- Email: [email protected]
STERILE OPERATING-THEATRE SYSTEM
661 not
passed into the anterior cardiac veins
or
the coronary
sinus.
Thirty-four samples have been taken from sixteen patients using the King’s instrument. Two or more samples have been obtained in each patient using the King’s bioptome, and these samples have been suitable for detailed examination by light microscopy, histochemistry, and electron microscopy.9 No distortion of the myocardial fibre structure was found, and the samples can be retrieved in time to avoid autolysis. I thank Key Med Specialised Medical Equipment Ltd. for their cooperation during the developmental stage of this instrument, and Dr S. Oram for his encouragement and allowing me to investigate his patients. REFERENCES 1. 2. 3.
4. 5. 6.
7.
Konno, S., Sakakibara, S. Dis. Chest, 1963, 44, 345. Konno, S., Sakakibara, S. Circulation, 1964, 30, suppl. III, p. 108. Konno, S., Sekiguchi, M., Sakakibara, S. Radiol. Clins N. Am. 1971, 9, 491. Somers, K., Hutt, M. S. R., Patel, A. K., D’Arbela, P. G. Br. Heart J. 1971, 33, 822. Sutton, D. C., Sutton, G. C., Kent, G. Q. Bull. N.W. Univ. med. Sch. 1956, 30, 213. Weinberg, M., Raffensberger, J., Driscoll, J. F., Sutton, G. C., Tobin, J. R. Circulation, 1963, 28, 823. Sutton, G. C., Driscoll, J. F., Gunnar, R. M., Tobin, J. R. Progr. cardiovasc. Dis. 1964, 7, 83.
8.
Richardson, P. J. Paper read at a Ciba Foundation guest meeting on Cardiac Biopsy in Cardiomyopathies held in London on Oct. 1, 1973 (in the press). Olsen, E. G. J. Personal communication.
9.
Diagram of the proposed
Four main sources of pathogenic agents must be taken into account: (1) the theatre walls and the instruments, trolleys, drapes, swabs, and other equipment necessary to carry out the operation; (2) the air in the theatre; (3) the operating team; (4) the patient. We will consider these sources in turn and means of eliminating pathogenic agents from the wound site.
The
System
Theatre
procedures STERILE OPERATING-THEATRE
SYSTEM
R. N. Cox
Department of Aeronautics and Fluid Mechanics, University, Glasgow W2 * D. D. GLOVER
Department of Aeronautics, City University, London EC1
S. J. S. LAM South-East
Metropolitan Regional Hospital Board, London
Assuming that normal sterile procedures are adopted and that the air-supply to the operating-theatre is filtered, the only other sources It of infection are the surgical team and the patient. is proposed that the surgical team should be totally enclosed in suits of impermeable material and should carry individual air-conditioning units. It is further proposed that the patient should be introduced into an open-ended enclosure of flexible material which projects into the Sum ary
through a hole in the wall of the theatre and which is sealed to the wall opening. After application of a double-sided adhesive strip to the operation site, the flexible enclosure is locally sealed to the strip and the incision is made through both the enclosure and the strip.
theatre
Introduction For many types of operation it is regarded as essential take steps to prevent all extraneous pathogenic agents from reaching the operation site. A common source of to
infection are antibiotic-resistant bacterial strains carried on skin-scales in the 5-30 ju. ranged *
On leave from the
City University.
theatre system.
and equipment.-Conventional and techniques may be used.
sterilisation
Air in the theatre.-It is essential to supply sterile air the theatre. Only enough air is required to ensure that the theatre is at a slight over-pressure with respect to the surrounding rooms, so that the entry of pathogenic agents by way of doors and other openings is prevented. Only a relatively small supply of sterile air is required, preferably filtered down to particle sizes of about 1 M, diameter and with its temperature and humidity suitably controlled. The direction and nature of the air-flow is immaterial in the proposed system. The operating team.-Operating teams conventionally wear gowns and face-masks, but it has been shown3 that skin-scales can nevertheless be transported to the theatre environment. One-piece ventilated garments have been proposed for orthopaedic surgeons.4 We propose that each member of the team, including all surgeons and nurses, should be completely enclosed in light garments of a material impermeable to the passage of pathogenic agents. These garments, similar in concept to space-suits, would be equipped with visors, communication systems, and air supply and conditioning facilities. In particular it is suggested that individual air-conditioners should be carried by each member of the team to avoidthe trailing tubes which are a source of hindrance in existing body-exhaust systems. The accompanying figure shows the theatre (1) provided with a supply of sterile air at (2) and with an outlet at (3). Any convenient method of air supply can, however, be used provided that the air is filtered. The operating-table is shown at (4), and a typical member of the team is shown at (5) enclosed in a garment (6) and carrying an individual airconditioning unit (7).
