Sterile precaution in Orthopaedic Surgery

                                                                                                                                   

嗾.鳥肫菠  籥覬壇芩

..憾秉  華鷓疿埳儒

蠍.嗾.靘識   酵倇坐鴩桯

 

            ÷繭埭鄋郪芮譎鉲喔敷潸珛挬 漺轉忠眓苂骳岑婰扼僩狶迋鏈漈閩椒﹋ 塾暽 轅敷鉌梒煬韏畛轄轄∩錘я狳冓餌飽疰鉧婰 morbidity 菔芞湇餉Ъ 佸谹方疰恁奿壇珘疻煬韏樿抉戰餑菸謠 銑豕媞揤煬飺狺л肫迋鏈漈閩椒﹋ 仇凊噸薰疺腕 佩朊襲 ̄喬賸痀埸觴竊 ÷羹骳萃棵駍嫘阰 鉬蝜 elective case 慞冓餌 clean surgery 鄋頩÷羹骳萃毯<餔ョ挹 Total joint replacement Spinal reconstruction Щ隞勣均疰蒘 Implant 疚埭邰頩 鄋頩 fracture fixation   庠閫 Instrument 鉖髓珗淶 鉬蝜卄扭酷◆攪蟋駖鏡狶÷  鏡狶÷癒蝔郋觴觴薄茖挬迋●橶 Inflammatory process  徶橶骳鄐譙駖岐谹鉖髓珗淶佬照例﹊捗楮煬餑 Reaction 寥苂廘銵諙錘銧橚轄瞻й豳骳佬靾餑 reaction  庠閫照蒶擗嫣a煉彤芤懧蜓埭唌抇轅匹畛鉌涷禮菔矷疰菠毯臥樿

It will make no sense to use antibiotic as preventive medicine  勣扭鍾я 銑豕媞揤佬轅÷蠍痋奿 慞釓捸疰蒶 prophylactic antibiotic 苂骳扭壅駎籤 漺繚涷證禮珗抌Л蒶剛佬豐嗽揤я疺畛疰隅陓替痀 Post operative infection 銧 廘銵諙錘銧曋桄弄蟈 棋完桄飽疰蒶 Prophylactic antibiotic 併找錘銧橚轄瞻й豳骳 捇轍噸鎳佬弅轄繹霽匹畛蒘魬具嫩譙駖 sterile precaution 銧 ÷羶樿均揤漺邃呯 Antibiotic 鉬蝜÷轔⊿煬頠籤轉佽  鉧證冓避駖鄋郪俋瓣遉橏忭餖骳均畟慞橶∠佬隞供滿挹 Foreign material (Surface of implanted material) 壅樿薄挹岋橏抉 ̄眓駁竻×僱嫩竻 (Biofilm) H暽轄 庠閫鉡郯虮鏑狶 Biofilm 銧樨褽棆喬慞橶鏡狶÷穡苤茖挬鄋郪  Bacteria 迋∩湧觴℅牷 佸谹迗芋髓痀銧橶骳靾駔畛疰間茖挬銧   佴紬扼嘟砫佽媟涷弝天迨谹 antibiotic 佬靾駔畛疰須陓 Biofilm 銧 ÷轔⊿銚 Post operative  infection 蓍 ̄博塹歖=芮煤擏佹捶迮樿巫抉苂湧Ъ÷繭樿完 implant    鄐譙駖岐谹鉖髓珗淶碳妒墊棺狺疺晪轄 碳妒墊棺狺畛牷﹊骳佴紬扭妏碳 鉡郯芤Щ方砳芷刻畟例 方皊樿岔恁奿 方皊樿尬骳萃 方畟 慞倰郯寞 煬韏樿抉戰餑H暽鉡郯芩 Post operative infection 佬噥я疺晪轄 蓍碳均籀捸疰寣毈卄狳來鉬蝜菟竻轅÷羹骳萃換橔邯﹌籤瞻識擏鉧郯芤恁奿檠з菠毯臥樿塹 碳岔畟迗豕迠盓 limb amputation 譙迋狳鉌梒肪л萎湧 湧Ъ鉖華敷棋均髓痀彄溘儤湇棻慞識﹎砡瓚種勿牷繩涷遄涷藉a竻來鉬蝜菟竻遉橏膍勣弄竊﹛疰鉭郪竻菟飾竻÷羶耽碧菠萃ч擋駖霽獌÷呏竻÷繭埭鄋郪侲侜骳塹殫呯轄◎涷忐

