burns, irrigating cavities, and rinsing the oral cavity.

Asepsis (from Greek a-, meaning absence or negation, and sepsis, meaning putrefaction) is a set of measures aimed at preventing The entry of pathogenic microflora into wounds, cavities, and Blood Vessels, thereby averting The Development of infection within the body during surgeries, diagnostic examinations, and therapeutic procedures.

Asepsis forms the foundation of the aseptic method, of which antisepsis in its narrow sense is an integral component.

Asepsis encompasses a complex of measures diverse in content and mode of action against microflora, including organizational, technical, hygienic, physical, and chemical methods. While their individual weights within the comprehensive system of aseptic measures vary, The Significance of each is paramount.

Depending on the source of entry into the body, pathogenic microflora is categorized as either exogenous or endogenous. The former invades wounds or cavities from the external environment (air, various objects, and the patient's body surface, particularly the skin and mucous membranes), whereas the latter originates from foci already present within the body (chronic and acute inflammatory processes such as tonsillitis, periodontal disease, periodontitis, lymphadenitis, cholangitis, asymptomatic bacterial carriage, etc.).

Exogenous microflora (infection) can be airborne, droplet-borne, air-droplet-borne, or contact-based. Airborne and air-droplet microflora enter the body or wound via the air, while contact infection is transmitted through objects contaminated with infectious agents and hands that come into physical contact with the wound. A specific variant of contact infection is the so-called implantation infection (from Latin implantatio — insertion or grafting), which is introduced into tissues via objects contaminated with microflora. Such objects may include ligatures, vascular and Heart valve prostheses, joint replacements, and occasionally plastic materials or threads used to tie off vessels in tissues and suture wounds.

A distinctive feature of implantative pathogenic microflora (infection) is its prolonged persistence within the body due to the enclosed Nature of the tissue space. Deep within the tissues, alongside a foreign body, microflora is rarely encapsulated by the surrounding Connective Tissue; more frequently, it provokes purulent inflammation around the foreign object. The infection can only be eradicated once the inciting foreign body is removed. In some instances, such localized implantation infection may precipitate a generalized systemic infection (sepsis).

Exogenous microflora accounts for the largest share and is commonly referred to as exogenous infection (although these terms are not strictly synonymous, surgeons generally equate microflora that frequently causes disease with the infectious process itself).

Consequently, primary efforts are directed precisely at preventing exogenous infection, though the role of endogenous microflora must not be underestimated.

The prophylaxis of exogenous infection begins with the Rational design and siting of the hospital or surgical building, alongside a hygienically sound layout of the functional units within the surgical department—namely the operating and dressing blocks, wards, dining facilities, restrooms, and so forth.

Ideally, the surgical department should be housed in a separate building, set back at a safe distance from roadways. If this is unfeasible for various reasons, vehicular traffic near the building must be prohibited or at least restricted during working hours. When a surgical department is located within a multi-story building, the upper floors should be allocated to it so that dust and polluted air reach its premises to the minimum possible extent. The floor space of the department, its units, wards, and corridors, as well as the lighting, must comply with established hygienic standards.

The so-called "clean" department and the septic (purulent) department must be strictly segregated. Each must feature its own operating and dressing blocks, wards, dining areas, and restrooms, and patients from these distinct units must not intermingle.

In the absence of a dedicated purulent department, patients with infectious complications must be isolated in separate wards. Their dressings should be changed (if a separate dressing room is unavailable) as the very last priority. The department should be equipped with an effective transom ventilation system for the wards. Wards must be spacious, accommodating 2 to 4 beds. The floor space allocated per patient (bed) is 7 m². Ward walls are painted in light colors, and floors are covered with linoleum to facilitate wet cleaning. Windows should be fitted with blinds or curtains to prevent direct sunlight from beating down on patients during hot weather. Special attention must be paid to the Organization OF THE operating block. It typically comprises the operating room(s) proper, the scrub room (pre-operative room), a material storage room, a staff changing room, and in some departments, an induction room for putting patients under anesthesia.

