【正文】 coholbased rub for three minutes32. An alcoholbased rub should be used for each subsequent case. The use of scrub brushes is not remended. 有學(xué)者最近的一項Cochrane綜述【28】發(fā)現(xiàn)，含有乙醇、異丙醇或正丙醇的酒精擦劑與水溶液相比，對于預(yù)防患者手術(shù)部位的感染具有類似的效果【29】。Hajipour等【30】報道酒精擦劑比洗必泰葡萄糖酸鹽或含碘洗滌劑都更為有效，因為前者可減少術(shù)者手上的細菌菌落形成單位（CFU）。另外還有學(xué)者報道應(yīng)用毛刷對于手部消毒并沒有明顯的效果，并且事實上由于會損傷皮膚反而會增加感染的風(fēng)險【31】。根據(jù)這些證據(jù)，術(shù)者術(shù)前手部消毒推薦的方式為，在當(dāng)天初次刷洗之前或手部嚴重污染時，手術(shù)人員應(yīng)該用肥皂和水洗手，并用指甲簽將指甲下方的污物清理干凈，然后用紙巾擦干。然后，術(shù)者再用含酒精的擦劑涂抹3分鐘【32】。后續(xù)的手術(shù)每次都應(yīng)該用含酒精的擦劑進行涂抹，但不推薦應(yīng)用毛刷進行刷洗。Surgical Site Preparation手術(shù)部位的消毒Chlorhexidine gluconatebased solutions have supplanted alcohol and iodinebased solutions for surgical site preparation. Ostrander et examined the residual amounts of bacteria on feet prepared with a chlorhexidine gluconate, iodine/isopropyl alcohol, or chloroxylenol scrub. They found that chlorhexidine gluconate was superior to the other two preparation solutions in reducing or eliminating bacteria from the feet prior to surgery. Chlorhexidine gluconate skin preparation was superior to either 70% alcohol or iodine in decreasing infection associated with the placement of central venous catheters and the drawing of blood for culture34,35. Thus, the current evidencebased remendations and bestpractice guidelines call for the use of chlorhexidine gluconatebased solutions for surgical site preparation and placement of central venous catheters. 手術(shù)部位的消毒液，洗必泰葡萄糖酸鹽溶液已經(jīng)替代酒精和含碘的溶液。Ostrander等【33】對洗必泰葡萄糖酸鹽、碘/異丙醇或氯二甲苯酚的擦劑消毒足部后，檢測殘余的細菌數(shù)量，結(jié)果發(fā)現(xiàn)在術(shù)后減少或消除足部細菌的功效上洗必泰葡萄糖酸鹽優(yōu)于其他兩種消毒劑。而在置入中央靜脈導(dǎo)管和抽血樣做培養(yǎng)等操作時，應(yīng)用洗必泰葡萄糖酸鹽進行皮膚消毒，相比70%的酒精或碘劑，均可減少感染的發(fā)生率【34,35】。因此，在術(shù)區(qū)消毒以及置入中央靜脈導(dǎo)管時，基于現(xiàn)有證據(jù)的建議和最佳操作指南都提倡應(yīng)用洗必泰葡萄糖酸鹽溶液。Decreasing the Risk of Surgical Site Infection Related to the OperatingRoom Environment降低手術(shù)部位感染相關(guān)的手術(shù)室環(huán)境Although the arcane details of techniques used to sterilize surgical instruments are beyond the expected knowledge of most orthopaedic surgeons, many of a surgeon39。s actions can adversely affect sterilization and increase the risk of surgical site infections. Flash sterilization is a procedure used by operatingroom staff to sterilize instruments or implants with steam, on an asneeded basis. Flash sterilization is not equivalent to sterilization in central processing36,37. In central sterile processing, instruments are properly cleaned and all lumens are inspected。 the instruments are then sterilized and allowed to dry pletely, after which they are delivered in closed containers that ensure maintenance of sterility. Most importantly, the process is performed by trained, focused professionals. The entire process takes three to four hours. Flash sterilization should be used only for dropped instruments or in an emergency situation. Preventable reasons for flash sterilization include an insufficient quantity of instruments, loaner instruments and/or instruments not delivered in time for proper processing, and inaccurate or inplete surgical booking requiring the emergency, unplanned use of instruments and/or implants. 雖然手術(shù)器械滅菌方法中很多不為人知的操作細節(jié)并不是大多數(shù)骨科醫(yī)生都期望掌握的知識，但外科醫(yī)生的很多做法卻可對滅菌過程產(chǎn)生負面的影響，并會增加手術(shù)部位感染的風(fēng)險?？