                                                                                     

Wound infection rate after general surgical operation

Clean

1-2%

Clean-contaminated

<10%

Contaminated

15-20%

Dirty

<40%

    

            Wound Infection 遄埭例 bacterial contamination 蓍廒 迕腕牷疰菠毯臥樿鉬蝜庍棵駍飽挹

                        - 來嘎 bacteria                            - 疚埭卄 bacteria

                        - ÷羹骳萃晰涷蓍 mucous surface      - ÷藪梏痀迮埭鄋郪俁嘔骳均畟∟芧潸珛挬

                        - ÷辭芷 prosthetic implant

慞陔悝H暽× risk factor 邯﹌籤蟬鎔狶 malnutrition, metabolic disease 鄋頩 DM immunosuppression, Colonization and translocation of GI tract, Poor perfusion , Poor surgical technique.    Elek Conen 銧曋荂疰毀攪妝桭 Staphylococci 遉橏蓍樊г塾彤疺疺蹊勻噥я珔橏轅鉎扞佹 (Silk stitch) 苂湆湧Ъ慞橶佬照蒶歖√插疰菠毯臥樿煬頛堌佴悝銧殪朝膋 Bacteria 煬閮郱赶呯遄埭÷繭埭鄋郪俁麂蚢Л煬頩樿癒я瓞堌說菠 勣 10,000 鈮骳 慲揮я牷疰轅彸閫廙禳酷芩苂湆蓍鏡狶÷臏梩韁赶呯鏡狶÷轉戰餑匹畛鉌涷禮菔矷疰菠毯臥樿並唭

           

Bacteria

            漺罈△ intact epithelial surface 佬鉬蝜萃У樿均揤÷繭埭鄋郪 bacteria barrier 塹曊晼照籤繚揤煬漺癒疰潸珛挬  抌Л慬髓孚涷轄卄 bacteria 塾暽轄銧擉牷侜畟煉 蓍煉庇捇癒藤褶桎ы銓狳轄例 Visceral organ 佸谹邰頩   廘魬僩狶 Orthopedic  Surgery 瘉骳 98% orthopedic infection 塾暽 contaminated organism 抌Л蒶剛轄例∼嗶牷疿  漺 30% 卄抉臥樿佬窗襲例﹠牷疿蒘魨敷漺繕癟 煬魰侜谹佬窗襲隞苂湆犒潮珨椇骳萃氮瓚遉橏忭魨敷蓍煬駔奡   例★桄 Bacteria 冓÷迮埭 (adhesion) × biomaterial damaged tissue surface 庠閫鉬蝜C暽腴嫗獺卄均疰 colonization 鉡郯侲√插疰遄眓菠氮體ч臥樿抌Л蒶剛佬苂湆蓍 biofilm slime layer 煬魰÷迮埭苂湆×獐堌и妠堳紬 biofilm 冓餌嫩 ̄眓駁竻× bacteria 矷例﹋婰扭Ж體芩菔狶

           

Pathogenesis of biomaterial-centered resistant infection

            漺罈△婄避駖轅÷ contamination 卄抉臥樿熁戈a疺湆碳氮敷  鄋郪侲侜骳塾暽佬嗨◎蚥畟漺 host defence system  癒鉲暽蓍 ̄博煬餑梬悃供繕駖隞塹 銧殧∟ 鄋郪俋瓣酵埡珜轄  檠з濟轂尺橧×匱埭說菠  ÷繳珒鄖蝥卄尬堌鉆郪侲豐駖  轅и妠嵎酷◆攪錨嫗敷 慞冓塽樿鉰郯芮譎鉲章桄飾珒鉣谹港韶纓樲  庠閫佬照蒶憿疰照籤 Bacteria 照銧毈錘椎   

 

C暽腴飽疰遄埭÷繭埭鄋郪俁嘛痀郱涷轅 biomaterial foreign body 弅轄繹岋婸銧暾悝塹 (檠噱譜﹠)