The operating room must be exceptionally clean. Its windows are usually oriented toward the north or northwest (never the south) to prevent summer sunlight from overheating the air and interfering with the proper illumination of the surgical field (sunlight is insufficient for deep-tissue procedures, prompting surgeons to rely on shadowless surgical lights). An area of 15–20 m² should be allocated per operating table. Ideally, an operating room should contain only a single table. If a room houses two or three tables, movable partitions are placed between them.

The walls, ceiling, and floors of operating rooms require frequent washing and wet cleaning. For this reason, floors are covered with linoleum or tiles, walls with tiles or oil-based paint, and ceilings with oil-based paint. Operating room walls are typically painted in light hues. The interior design of the operating room should be as minimalist as possible—free of ornamentation or decorative molding, and featuring rounded corners, as corners tend to accumulate dust and, consequently, microbes.

Operating room furniture must be of the simplest possible construction (excluding the operating table itself) and kept to a minimum. Standard furnishings typically include: an operating table equipped with a mechanical or automatic device to position the patient as required by the surgical Procedure; a large rectangular table for dressings, instruments, etc.; a mobile instrument table; stands for sterilization drums (bixes) and the drums themselves; metal swivel stools; tables for suture materials and medications (primarily antiseptic solutions); a dry-heat sterilizer; mobile side-illumination lamps; and electric suction apparatus for body cavity fluids. The main overhead illumination lamp (shadowless) is permanently mounted to the ceiling directly above the operating table.

Near the HEAD end of the operating table, there should be an anesthesia machine connected to a wall-mounted central oxygen supply system, alongside an anesthesia mobile cart.

The operating hall is supplied with conditioned air, or, in the absence of air conditioning, through specially designed window ventilation structures. Modern operating rooms feature a forced-exhaust ventilation system designed to draw microflora-laden air away from beneath the operating table. In addition, operating rooms are equipped with bactericidal ultraviolet quartz lamps. Operating units situated amidst greenery far from roadways are ventilated by opening windows after surgeries; however, in operating rooms where daytime ventilation is impossible due to heavy street dust, this is carried out exclusively at night.

To maintain rigorous cleanliness in operating rooms, they undergo thorough cleaning regimens. These include routine cleaning (retrieving dropped items from the floor and wiping down surfaces), cleanup after every single operation, end-of-day cleaning (including washing the floors), and terminal (general) cleaning at the end of the week (involving the thorough washing of floors, walls, and ceilings). Advanced technical systems are also employed to maintain and support the aseptic regime in the operating room. For instance, in operating rooms dedicated to ultra-clean procedures (cardiac surgery, bone surgery, organ transplantation, etc.), sterile filtered air is delivered via laminar flow at low velocities, and a protective canopy is erected over the surgical team.

When necessary, specialized equipment (electrocardiographs, defibrillators, electroencephalographs, etc.) may be brought into the operating room to monitor organ and systemic Functions, though this occurs sporadically rather than systematically.

Pre-operative rooms, anesthesia preparation rooms, and supply rooms, while representing zones of lower sterility compared to the operating room proper, must nevertheless fully comply with the aseptic requirements of the surgical block.

The dressing room of an "aseptic" surgical department is fundamentally a subdivision of the operating block: it is organizationally and materially subordinate to the operating room, and its operations are directed by the head of the surgical department or the physician responsible for the operating block, in direct coordination with the head nurse of the surgical unit. The latter dispenses dressings, instruments, linen, medications, and other supplies while monitoring adherence to asepsis in the dressing room. The nurse in charge of the dressing room (or the senior nurse, if the dressing room staff comprises multiple nurses) works in close collaboration with the head operating nurse, reports to her, and jointly plans the work of the dressing room.

The dressing room within the operating block of a surgical department serves both for changing dressings on postoperative patients and for performing minor surgical interventions, predominantly under local anesthesia or (rarely) intravenous sedation. Consequently, the dressing room must be fully stocked with all instruments required for these procedures, including local anesthesia supplies (syringes, needles, etc.), instruments for dividing and uniting tissues, hemostatic tools, as well as surgical linen, dressings, various types of drains, anesthetic and antiseptic solutions, and other pharmacological agents.