to
The patient.-The only remaining source of pathogenic agents is the patient. It is proposed that a hole large enough to allow passage of the patient be provided in the theatre wall and that an open-ended enclosure (10) of flexible material impermeable to pathogenic agents and suitably shaped is sealed at its open end around the periphery of the hole (8). The patient is introduced
662 into the enclosure from outside the theatre. Because of the over-pressure in the theatre it may be necessary to use, for instance, a light frame-work to ensure that the enclosure projects into the theatre and to facilitate the introduction of the patient. The operating-table (4) is located below the enclosure (10) and the patient (9) is shown in the enclosure. A suggested procedure is that the operation site should first be covered with a doublesided adhesive incision drape and that after introduction of the patient the enclosure is sealed locally to the drape by one of the operating team. An incision can then be made through the drape and the operation can proceed in the normal way. Comment The advantage of this procedure is that the operation site is exposed to the theatre only through the enclosure (10) and the strip (or incision drape) (11), and the theatre is free of all pathogenic agents other than those from the operation site itself. The administration of anaesthetics and infusions, monitoring, &c., can be effected from outside the theatre: in particular, this contributes to the reduction of hazardous gases within the theatre. A major advantage claimed for the system is that,
besides providing a completely sterile operating environment, it can be manufactured simply and cheaply. It can be either custom-built or constructed as an enclosure in an existing theatre; indeed, it could be constructed in the form of a tent for field-surgery. The system proposed is protected under U.K. provisional patent application no. 51039/73. We express our gratitude for useful discussions held with: Miss Sheila Scott, of the Department of Health and Social Security; Mrs Ruth S. Metzer, of the American Association of Operating Room Nurses; Mr R. P. Clark and the late Dr H. E. Lewis, of the National Institute of Medical Research; Mr W. Whyte, of the Building Services Research Unit, Glasgow University; Dr L. H. Townend, of the Ministry of Defence; and Dr J. M. Bowie, of the Department of Bacteriology,
Edinburgh University. Requests for reprints should be
addressed to R. N. C.
REFERENCES 1. 2.
3.
4.
Davies, R. R., Noble, W. C. Lancet, 1962, ii, 1295. Lewis, H. E., Foster, A. R., Mullen, B. J., Cox, R. N., Clark, R. P. ibid. 1969, i, 1273. Clark, R. P., Cox, R. N. in Airborne Transmission and Airborne Infection (edited by K. C. Winkler and J. F. Ph. Hers). Oosthoek, 1973. Charnley, J., Eftekhar, N. Lancet, 1969, i, 172.
Reviews of Books Clinical Cardiac KEITH
Intractable Pain
Major Problems in Anaesthesia: vol. II. MARK MIEHT2 London : Saunders. 1973. Pp. 287. f6. SINCE nerve blocks form such an important part of in tractable pain relief, it is not surprising that anaesthetist are so interested in them; however, the emphasis through out this book is on intractable pain relief as a multidisci plinary specialty. The book suffers from a defect commo] to all publications which seek to cover a wide area in :: limited number of pages: detail has to be sacrificed, ani many subjects are mentioned only briefly. Migrainou neuralgia, atypical facial pain, and trigeminal neuralgi; form the bulk of non-malignant intractable pain affectinl the face, and would, with more space, deserve thorougl consideration. This is not possible, and Dr Mehta get round the problem by suggesting further reading. Th book is divided into three sections. The first covers th assessment, anatomy, physiology, and theories of pain am provides the background to the rest of the book. Th section on analgesic and allied drugs is sensibly limited Section 2 covers the conditions giving rise to intractable pain and, while it is possible to quibble about the relative importance given to the various conditions all the impor tant ones do get mentioned. Methods of dealing witl spasticity and painful muscle spasms and pain of uncer tain origin are given a short chapter each and Dr Meht, makes practical suggestions for dealing with them. The valuable methods of Winnie and Collins in differentiatin pain of sympathetic, somatic, and central origin are de scribed briefly but adequately. The third and by far thi largest section is that concerned with treatment. The common practical techniques, such as intrathecal pheno in cancer pain, are fairly fully described. The value o neurosurgery, psychotherapy, hypnosis and other therapie are sanely discussed and assessed in the light of the author’s wide experience. Xo excessive claims are made. It essence, this book gives a rapid review of the whole sub. ject of pain relief, and as such will be useful to medica students, anaesthetists in training, and those specialist who need an introduction to the subject of relief of intractable pain.