            1. Bacteria 遉橏忭頨珒廒

            2. Bacteria  遄眓菠插挹樊ヨ竻и妠媌譙虮婰扭酷◆攪蟋骳扳 慞倰狳銧暺譜熆疚鴩牷敷卄 Antiphagocytic effect biomaterial  例★桄 Bacteria  佬鈱婰購鏑狶  biofilm 庠閫佬謹閫駁竻×僱捚蹊嫩竻例  Phagocytic uptake  non-immune antibacterial serum factor

            3. 鉡郯 Colony Bacteria  轅Ⅰ珒蒶剛H暽 ÷繩荍珗卄 ion-exchange Glycocalyx 佬謹閫說駁竻萃  Bacteria  例‾珨耽肪Л  antibody 菔狶

            4. 迗阪捸疰 ̄迮嵂嫩臥樿邰頩佸谹 opportunistic infection 赶呯鉬蝜 polymicrobial infection

            5. 轅÷繩蚥畟 ̄迡晼慞冓塽樿鉰郯祂橏抉孔禮

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Molecular mechanism of Microbial adhesion

            Surface adhesion 卄 bacteria H暽苂湆×瘍恁伈郱狶÷臍瓴卄 bacteria-fluid interface 慞 substratum 卄孚堙樊ヨ竻и妠 鉡郯虮捘槽吽挹 biological environment 佬遄埭檠з轅 film glycoprotein albumin, fibronectin fibrinogen 蓍芾ロ愨 bacteria 佬遄眓菠晰涷樊Ж橶 Van-der-Waals force 例★桄麂冓譎餑轅 hydrophobic interaction ×獐堌и妠. 嗶”牷塹 Barteria 侜畟疚埭覲尬籥 extra capsular polysaccharides 慞 glycoprotein component (Glycocalyx, slime , adhesive , fimbriae) H暽轄匼橧萃ч竻閟砪①

 

Type of cell to-surface interaction  

Class 1:                 physical force , particle changes Van der walls force 慞 hydrophobic interaction  

                Class 2: non-specific chemical binding 菔芞堌и絮, bacteria 邰頩 佸谹 tissue 漺 covalent, polar 佸谹 hydrogen bonding

                Class 3: Specific bacteria receptor to surface protein ligand interaction 例 bacteria receptor surface molecule + Extracullular polymers : the glycocalyx slime and biofilm                

 

Biofilm

檠薦竊夾牷 bacteria 鈱婰鍍箄孝捚慞冓a砪韶÷凅劃譎鉲喔敷檠邃 3-4 祀. 園畛梏痀冓佹眓岏 bacteria 佬岋橏 polysaccharide polymer    Exopolymer 塹擉冓戰餑÷ adhesion 菔芞堌и妠嵎瓚 ̄迮嵂 cell 邰頩 蒶橧砫÷迮埭 庠閫墓隞忭 polymicrobial infection

            嗶”牷塾暽 biofilm slime 佬 resist 菔 host defense 漺藏滿Л phagocytosis , ÷藤挹贊憸竻 antigen presentation 慞陓酵倇埸詳檠麩竻 antibiotic, antibody 慞 phagocyte cell

            Bacteria 慞 biofilm 迗邑晼照蒶憿譜例邇朝愨孝骳 照蒶歖√ distant abscess septic hematogenous emboli 庠閫墓隞忭 distant seeding , secondary infection , exotoxin production 慞 Septic shock

            蓍嵺鋡竻 antibiotic resistance × biomaterial 噥я bacteria 煬魰÷迮埭× polymer 佬鉧婰 resistance 菔 antibiotic 轄﹛я bacteria 犒 metal surface

 

 

 

 

 

 

 

 

 

 

 

 

 

 

           

檠 Electron microscope 卄尬堌и妠媟涷菠毯臥樿 慞  Biofilm

 

÷藤釓挬譜и宏樿均揤廕閫銧歖餌 3 抌Л尤 ÷蹴腕梒謎湇餉Ъ  ÷蹴腕梒褽堣籤 ̄ 慞 呯竻潸珛挬

 

÷蹴腕梒謎湇餉Ъ

            鏡狶÷瞽竻褸婻鎳鉬蝜懊佴苠竻 bacteria 侜畟疚埭 ÷蹴腕梒謄骳均畟樑暺駍 鉬蝜抌Л佴紬坎竻÷羶樿均揤÷繭埭鄋郪祂桄嗾郪僭珗 鈱婰蟋暽萃擏廘銵疰苂湆熁屁觴碳禳駖匱骳萃 園疰陔冓Э牷疰苂湆熁屁觴碳戀桄嗾瘉骳芾Ъ霽 pathogenic bacteria 匱堌佴悝慞凅鼓駖夾還 (nasal carrier state) (S.Aureus)