The dressing room must also be equipped with resuscitation gear (for artificial lung ventilation, cardiac resuscitation, etc.). The aseptic regime in the dressing room (both clean and septic) must be just as rigorous as that of the operating room. Both rooms must feature bactericidal lamps—both unshielded wall-mounted units activated in the absence of personnel (after hours) and mobile, preferably shielded lamps that can be operated for up to 6 hours even in the presence of people.

Wards must be furnished with metal beds or beds with metal mesh bases to permit thorough disinfection Processing. Mattresses should be soft, removable, and subject to physical sanitary disinfection. In addition to the bed, each ward should feature a bedside wooden cabinet for the patient's personal belongings, a portable vertical clothes rack, a night light, and a nurse-call signal system. Essential ward amenities also include a refrigerator and a radio outlet.

The organizational, technical, and hygienic measures designed to ensure asepsis in the operating and dressing rooms of a surgical department are not limited to rational architectural and structural features (Location, layout, interior furnishing, ventilation mechanisms, etc.) of these and other units. They equally govern the conduct of personnel and visitors within surgical facilities, most notably the operating suite. Presence in the operating hall must be strictly restricted to the surgical and anesthesiological teams. Students and observers must monitor the progress of surgery exclusively through the Glass observation dome situated above the operating theater.

Minimizing operating room traffic, human movement, and talking should be an absolute rule when working in surgical departments. Air conditioning in operating rooms, the use of mobile recirculating air purifiers, protection against static electricity (which facilitates the spread of dust and microbes), regular ventilation, and the irradiation of air with bactericidal lamps, as well as spraying bactericidal aerosols shortly before surgery (no later than 2 hours prior), are essential measures in combating airborne microflora. Droplet infection is prevented by the mandatory wearing of masks that cover both the Mouth AND Nose. Controlling carrier states among operating room personnel is also a crucial measure in preventing exogenous and droplet infections.

A significant role in preventing airborne infection is played by minimizing the contact between the surgical wound and the operating room air, which becomes contaminated with microflora shed by the surgical team and the patient.

Minimizing the patient's preoperative hospital stay and taking a hygienic shower on the eve of surgery are critical prerequisites for preventing nosocomial contact infections. However, the cornerstone of combating contact infection is the treatment of everything that comes into contact with the wound—linen, dressings, instruments, hands, gloves, suture material, drains, etc.—using chemical and, above all, physical methods. Since contact infection is more dangerous than airborne infection (assuming proper prevention of the latter), and physical factors—primarily high temperature—form The basis of its prevention, asepsis is still often regarded as a system or a comprehensive method of destroying pathogenic microflora and preventing infection through physical means. This somewhat narrows the Definition of the term "asepsis".

Chemical and physical asepsis are fundamentally based on the disinfection and sterilization of all objects and instruments that come into contact with the surgical wound.

PREPARATION OF THE SURGEON'S HANDS AND PREPARATION OF THE OPERATING FIELD

The surgeon's hands are the most frequent and earliest point of contact with the wound. Therefore, great attention is paid to their preoperative preparation. There are numerous methods for hand antisepsis—mechanical, chemical, and combined. The classic methods, though no longer used in their original form, retain elements that are present in almost all modern techniques: the Fürbringer method and its modification, the Alfeld method.

The Fürbringer method (1888) is carried out as follows. The hands are washed using two brushes for 5 minutes each under warm running water with soap. After drying, the hands and forearms are treated for 3 minutes with 70% ethanol and 3 minutes with a 0.5% mercuric chloride (sublimate) solution. Finally, the fingertips are treated with a 5% alcoholic iodine solution.

Mechanical cleansing softens the skin, removes desquamated epithelium, and washes away microbes, while ethyl alcohol and mercuric chloride exert bactericidal and bacteriostatic effects on the microflora both on the skin surface and within its pores.

Alfeld slightly modified this method by omitting the mercuric chloride step, as it can penetrate the body even through intact skin. Instead of 70% ethyl alcohol, he used 96% alcohol, which tans the skin and effectively traps microbes within its pores (the excretory ducts of the sweat and Sebaceous Glands).

When scrubbing hands with a brush in warm soapy water, the following sequence must be observed: first, wash the fingers, especially the Nails and interdigital spaces, and then gradually move upward to the upper third of the forearm. Lather and rinse frequently, keeping the hands elevated so that the soapy water drains toward the forearms rather than the fingertips.