Radiology
JEFFERSON,
M.A.,
F,R.C.P.,
F.F.R.,
and
ST9i(1N
REES, M.A., M.R.C.P., F.F.R. London : Butterworths. 1973. Pp. 314. 15. Tms new book is intended as a practical guide to the radiology of the heart for radiologists and clinicians. It is based on the study of the films of over 1500 patients for whom the anatomy of the heart and the details of the physiology of the circulation were known. As a result, the authors present an exhaustive and admirably clear account of a very extensive range of cardiac abnormalities. The subject matter is arranged in two parts. The first covers the general radiology of the heart and lungs with an emphasis on anatomy, physiology of the pulmonary circulation, and the changes in disease states. The second part describes various lesions arranged in groups with similar pathology (e.g., shunts with and without cyanosis, obstructions, regurgitations). The book is lavishly illustrated with high-quality reproductions of radiographs and some drawings. Emphasis is placed on the changes to he found on plain chest films, and the corresponding angiocardiograms are used to illustrate the details of the lesions. This careful study of the plain-film changes BB il1 be of great value even to experienced cardiologists and radiologists and should provide a stimulus to the trainee to inspect their material more carefully. The radiographic technique for plain films is described, but angiographic techniques are not. For all but the specialist the understanding and investigation of the lesions in congenital heart-disease are especially difficult, and this section of the book would have been much better with a brief account of the embryology. Furthermore, many of these lesions are very difficult to visualise, and the inclusion of more line drawings would help-as they would in the interpretation of some of the angiograms. No doubt, the authors wanted to avoid allowing the book to become too big. However, this book will become a standard work ( the subject, and some increase in size would be acceptable if it made these difficult aspects easier to follow. Tins
beautifully produced
book is a pleasure to study, and is excellent value for money. It should be in the libraries of all X-ray and cardiac departments and in the mn:’’ libraries of hospitals and medical schools.
passed into the anterior cardiac veins
or
the coronary
sinus.
Thirty-four samples have been taken from sixteen patients using the King’s instrument. Two or more samples have been obtained in each patient using the King’s bioptome, and these samples have been suitable for detailed examination by light microscopy, histochemistry, and electron microscopy.9 No distortion of the myocardial fibre structure was found, and the samples can be retrieved in time to avoid autolysis. I thank Key Med Specialised Medical Equipment Ltd. for their cooperation during the developmental stage of this instrument, and Dr S. Oram for his encouragement and allowing me to investigate his patients. REFERENCES 1. 2. 3.
4. 5. 6.
7.
Konno, S., Sakakibara, S. Dis. Chest, 1963, 44, 345. Konno, S., Sakakibara, S. Circulation, 1964, 30, suppl. III, p. 108. Konno, S., Sekiguchi, M., Sakakibara, S. Radiol. Clins N. Am. 1971, 9, 491. Somers, K., Hutt, M. S. R., Patel, A. K., D’Arbela, P. G. Br. Heart J. 1971, 33, 822. Sutton, D. C., Sutton, G. C., Kent, G. Q. Bull. N.W. Univ. med. Sch. 1956, 30, 213. Weinberg, M., Raffensberger, J., Driscoll, J. F., Sutton, G. C., Tobin, J. R. Circulation, 1963, 28, 823. Sutton, G. C., Driscoll, J. F., Gunnar, R. M., Tobin, J. R. Progr. cardiovasc. Dis. 1964, 7, 83.
8.
Richardson, P. J. Paper read at a Ciba Foundation guest meeting on Cardiac Biopsy in Cardiomyopathies held in London on Oct. 1, 1973 (in the press). Olsen, E. G. J. Personal communication.
9.
Diagram of the proposed
Four main sources of pathogenic agents must be taken into account: (1) the theatre walls and the instruments, trolleys, drapes, swabs, and other equipment necessary to carry out the operation; (2) the air in the theatre; (3) the operating team; (4) the patient. We will consider these sources in turn and means of eliminating pathogenic agents from the wound site.