            樊г塾扭鍾я狳冓餌 barrier 煬韐 廘駍骳菔芩銚蹊 慞陏晬媮Ⅰ 鉬蝜煬駖疿捔卄 bacteria 煬韐淀芾飽揤 樑暺駍薹畛疰嗣餌嗾皊邿豻臥樿遉橏呯竻潸珛挬銧 棋完桄馱Ы迗犒橔湧Ъ antiseptic soap 嘎揤∟芧潸珛挬慞 2 祀. ∟芧潸珛挬 ÷襖珘寥荋橶 hexachloraphane 轅膋樿鎔狶彄鏡侜畟蓍岆淀晶  抌Л煬閮邾骳萃氬呯咍俔①湧Ъ潮疺倰珒 ∟芧隞呯竻潸珛挬樑暺駍瞻Ы體狶鄐譙駖廷蚐狶迋, 傯毯勻郯竻酵迡挹煥〞婩嫗瓚鉬纓餔嫩忑樿潮砫忠眓煬閮冓a皊樿尬骳萃 ÷轎★Ⅰ疑婄Ё潸珛挬匹繩赶嘈樿抉腕梒薑嫣a鈮骳塾暽 鉧證倓牷照煬駎樿尬湇餉Ъ廒韁涷遄埭例﹛疰漶飾嘟畛疰 contaminate room air 湧 蓍呯竻潸珛挬抌Л煬閮郱荂疰潸珛挬佬膋 alcohol-base detergent chlorhexidive povidone iodine 諦﹠捸勻桄 慞迮樿抉芰氬呯慬擏鉧郯芼樿均揤迕僱證穡牷鄐譙駖夾淶靽輸

 

÷蹴腕梒蟋捚卄宋堣籤 ̄

            種勿牷繩涷轅 skin lesion 鄋頩 paronychia 佸谹轅÷繭埭鄋郪 鄋頩 upper respiratory tract infection 匹襠纓﹤纓餔 ÷蹴a砳嘈樿尬骳萃  鉌郪芞橏臾晰荍珗例㊣畟嗶﹦朝鄔懊郱涷鉬蝜 nylon bacteria 遄眓苂湆鉧證陎骳轅 static electricity 棋完桄馱Ы蒘魰忠眓臾揪桄嫘僩涷來鉬蝜苂湆蒫撉奡遉橏呯竻潸珛挬 靾銴Ы岆褶挹÷抉“,  ̄凄酵 佸谹鉌郪芛涷蒘餑狳牷檠繒矷慞橶遉橏轄檠邃嘈樿尬骳萃  蠅褻盓靾銴Ы蒘隤奡照忌嫘嘈樿尬骳萃港韶椒僑橏凳矷漺臏淀忑樿 Gown 勿媮煤 慞苳Ы傯毯勻郯竻酵迡挹 鄋頩 岋樿瞽樿避 ±靻 慞凊侞 迋﹛駖

           

Skin desquamation 遄埭抌Л蒶剛煬銴譆閫髓狶卄岔骳均畟 ÷蹴酷涷繒轄蒘隤奡潮疻埳埳芾Ъ霽來嘎 bacteria 湧 贊犒潮瓟橏臏掅境 ~ 100 mm skin scale 轅Ⅰ珒鉧梒 5-60mm 棋完桄 鉌郪芞橏賡畟靾魬芾 barrier 煬韐   ÷蠍痋奿噥я珘堣勿迗阪 particle 迋”牷鏡狶÷邈湧轄▲盓 100,000-300,000 particle 菔芧珝 慞  microorganism 3,000-5,000 菔芧珝掅紩飽挹√芋藤褶涷照慞冓忑樿潮珝涷岆

棋完桄嫩忑樿÷抉“煬魬抌匹藪 elastic cuff 煬魨Ⅰ慞苠 噥я猁駍藍 bacterial count 銧 47% 

           

 

 

 

 

 

 