Because the skin softens during surgery, its pores open up, and microbes can resurface. Therefore, 15–30 minutes later, hands prepared via the Fürbringer-Alfeld method must be re-washed with a sterile isotonic sodium chloride solution, dried, and treated again with 96% alcohol.

From the 1930s to the 1980s, the classic Spasokukotsky-Kochergin method of hand preparation was widely used. Hands were washed sequentially in a 0.5% ammonia solution (Lig. Ammonii caustici) using two separate basins for 3 minutes each. This method is reliable and skin-friendly, though somewhat inconvenient.

Modern practice relies on chemical hand antisepsis methods preceded by a 1- to 3-minute hygienic wash with soap and water. The most commonly used chemical method for hand disinfection involves immersing the hands and lower third of the forearms for 1.5 minutes in Ts4-perвомуr (perвомуr) solution. This solution is a mixture of hydrogen peroxide and formic acid. To prepare it, 17.1 ml of 33% hydrogen peroxide solution and 6.9 ml of 100% formic acid are added to 1 liter of water. The hands are kept in this solution for 1.5–2 minutes and then dried with a sterile towel. Hands can also be disinfected with other chemical agents: iodopirone or povidone-iodine (1%) for 3–4 minutes; 0.5% alcoholic chlorhexidine digluconate (Hibitane) for 3–5 minutes. In emergency cases, hands can be treated with 96% ethyl alcohol for 1–3 minutes.

However, despite all preparation methods, hands do not become completely sterile. To achieve sterility, sterilized surgical rubber gloves are worn. Because gloves frequently lose their integrity during surgery (puncturing or tearing), sometimes imperceptibly to the surgeon, and microbial-laden glove contents can enter the surgical field through these defects, donning gloves must be preceded by thorough hand disinfection using one of the established methods. It is worth noting that a surgeon must primarily protect their hands from roughness and domestic trauma, trim nails in a timely manner, apply hand cream at night, etc.

The operating field, just like the surgeon's hands, requires careful preparation. Field preparation includes hygienic processing (a full-body shower and washing the surgical area, shaving the skin 30 minutes prior to surgery, degreasing the skin in the surgical area with 70% alcohol, and chemical disinfection of the field within a 10 cm radius around the proposed incision line). The most commonly used disinfectants are a 5% alcoholic iodine solution, applied twice (according to Grossich's method), and iodophors—such as iodopirone, povidone-iodine, iodonate, as well as Hibitane and 70% ethyl alcohol.

Iodophors are used in a 1% concentration. The solution is applied to the surgical field twice. Hibitane (0.5% chlorhexidine digluconate solution), 70% ethyl alcohol, and other chemicals are used for operating field disinfection in cases of patient intolerance or hypersensitivity to iodine (the latter is mostly observed with alcoholic iodine solution and rarely with iodophors).

In children and in areas with sensitive, delicate skin in adults, the operating field is prepared using 70% ethyl alcohol or iodophors rather than an alcoholic iodine solution. Recently, it has become common practice to cover the operating field with sterile adhesive drapes after disinfection, making the incision directly through them. This enhances the aseptic conditions of the procedure.

STERILIZATION OF SURGICAL LINENS AND DRESSINGS

Sterilization of surgical linens (gowns, sheets, towels, stockings, etc.) and dressings (gauze, cotton wool, bandages) is carried out in special apparatuses called autoclaves, using steam under a pressure of 2 atm (0.22 MPa) at a temperature of 132 °C.

Autoclaves (Fig. 12) vary in size, shape (cylindrical, round, cabinet-like), and capacity, but share a similar structural design.

An autoclave consists of the following components: a water reservoir, a water gauge glass, a heating element, a steam chamber, a sterilization chamber, an outer casing, a lid with airtight sealing mechanisms, a pressure gauge to measure chamber pressure, a thermometer, and a steam release valve.

Linens and dressings are sterilized in special metal containers called drum boxes (baxes), in which the materials are packed compactly but not tightly. A sterilization indicator is placed inside each box. Most commonly, this is sulfur powder (contained in a small glass antibiotic vial), which melts at 120 °C and fuses into a solid mass. Benzoic acid, naphthol, and urea have melting points of 120–132 °C, but are used less frequently.