The
System
Theatre
procedures STERILE OPERATING-THEATRE
SYSTEM
R. N. Cox
Department of Aeronautics and Fluid Mechanics, University, Glasgow W2 * D. D. GLOVER
Department of Aeronautics, City University, London EC1
S. J. S. LAM South-East
Metropolitan Regional Hospital Board, London
Assuming that normal sterile procedures are adopted and that the air-supply to the operating-theatre is filtered, the only other sources It of infection are the surgical team and the patient. is proposed that the surgical team should be totally enclosed in suits of impermeable material and should carry individual air-conditioning units. It is further proposed that the patient should be introduced into an open-ended enclosure of flexible material which projects into the Sum ary
through a hole in the wall of the theatre and which is sealed to the wall opening. After application of a double-sided adhesive strip to the operation site, the flexible enclosure is locally sealed to the strip and the incision is made through both the enclosure and the strip.
theatre
Introduction For many types of operation it is regarded as essential take steps to prevent all extraneous pathogenic agents from reaching the operation site. A common source of to
infection are antibiotic-resistant bacterial strains carried on skin-scales in the 5-30 ju. ranged *
On leave from the
City University.
theatre system.
and equipment.-Conventional and techniques may be used.
sterilisation
Air in the theatre.-It is essential to supply sterile air the theatre. Only enough air is required to ensure that the theatre is at a slight over-pressure with respect to the surrounding rooms, so that the entry of pathogenic agents by way of doors and other openings is prevented. Only a relatively small supply of sterile air is required, preferably filtered down to particle sizes of about 1 M, diameter and with its temperature and humidity suitably controlled. The direction and nature of the air-flow is immaterial in the proposed system. The operating team.-Operating teams conventionally wear gowns and face-masks, but it has been shown3 that skin-scales can nevertheless be transported to the theatre environment. One-piece ventilated garments have been proposed for orthopaedic surgeons.4 We propose that each member of the team, including all surgeons and nurses, should be completely enclosed in light garments of a material impermeable to the passage of pathogenic agents. These garments, similar in concept to space-suits, would be equipped with visors, communication systems, and air supply and conditioning facilities. In particular it is suggested that individual air-conditioners should be carried by each member of the team to avoidthe trailing tubes which are a source of hindrance in existing body-exhaust systems. The accompanying figure shows the theatre (1) provided with a supply of sterile air at (2) and with an outlet at (3). Any convenient method of air supply can, however, be used provided that the air is filtered. The operating-table is shown at (4), and a typical member of the team is shown at (5) enclosed in a garment (6) and carrying an individual airconditioning unit (7).
to
The patient.-The only remaining source of pathogenic agents is the patient. It is proposed that a hole large enough to allow passage of the patient be provided in the theatre wall and that an open-ended enclosure (10) of flexible material impermeable to pathogenic agents and suitably shaped is sealed at its open end around the periphery of the hole (8). The patient is introduced
662 into the enclosure from outside the theatre. Because of the over-pressure in the theatre it may be necessary to use, for instance, a light frame-work to ensure that the enclosure projects into the theatre and to facilitate the introduction of the patient. The operating-table (4) is located below the enclosure (10) and the patient (9) is shown in the enclosure. A suggested procedure is that the operation site should first be covered with a doublesided adhesive incision drape and that after introduction of the patient the enclosure is sealed locally to the drape by one of the operating team. An incision can then be made through the drape and the operation can proceed in the normal way. Comment The advantage of this procedure is that the operation site is exposed to the theatre only through the enclosure (10) and the strip (or incision drape) (11), and the theatre is free of all pathogenic agents other than those from the operation site itself. The administration of anaesthetics and infusions, monitoring, &c., can be effected from outside the theatre: in particular, this contributes to the reduction of hazardous gases within the theatre. A major advantage claimed for the system is that,
besides providing a completely sterile operating environment, it can be manufactured simply and cheaply. It can be either custom-built or constructed as an enclosure in an existing theatre; indeed, it could be constructed in the form of a tent for field-surgery. The system proposed is protected under U.K. provisional patent application no. 51039/73. We express our gratitude for useful discussions held with: Miss Sheila Scott, of the Department of Health and Social Security; Mrs Ruth S. Metzer, of the American Association of Operating Room Nurses; Mr R. P. Clark and the late Dr H. E. Lewis, of the National Institute of Medical Research; Mr W. Whyte, of the Building Services Research Unit, Glasgow University; Dr L. H. Townend, of the Ministry of Defence; and Dr J. M. Bowie, of the Department of Bacteriology,
Edinburgh University. Requests for reprints should be
addressed to R. N. C.