竊﹎創卄弄豳﹞臢醜a皊樿尬骳萃 匹癡迮樿坐臢錨呯鈱梒疑樿 漺轉∠獐褶桄弄蟈遉橏檠邃僎橏鉬蝜隞銧擗Ы膋 head cover 煬銴媗鍍體У埭抌Л夫扭瓚友煤擏佹 潮狺臢覬牷慞虼還 (mask) 來鉬蝜苂骳岑婰扼飽疰潸珛挬煬餑 implant 噥я砩朝鄔纓餔轅 bacteria 36 萃 / 太撼 100 太 例 oropharynx            例 ̄棡 湧珗〥珗骳佬鉬蝜÷羶樿均揤煬韐梫涷忐

           

 

 

 

 

 

÷藷橏岐谹∟芧遉橏潸珛挬蒶暺耽碧菠菸謠珛簸珗膋歖Э疰Щ 3-5 境煬 漺 chlorhexidene soap 佸谹 povidone-iodine soap 噥я chlorhexidene soap 轅尺傘褽捄埸涷 broad spectrum 慞陏陔冓Э珝涷之苂湆犒樊г塾岐桯珗﹊骳 povidone-iodine   鉡郯侲Э瓞骳嫣鄘谹卄宋堣籤 ̄煬餕橏廷倰珒慞橶轅獌÷岏淀臥樿銧樿捸例﹤邟郯俉瓚樊Ш畟蓍嗟岐谹

 

 

抌Л暱

膋擏珗

 

Chlorhexidene

Alcohol 0.5%

- Skin preparation

- Cumulative effect

(Hibiscrub)

 

 

 

 

Aques 4%

- Skin preparation

- against gram +ve

 

 

- Open wound

- stable in presence

 

 

 

of pus or fluid

Povidone-iodine

Alcohol 10%

- Skin preparation

- Broad spectrum

(Betadine)

 

 

- Some Sporicidal activity

 

Aques 7.5%

- Skin prep

- antifungal

 

 

- Open wound

 

           

 

呯竻潸珛挬

Aerobiocontamination

            蓍閣 1902 Koch ˍ骳ы①я Probably we cannot expect to eliminate air contamination but certainly some day we should be able to bring this contamination down to more adequate level, and work in a dustless atmosphere

           

佹畟勣 ÷羶嫩閤樿飾竻廒髒骳萃氯朝 bacteria 煬魨〥嘉苂苂湆蓍疑藕牷疿卄弄樿尬骳萃 鄋郪侲侜骳塹歖÷倰蹙銵挹諍頩佸谹鉎冱堌佴悝例 ̄骳均畟 抌Л蒶剛轄例□堌佴悝卄宋堣籤 ̄ 蓍疑藕牷疿說菠 bacteria 瓚弅轔〥嘉苂菔狶 蓍迗÷佬鄐纔駖僩涷腋芫鉲籤 漺臏梛砫佽堥牷÷邊侜卄彤牷疿煬餑捸疰鄐纔駖嫣侞漺瞻嫗瓚彸閫卄抉√毯餌 air turbulence H暽 慞苤疰遜鉬郪芧卄 bacteria 煬鳼錘銧橧狳牷 visceral organ 瘉骳抌Л蒶剛轄例◇藤觴÷蓍呯竻潸珛挬 弅轔〥嘉苂煬餑涴矷疺遜鉬郪芧忭魨敷潸珛挬轄℅恁轅Ⅰ珒蒶剛﹊骳 10 micron 慞倰捄證窗襲轄鈱褘蓍 1 股駍煻 棋完桄麂蚢Л允蓍呯竻菟竻苂湆鈮骳煬閮豻餌嫗瓚靾魰勿郯芧頖ч椒嫣鄘砩朝靾閮豻餌 蠅鍵辣盓÷蹴閩暑譜菱遉橏-迋 ∠弅轄繹遄埭÷繫棷鰻墓閟珘藤觴÷例㊣畟嗶﹤a畛砳嘈樿尬骳萃港湧鄋頩×

 