The drum box containing the materials remains open during sterilization (the ports of the special sliding belt are open). After loading the autoclave with these boxes, water is poured into the reservoir up to a specific level (2/3 of the water gauge glass), the steam release valve and lid are closed, and the heating device (usually electric) is turned on. Heating continues (the heating phase) until the pressure in the autoclave reaches 0.11 MPa (1 atm). At this point, the steam release valve is opened, and steam escaping under pressure (channeled through a special hose with its end submerged in a container of water) flushes out the air trapped between the linens inside the boxes. This is necessary because air is heavier than steam, settles below it in the autoclave, and—being a poor heat conductor—disrupts sterilization conditions: in its presence, even if the chamber temperature is at least 120 °C (as indicated by melted sulfur), the temperature in the air pocket will always be lower. Furthermore, air causes steam Condensation, which also reduces the temperature. Once the air is expelled, the steam release valve is closed again, and heating continues until the sterilization parameters are reached—typically a pressure of 0.22 MPa (2 atm). The sterilization phase then begins, lasting 20–30 minutes (depending on the degree of microbial contamination). If the linens are heavily contaminated, sterilization takes longer—45–60 minutes.

Fig. 12. GK 100-2 Autoclave: a — front view; b — side view;

1 — pedestal; 2 — electric heaters; 3 — steam generator cover; 4 — level sensor; 5 — siphon tube; 6 — electrocontact pressure gauge; 7 — branch pipe; 8 — electrical panel; 9 — indicator light; 10 — switch handle; 11 — drain valve; 12 — lever; 13 — pressure gauge; 14 — siphon tube; 15 — chamber casing; 16 — retaining ring; 17 — rubber gasket; 18 — lid casing; 19 — steam chamber; 20 — sterilization chamber; 21 — lid; 22 — clamping body; 23 — safety valve; 24 — funnel; 25 — steam generator; 26 — Column; 27 — hose

Thin rubber items (gloves), latex, and polymers are sterilized in an autoclave at a pressure of 0.11 MPa (1 atm) and a temperature of 120 °C for 45 min.

Before sterilization in an autoclave, rubber gloves are dusted inside with talcum powder (to prevent them from vulcanizing).

Upon completion of the sterilization cycle, heating is stopped, and the autoclave is allowed to cool down to 60 °C (rather than to room temperature). The valve is then opened to release residual steam, and the autoclave lid is opened. Immediately afterward, the drum containers (bixes) are hermetically sealed using their respective locking mechanisms.

Special labels are attached to the bixes, indicating the type of material, date of sterilization, and the name of the person who performed it. The prepared bixes are placed on designated shelves in the material room, where they are stored until use.

STERILIZATION OF INSTRUMENTS, UTENSILS, GLOVES, AND DRAINAGE TUBES

Instruments, gloves, and drainage tubes can act direct Transmitters of contact infection during surgical interventions and diagnostic procedures. Therefore, their sterilization must be highly reliable. The primary method for sterilizing non-cutting instruments and glassware is treatment with hot air in dry-heat ovens at 160–180 °C for 45–60 min. They can also be boiled in a 2% sodium bicarbonate solution (instruments) or water (utensils) for 15–20 min. Rubber gloves and drainage tubes can likewise be sterilized by boiling in water for 15 min. Alternatively, rubber gloves and drainage tubes are sterilized in autoclaves at a pressure of 0.11 MPa (or 1 atm) and a temperature of 120 °C for 45 min, as mentioned above. In addition, gloves and drainage tubes, including plastic ones, can be sterilized with a 2% chloramine solution or a C₄-perвомур (perвомур) solution for 15 min.

Cutting instruments—namely, scalpels, scissors, and needles—are sterilized using a 6% hydrogen peroxide solution (for 3 h), 96% ethyl alcohol (for 24 h), or a 2% chloramine solution (for 2 h).