REFERENCES 1. 2.
3.
4.
Davies, R. R., Noble, W. C. Lancet, 1962, ii, 1295. Lewis, H. E., Foster, A. R., Mullen, B. J., Cox, R. N., Clark, R. P. ibid. 1969, i, 1273. Clark, R. P., Cox, R. N. in Airborne Transmission and Airborne Infection (edited by K. C. Winkler and J. F. Ph. Hers). Oosthoek, 1973. Charnley, J., Eftekhar, N. Lancet, 1969, i, 172.
Reviews of Books Clinical Cardiac KEITH
Intractable Pain
Major Problems in Anaesthesia: vol. II. MARK MIEHT2 London : Saunders. 1973. Pp. 287. f6. SINCE nerve blocks form such an important part of in tractable pain relief, it is not surprising that anaesthetist are so interested in them; however, the emphasis through out this book is on intractable pain relief as a multidisci plinary specialty. The book suffers from a defect commo] to all publications which seek to cover a wide area in :: limited number of pages: detail has to be sacrificed, ani many subjects are mentioned only briefly. Migrainou neuralgia, atypical facial pain, and trigeminal neuralgi; form the bulk of non-malignant intractable pain affectinl the face, and would, with more space, deserve thorougl consideration. This is not possible, and Dr Mehta get round the problem by suggesting further reading. Th book is divided into three sections. The first covers th assessment, anatomy, physiology, and theories of pain am provides the background to the rest of the book. Th section on analgesic and allied drugs is sensibly limited Section 2 covers the conditions giving rise to intractable pain and, while it is possible to quibble about the relative importance given to the various conditions all the impor tant ones do get mentioned. Methods of dealing witl spasticity and painful muscle spasms and pain of uncer tain origin are given a short chapter each and Dr Meht, makes practical suggestions for dealing with them. The valuable methods of Winnie and Collins in differentiatin pain of sympathetic, somatic, and central origin are de scribed briefly but adequately. The third and by far thi largest section is that concerned with treatment. The common practical techniques, such as intrathecal pheno in cancer pain, are fairly fully described. The value o neurosurgery, psychotherapy, hypnosis and other therapie are sanely discussed and assessed in the light of the author’s wide experience. Xo excessive claims are made. It essence, this book gives a rapid review of the whole sub. ject of pain relief, and as such will be useful to medica students, anaesthetists in training, and those specialist who need an introduction to the subject of relief of intractable pain.
Radiology
JEFFERSON,
M.A.,
F,R.C.P.,
F.F.R.,
and
ST9i(1N
REES, M.A., M.R.C.P., F.F.R. London : Butterworths. 1973. Pp. 314. 15. Tms new book is intended as a practical guide to the radiology of the heart for radiologists and clinicians. It is based on the study of the films of over 1500 patients for whom the anatomy of the heart and the details of the physiology of the circulation were known. As a result, the authors present an exhaustive and admirably clear account of a very extensive range of cardiac abnormalities. The subject matter is arranged in two parts. The first covers the general radiology of the heart and lungs with an emphasis on anatomy, physiology of the pulmonary circulation, and the changes in disease states. The second part describes various lesions arranged in groups with similar pathology (e.g., shunts with and without cyanosis, obstructions, regurgitations). The book is lavishly illustrated with high-quality reproductions of radiographs and some drawings. Emphasis is placed on the changes to he found on plain chest films, and the corresponding angiocardiograms are used to illustrate the details of the lesions. This careful study of the plain-film changes BB il1 be of great value even to experienced cardiologists and radiologists and should provide a stimulus to the trainee to inspect their material more carefully. The radiographic technique for plain films is described, but angiographic techniques are not. For all but the specialist the understanding and investigation of the lesions in congenital heart-disease are especially difficult, and this section of the book would have been much better with a brief account of the embryology. Furthermore, many of these lesions are very difficult to visualise, and the inclusion of more line drawings would help-as they would in the interpretation of some of the angiograms. No doubt, the authors wanted to avoid allowing the book to become too big. However, this book will become a standard work ( the subject, and some increase in size would be acceptable if it made these difficult aspects easier to follow. Tins
beautifully produced
book is a pleasure to study, and is excellent value for money. It should be in the libraries of all X-ray and cardiac departments and in the mn:’’ libraries of hospitals and medical schools.