            蓍呯竻潸珛挬煬鳼錘銧橧捸疰嗉畟鈮迗÷迗防 bacteria 嗶牷疿銧曊盓 3000 colony forming unit (CFU) 菔芚疰狶鉡腕 慞迠橏轅÷藤郕畟迗÷煬韐旍衁駍藍捶蚢Л bacteria 侜谹 200 CFU/m2 飾創煬頞橏菠斯桄抉勻郯竻 Ultra-clean-air 狳霽 bacteia 湧鉖纔 10 CFU/m2   庠閫呯竻潸珛挬廕箋椒褸淶佬庈迗晰涷忐氬僱芧鄋橏煬駖牷疿例㊣畟嗶 佸谹÷蹴a眝矷 慞冓勿郯芧頖ヨ竻種中鷓悝寥苂  棋完桄飽疰供棠荋挹允銚歖擋駖潸珛挬蓍廘餕陎揤 匹臘唻疰勞供棠恁伈苤疰潸珛挬煬駔倰珒∟芧 鄋頩÷蹴酷涷繒a侲煬臏 佸谹÷羹骳萃插譜棻﹋揤侜悝  漺穡挬允銚橝恁伈邿淶遉橏識滿疰潸珛挬∟芧允銚曋涷轅碳氮敷靾駔倰珒  蠅褻盓靾銴Ы供握嫣a煬餑涫敷靾駔倰珒 佸谹吽酵 遉橏潸珛挬壅樿薄挹允銚樿郯寞蓍呯竻a狶鄐梒抉塽駖夾牷迗兒√插疰彄鏡 ̄虼畟鄋郪俋朝潸珗煉宋堣勿牷繩涷鉥埳隞轄譜侞骳孚桄廷竻呯竻銧

            ÷臘挐境 Laminar-air flow 寡狳冓餌馱茧芮煬韐掅竻÷瓣М尺薄疰遜鉬郪芧鄋郪俋瓣蓍疑藕牷疿漺蟬牷疿檠繒矷佬嗨﹛襖 慞

 

 

 

 

 

 

 

pressurized 慞冓餉疻岐砳嫗嘎萃擏例﹤噹珗苂湆檠邃飾芮遉絲涷×暽 庠閫 particle 牷檠繒矷∠佬靾駔畛疰黑樿嫩a畛砳劃譎鉲頃骳萃港湧 廘餕恁伈迡悝ˍ骳ч餌嫣颱湧觴∼僩狶趙埏捄婄壅眓 ̄凊岒褶涷鉬骳襲轄 鉬譏繙鉌避芧寥茧﹌牷轅迖鞀轄〥狶煉均蝔冓√ turbulence flow H暽 棋完桄 靾銴Ы轅и絮媌樿穡牷鉧棍, 滮鍵蕙涷膋曀樿彤矷廕瑭珒 塾閫潸珛挬刳◎赸湧  鄋蝝阹說籀憼瓚擋暽蒶樨倰珒鉌趨

 

 

 

 

 

Surgical Skill

A good surgical technique is the best prophylaxis for infection

            鉆郪侲豐駖煬韏畟例﹛疰潸珛挬, hematoma 例﹛疰呯畛鉣谹晰涷靾韐淀侜骳塹歖餌嗶皊疰煬韐掅竻 bacteria ÷蹴腕梒蟋捚卄庇捇轍噸鎳匹癡迮樿屁鏑芩蓍煥●橏僩桄岔骳均畟, 匹畛贊殧瓚鄐譙駖岐谹         

            蓍譜侞骳均疰潸珛挬鉆郪侲豐駖煥〞墊捶凊呯夾牷敷卄巫褶涷鉬骳轄慞苳й謄樿麂牷侜芫靽 鉬譏繙鉌避芧允鉥埳蓍煩鉣溼畟 ÷羶樿均揤匹繩赶呯鉆郪侲豐駖臥暽湧Ъ isotonic saline 煥 10-15 境煬 4郱涷照÷羶埭廒禳疰蒘 suction drain 迗豕衁駍藍插疰遄埭 hematoma 銧 慞 negative pressure 轅抌Л棉 tissue 遉橏轄耤體×嫩擋駖鉧婰趨捄證÷襠畟卄宋珒廒

           

 

 

 

 

 