Surgical instruments composed of materials with different chemical structures (metal, glass, plastic)—such as cystoscopes, endoscopes, and ureteral catheters—are sterilized for 12–24 h with formalin vapor in enclosed metal cabinets on perforated shelves. Rigid endoscopes are also sterilized with a 2% glutaraldehyde solution, a 20% formaldehyde solution with The addition of 0.2% sodium nitrate for 3–12 h, or a gas mixture of Ethylene oxide and methyl bromide in a 1:2.5 ratio for 40 min.

Fiber-optic endoscopes, following mechanical cleaning and rinsing, are sterilized in special chambers with ethylene oxide for one hour or with formalin vapor for 12 h. In recent years, a 1% Virkon solution—a balanced formulation of a peroxygen base with organic acids and other agents—has been used for the disinfection of endoscopes and other instruments, providing effective decontamination within 10 min.

Heat-resistant glass syringes are sterilized in dry-heat ovens at 160–180 °C for 60 min, whereas non-heat-resistant glass syringes are sterilized by boiling in water for 15 min. Disposable instruments (syringes, needles, scalpels, etc.) are widely used; these are sterilized and packaged industrially during manufacturing.

STERILIZATION OF SUTURE MATERIALS

Suture material poses a risk for implantational infection—a specific type of contact infection—since it largely remains embedded deep within tissues permanently. Consequently, special requirements apply to its sterilization. Surgical suture materials vary in chemical structure, physical properties, and origin. The principal ones include silk, cotton, and synthetic threads (some absorbable—dexon, oxelon, polypropylene, and other derivatives of glycolic acid and oxycellulose; others non-absorbable—capron, lavsan, dacron, teflon, etc.), sutures made of stainless steel, tantalum, and silver (wire, staples, etc.), and threads of biological origin (catgut, manufactured from the submucosal layer of sheep, cattle, and goat intestines). Silk is rarely used nowadays because it is highly tissue-reactive (reactogenic). However, in rare instances prior to use, it is sterilized using Kocher’s method or by using factory-sterilized silk (stored in sealed glass ampoules). According to Kocher’s method, silk threads, after washing and drying, are immersed in ether for 12–24 h for degreasing, followed by immersion in 76% ethyl alcohol for the same duration. They are then sterilized by boiling for 10 min in a 0.5% sublimated mercury (mercuric chloride) solution. The sterilized silk is transferred to a jar containing 96% ethyl alcohol for storage. Sterility is verified microbiologically (by culturing pieces of the thread onto a sterile biological medium). Before use, the silk is boiled for 2 min in a 0.5% mercuric chloride solution.

Silk, cotton, and non-absorbable synthetic threads can be sterilized in an autoclave (at a pressure of 0.11 MPa, or 1 atm, for 20–30 min).

Synthetic threads are primarily sterilized by boiling in water for 20–30 min. Metallic suture materials are also sterilized by boiling in a 2% sodium bicarbonate solution.

The most challenging procedure is the sterilization of catgut, which inherently harbors a diverse pathogenic microflora, including anaerobes (spore-forming clostridia of gas gangrene and tetanus). Depending on the thread thickness and chrome impregnation (chromic catgut), catgut is absorbed within 1 to 4 weeks. There are two main chemical sterilization methods for catgut: wet (the Claudius method and its Gubarev modification) and dry (the Sitkovsky method).

Claudius method: Catgut strands (coils) are placed in ether for 24 hours for degreasing and subsequently immersed in an aqueous Lugol’s solution (1 g of iodine crystals, 2 g of potassium iodide, 97 mL of water) for 9 days. Sterility is then verified by culturing on a microbiological medium. If sterile, Lugol’s solution is drained, and 96% ethyl alcohol is poured into the jar with the catgut. If, after 9 days in Lugol’s solution, the catgut is found to be non-sterile, it is re-immersed in the same solution for another 9 days.

Gubarev substituted an alcoholic solution for the aqueous Lugol’s solution, thereby shortening the sterilization time to 7–14 days.

Sitkovsky’s dry method involves suspending catgut coils inside glass-stoppered jars containing iodine crystals at the bottom (40 g per 5-L jar). The jar is periodically shaken to ensure thorough exposure of the catgut to iodine vapor. After 3–4 days, the catgut is tested for sterility. When using this method, it is advisable to immerse the catgut in a 2% potassium iodide solution for 1–2 min beforehand, as pre-moistened catgut sterilizes more effectively with iodine vapor.