焖贉缇鞘中g(shù)室工作人員常用的一種對手術(shù)器械或內(nèi)置物的滅菌方式，在一些必要的基座之上，應(yīng)用蒸汽?？焖贉缇⒉荒艿韧谥醒霚缇^程【36,37】。在中央滅菌處理中，手術(shù)器械先用適當(dāng)?shù)姆椒ㄇ謇砀蓛?，對所有?nèi)腔都進行徹底的檢查，然后在對器械進行滅菌，并可使其完全干燥，最后手術(shù)器械在運送過程中必須保持密閉的包裝，以確保維持其無菌的狀態(tài)。最為重要的是，這些操作都由經(jīng)過專業(yè)訓(xùn)練的人員完成，整個過程需要34小時?？焖贉缇挥性谛g(shù)中器械掉落或緊急狀況下方可應(yīng)用。有些因素是可以避免進行快速滅菌的，包括手術(shù)器械數(shù)量不足，應(yīng)用替代性器械和/或器械沒有按照合適的操作規(guī)程按時送達，手術(shù)預(yù)約錯誤或不完善需要緊急處理，非計劃性地應(yīng)用手術(shù)器械和/或內(nèi)置物等。To reduce the incidence of flash sterilization, we remend an increase in physician awareness about the inadequacy of the technique。 improvement in the accuracy of surgical booking。 mandating cooperation from vendors to ensure timely delivery of equipment, including financial penalties for late delivery。 purchase of more frequently flashsterilized items。 surgical scheduling to acmodate and mitigate equipment shortages。 and, finally, generation of incident reports when a flashsterilized implant is used in a patient. Adopting these policies and procedures leads to a decrease in the incidence of flash sterilization38. 為了減少快速滅菌，我們建議增強對臨床醫(yī)師的宣傳和培訓(xùn)，使其充分認識到這一方法的不足；提高手術(shù)預(yù)約單的準確性；要求供貨商密切配合，確保相關(guān)設(shè)備及時交付到位，對于延遲送達的應(yīng)考慮適當(dāng)給予經(jīng)濟懲罰；對于以往經(jīng)常進行快速滅菌的器械適當(dāng)增加購買數(shù)量；通過調(diào)整手術(shù)安排以適應(yīng)和緩解設(shè)備上的不足，最后，快速滅菌的內(nèi)置物應(yīng)用于患者后應(yīng)寫出相關(guān)的事件報告。采用這些策略和規(guī)程可有效降低快速滅菌的使用率【38】。Powderless GlovesTraditionally, surgical gloves contained powder to aid in the manufacturing process and to make donning easier. The powder was either talc or lycopodium spores. Because of concerns about granuloma formation and adhesions associated with the use of these substances, cornstarch is now the powder of choice39. However, cornstarch is not benign. It causes foreignbody granuloma formation and delayed woundhealing and can decrease the amount of bacteria required to cause a clinically apparent infection40. Cornstarch also leads to increased latex sensitivity in healthcare workers. TypeI and typeIV hypersensitivity reactions to latex protein in hospital staff lead to increases in sick time and decreased job satisfaction41. Powderless gloves decrease staff absenteeism and eliminate the potential for foreignbody granuloma formation. These gloves cost 25% more than powdered gloves, but the added expense is mitigated by increased productivity of the operatingroom staff41. 無粉手套以往外科手套都是有粉的，這樣在制造過程中便于操作，同時也可使穿戴更為方便，粉末的成分為滑石粉或石松子。由于考慮到應(yīng)用這些粉末可能會形成肉芽腫以及粘連，因此目前一般都選用玉米淀粉【39】。然而，玉米淀粉也不是沒有任何危險的，其可導(dǎo)致創(chuàng)口延遲愈合或形成異物性肉芽腫，并且它可使通常出現(xiàn)感染相關(guān)臨床表現(xiàn)所需的細菌數(shù)量減少【40】。玉米淀粉還會使醫(yī)務(wù)人員對橡膠的敏感度增加。醫(yī)院的工作人員對乳膠蛋白的I型和IV型過敏反應(yīng)會使不適時間延長，并使工作的滿意度下降【41】。無粉手套可減少工作人員的缺勤狀況，且可避免向體外形成肉芽腫的潛在可能。這些手套比有粉手套貴25%，但由此增加的費用會隨著手術(shù)室工作人員工作效率的提高而減少【41】。AntisepticCoated SuturesThe use of antisepticcoated sutures has generated increased interest. These sutures are typically coated with the antiseptic triclosan. Edmiston et al. demonstrated the effectiveness of coated sutures in inhibiting bacterial growth and contamination in an in vitro model42. In a randomized controlled trial, Rozzelle et al. reported a significant reduction in surgical site infection rates following cerebral spinalfluidshunt surger