佬鉖蝜銧橶骳銑豕捔煬駔閫鉌譎薄疰遄埭÷繭埭鄋郪芛涷廒髒骳萃氮瓚 Orthopedic implant 轅侜畟銑豕捔慞冓避駖轅÷繭埭鄋郪祂紩嘗砡體ョ疰識﹎砫餌嫩譙駖岑牷 抌Л煉岔陎悝駁竻×嘗桷牷轄  廘頨狶л試菟竻膋歖忍僩媢賸疿疻 鄋頩菠毯勻郯竻 ̄竻迗÷慞 Laminar air flow  佸谹 ÷繭挬鉌郪芞骳萃氮犖×凳橔慞陏郕畟迗÷   廘駎籤藉堋梛畛疰須赸湧湧Ъ給閟把朝彸閫煬餑梠蹙魨體 鄋頩÷轔菔孝捚 ÷藷橏岐谹遉橏潸珛挬 ÷癡荂挬來嘎馱嫘嘈樿尬骳萃氮瓚÷蹴勿郯芧頖 鉬蝜菟

 

           

煉局骳蟬芤懧蜓埭啎抇 漺職觴碳攣樿尬骳萃 銧擉挬照轄腕曼飽疰趙埏捄 鉧郯侲餌嫗嘎煉扼飽疰棻慞樑暺駍轍瓚÷癡挬÷繳譎鉲傚樿尬骳萃氬嫗菔瓚и 鉧郯芼譜熆疚壖晪忐

 

÷羶耽碧菠給4冓a畛珨耽碧菠忌嫘嘈樿尬骳萃 卄弄芞骳萃椅捇癒藤薄譜棻

 

1.      鉡郯芩珔盓佴橏呯竻潸珛挬  ̄堻珔芫襖抉琿砡瓚嗟抉琿珝涷蒘餑狳牷a狶嗶﹌樿尬骳萃棹矷

2.  鉬纓餔嫩忑樿潮砫餌鼓奡卄弄樿尬骳萃 漺轉酷涷繒鉌郪 ÷扭“佸谹 ̄凄酵 蠅褶桄抉忑樿煤瞄譙侲忑樿豐斯捚蓍迋●橶轉擋駖匹畛庈迗 例★桄嘟Щ佹ョ∟芧遉橏隞蓍疑婄Ё呯竻潸珛挬 漺繕樿坐臢謎錨呯佹氮瓚樑 mask ∟芧遉橏隞檠邃嘈樿尬骳萃  ÷羹晼 Mask 菟竻勿媮煤擏閡﹥瓚阪晼  ÷羹晼 Mask 煬鳼錘勿媮阪晼∠佬覲廷畛疰黍淀臥樿  S.Aureus 迋℅狳牷瘉婄Ё Nasopharynx

 

 

 

 

 

3.4倰蹙魬嘈樿尬骳萃 鉧郯芫椇骳萃  ̄堻砫椒嘈譙苂袡咍狶例◇譎鉲郭竻 sterile , 漟縟潸珛挬 慞冓菅禮潸珛挬苂骳完樿 1 矷鉆郯竻例﹌樿尬骳萃晶桄馱挹嶀筵菔阹說籀憼瓚鄐譙駖岐谹煬魬芷弝佸挹潸珛挬轅轄”盓卄匹畛鏡Щ避俁飽疰譜蹊棺陎悝÷羶嫩閤樿 (contaminate) 迕麂郱赶呯遄埭÷繭埭鄋郪祂竻廒髒骳萃港湧 慞冓勻郯竻避芮狶肴暽轅臾毯椎藉刳﹤√暑嫩閤樿麂釓梩禳譜滓菔矷疰潸珛挬銧

4.       ̄博煬閮陓橏岐谹鉧郯侲a瓞骳萃  ̄堻砡菔均畟蒶歖譏繙鏑苂 岆賸豳﹞臢謎錨呯佹 傯毯勻郯竻酵迡挹鄋頩 慬Л 佸谹菔狶厒迋﹤擋駖駁竻×飽疰菠毯臥樿慞郅樿均揤÷藤駍巫找颯嫗敷潸珛挬  匹臘挹屣嫩忑樿H暽鉖塽祂樿矷駁竻×凳橔鉬郪芧4陓橏岐谹 慞陓橏岐谹弝佸挹照刲絮÷辭阰 菸謠珛簸珗

5.      ÷辭抌 gown sterile 鉡郯芶橏岐谹鉌醮兕體 壇珘疻潸珛挬 佬鉬蝜樑樨閫潮砫芰期谹, 蒘魰忑樿 gown 瓚嗟岐谹蒶毈錘匹襠謹獐橏鄋蝝避俉瓚鉌郪 gown 竻鉧證邿橔煬韏埭苂湆×瑭谹慞凊Ⅰ迗佯織襲隞蓍 Sterile area 照蒶歖√插疰遜鉬郪芧銧 鉡郯侲岋蝔潸珛挬蒶橝橏坐證箋纔芫煬魰攪迠塈避迋矷∟芧 例★桄麂盓傯普塈避俁抌鞁殫僎悝庠閫й找①a狶侳狶體狶避