Prior to sterilization by any method, catgut must be placed in an incubator (for 24 hours at 20–35 °C) to allow Spore Forms of microbes to germinate into vegetative forms (according to Bokkal’s method).

Due to its high reactogenicity and sensitizing (allergenic) properties, The complexity of its sterilization, and the availability of absorbable synthetic threads devoid of these drawbacks, catgut is used less and less frequently today—mostly as factory-sterilized products stored in sealed ampoules. In response to an increase in postoperative infectious complications over the past two decades—often associated with lapses in aseptic practices within surgical facilities—and to ensure the safe operation of hospital autoclaves, central sterilization departments (CSDs) have been organized to supply all hospital units with sterile materials, instruments, etc. This centralized supply system, equipped with modern technologies and apparatuses, not only improves the quality of sterilization for medical supplies and products but also extends their shelf life through better packaging, thereby increasing the work efficiency of operating-room and ward nurses.

OTHER MEASURES FOR MAINTAINING AN ASEPTIC REGIME

Along with the aforementioned methods for preventing and combating infectious complications following surgical interventions and procedures, the professionalism, diligence, and discipline of the surgical staff—particularly in operating rooms and dressing rooms—are of paramount importance. A vital role in this regard belongs to the head of the surgical department or operating suite and the head operating nurse. The latter’s attitude toward asepsis and her strictness toward the staff largely determine the aseptic conditions in the operating and dressing rooms, as well as the rates of postoperative septic complications.

A well-organized workflow in the operating room, thorough preparation of all team members for surgery, a strict sequence of procedures (starting with the cleanest cases), close cooperation between the anesthetic and surgical teams in achieving and maintaining asepsis, personal hygiene and proper attire for all team members (all surgical and anesthesia personnel must wear specialized scrubs), limiting the movement of staff and observers within the operating room, precise delivery of instruments and suture materials by scrub nurses, and the prevention of gastrointestinal contents, urine, or Bile spillage into wounds and body cavities all contribute significantly to reducing the risk of postoperative infectious complications.

Measures aimed directly at preventing pathogenic microflora from entering the wound and destroying any present microorganisms will achieve maximum effect when combined with a careful (biological rather than mechanistic) approach to tissues. This includes making incisions with a sharp scalpel; avoiding blunt traction, crushing, and tissue maceration; achieving reliable hemostasis and precise clamping of bleeding vessels; blotting rather than wiping wounds; applying a rational minimum of sutures placed 0.3–0.5 cm away from the wound edge to preserve maximal Blood supply to the margins; and applying a non-constrictive adhesive wound dressing. High tissue viability is the cornerstone of resistance to infection. When tissue viability is compromised, wound infection can develop even with minimal microbial contamination—far below the critical threshold (which for purulent infection is 10^5–6 microbial bodies per 1 g of tissue).

SURGICAL OFFICE (DEPARTMENT) OF THE OUTPATIENT CLINIC

The majority of patients with surgical conditions are treated in outpatient clinics and ambulatory care facilities. Outpatient surgical care for patients with both acute and chronic injuries is provided in surgical offices and departments of polyclinics, as well as in paramedic stations and trauma centers.

However, the primary role is played by the surgical offices and departments of municipal and district polyclinics. They conduct their operations in compliance with current legislation regulating the structure and scope of their work.

The structure and staffing of surgical offices and departments depend on the polyclinic's layout, the number of patient visits per shift (polyclinics are categorized into 5 tiers based on this, ranging from 400 to 1,200 visits or more), its functions and tasks, and particularly the patient demographic. According to standard healthcare norms, the population's need for outpatient services is estimated at 12.9 visits per year per urban resident and 8.2 per rural resident, which includes 1.4 visits to surgical offices (departments).

The surgical office of a district polyclinic typically consists of two rooms, less frequently one or three. In the first room, the surgeon conducts examinations, registration, and patient consultations; the second room, connected to the first, serves as a dressing room. If the office is single-roomed, the doctor's desk and examination couch are located in one half of the room, while the dressing table is in the other, separated by a screen. If the office or department consists of three rooms, the middle one is equipped as the physician's office for patient consultations, while the two adjacent rooms on either side serve as a dressing room and an operating room, or (less commonly) two dressing rooms—one for clean procedures and one for purulent cases.

In large polyclinics (municipal, regional, etc.), the surgical department comprises four or more rooms: a physician's office, two dressing rooms (clean and purulent), an operating room, a preoperative room, and sometimes a sterilization room. This constitutes a complete surgical-dressing suite.

In a surgical office connected to a dressing room, the Separation of patients with clean versus purulent wounds and infections is achieved through scheduling: patients with clean wounds are examined and treated first, followed by those with purulent conditions. When two dressing rooms are available (without a separate operating room), the clean room is used for the primary surgical care of fresh wounds, clean dressings, and elective surgeries. In surgical departments that also feature an operating room, elective surgeries and the primary treatment of fresh wounds are performed in the operating room.

The premises of a surgical office or department, particularly their dressing and operating rooms, must structurally and environmentally meet all Sanitary and hygienic standards required of equivalent facilities in inpatient surgical units. Measures to maintain aseptic conditions are implemented with the exact same rigor and protocols as in inpatient surgical departments, especially within the surgical-dressing suite. The surgeon's office should contain a minimal amount of simple, sturdy furniture. The required medical equipment and instruments in the physician's room include a negatoscope, a blood pressure monitor, a thermometer; while the dressing room should be equipped with a patient examination table, a supply table for dressing materials, a cabinet for solutions and medications, a sterile instrument table, a stool, a step stool to assist patients onto the table; a FOOT-pedal-operated waste bin for old bandages; drums containing sterile materials and linen, a sterilizer (if centralized sterilization is unavailable), surgical instruments, and syringes. Frequently, it should also include an anesthesia machine, resuscitation equipment, Shock-mitigating solutions, antiseptics, and other medications, including tetanus toxoid and serum (gamma globulin) for tetanus immunization. In addition to overhead lighting, the dressing room must be equipped with portable examination lamps and germicidal UV lamps.

In the operating room, alongside the operating table, there must be a table for sterile linen and materials, an instrument table, stools, a surgical instrument set, syringes, an oxygen supply (centralized or via oxygen cylinders/pillows), an anesthesia machine and anesthetic agents, antiseptics, disinfecting solutions, and local anesthetics.

Operating rooms must be equipped with stationary shadowless and germicidal lamps, as well as portable surgical lights.

Office documentation includes: a patient registration log, an operation log, a vaccination record log, temporary disability certificates along with their tracking log, outpatient medical records, and a register of routine medical examinations, among others.

THERAPEUTIC AND DIAGNOSTIC WORK OF THE SURGICAL OFFICE (DEPARTMENT) OF THE OUTPATIENT CLINIC

Therapeutic and diagnostic work is a vital component of the activities carried out by a polyclinic's surgical office (department). The Scope of services, particularly surgical procedures, depends on the polyclinic's capacity, working conditions (equipment, staffing levels, etc.), the proactiveness and qualifications of the surgeons, the availability of inpatient surgical care in the service area, and A number of other factors. It encompasses: identifying and diagnosing conditions using methods accessible in an outpatient Setting (physical examinations, blood tests, and other biochemical assays; X-ray and endoscopic examinations, etc.); treating various conditions, including minor procedures such as the removal of superficial atheromas and small tumors, foreign body extraction, opening cutaneous and subcutaneous abscesses, cleansing and primary surgical management of shallow wounds and localized superficial (and occasionally deep) burns, treating purulent wounds, trophic ulcers, and certain types of fistulas (including ligature fistulas), etc.; referring patients with diagnosed or suspected—yet unverified—surgical conditions (primarily internal organ pathologies) to an inpatient facility for further evaluation or treatment; issuing referrals and arranging emergency ambulance transport for patients identified with acute abdominal conditions or other acute emergencies; providing follow-up care and dressings for postoperative patients discharged from inpatient units; organizing and participating in disability expert evaluations; developing and implementing medical rehabilitation programs for postoperative patients; conducting medical examinations for individuals applying for employment at specific enterprises or entering educational institutions; providing consultations for patients from other polyclinic departments or home visits; and participating in medical boards and consultations.