6.      蓍 ̄博 infected case 種勿牷繩涷錘銧歖a瓞骳萃氮菔苂湆蓍呯竻潸珛挬塾暽菟竻蒘魰忑樿勿媮腋芫÷羹骳萃毯避駖鉌醮釆骳萃 佸谹佬迋”牷呯竻潸珛挬∟芧÷羹骳萃毯岋蝔蒶曊芫襖抉琿 佹ョ mask ①檠邃嘈樿尬骳萃毯擋駖照÷襖漲骳鄋郪 慞橶鉬纓餔嘔竻鈮橏佹ョ mask 佹頝涷鄖橏佴橏煬閮挬鞁 靾銴Ы鉥埳隞 轄 譜侞骳弄樿尬骳萃晰涷照潸珛挬 case 倰珒×瞄樿 infect

7.      ÷蹴a皊樿完橔 菟竻鉬纓餔嘔竻鈮橏弝佸挹遉橏呯竻寥貣朝鄔懊 鉧郯芼樿均揤÷羶嫩閤樿飾竻彸閫吽酵﹤a畛甡畟蓍呯竻潸珛挬

8.       ̄博煬颲瘉骳樑暺駍繞骳蟬堥例譜檠薦竊均疰潸珛挬彸暽忐 蒶暺耽碧菠鄋頩鉥梒ョ挹 ̄博樑暺駍繕埭鄋郪

9.      ÷辭抌弅薹Л銑巠痀凅呯謫森竊 aseptic technique 漺轉勻閫勻挬 漺邃呯酵苤芮弅 Foley 遉橏×熄塈銑巠痀迮桄扭菔菟嫩擋駖蒶歖餌 Closed system 佬銧暺樿均揤÷羶嫩閤樿

10.  靾銴Ы墓迗刳轔瓚鄐譙駖妥郯褶堙疚埭遉橏轄蓍疑婄Ё呯竻潸珛挬

11.   ̄博轅÷蟾閫肴暽鉆郪侲擋駖腕ヮ戰鉎扜呯墓肴暽鉆郪俔頗芾蓍 10% formalin 朝蒘 formalin 襲隞 3/4 卄尾猁塵煬魬抌肴暽鉆郪 例★桄僱埭臥駖-吽媗 HN 慞迮痋卄尬湇餉Ъ煬飺猁塵疑癡堛婩嫩塽樿 墓隞蒘頞塈 識暑牷嗟扼呯廜頩壅樿褶桄抉G繒蒪抌妒婩嫩塽樿鉣蝖樑∩①煬頠牷嗟 鉧郯芼樿均揤÷蟾閫肴暽鉆郪芞埭嬝珒  漺繕蠅京芮臥駖-吽媗 卄尬湇餉Ъ蒶曊晼菟竻∟芧й扼僩涷供港①蒶

 

廜Й狶÷羶耽碧菠÷藷橏岐谹鉧郯豖捄間疰蒶剛 (Surgical hand washing)

1.      鉞譏臏萃ョ駖嘉橏岐谹

Ø    弝蠅角й醜譏繙鏑苂卄抉忑樿潮瓴挹屣嫩忑樿鉖塽祂樿矷 佹ョ菟竻勿媮撙蒶橚蟈 慞 mask 蒶樿蹙魬僱貤佴閫煬頞晼菟竻

Ø    傯毯勻郯竻酵迡挹煥〞墊棹矷例★婩 慞苠樿避 蠅褶桄孝嵂賸

Ø    鉣蝥避芚樿孝挬蒶樨桄嫗瓚庈迗

2.      豐嘈骳彤骳完橔憩酵釓珜 鉬埭㏒矷寥荋橶瞽樿矷佸谹遉骳 靾銴Ы蒶暽橔蒶鑤癟轄﹤√嫣

3.      ●寥蚋疻橏岐谹湧Ъa虯矷 諦▲椑谹例★婩Щ谹 質畛谹 侜悝避 扯畛墊橶避 邦勣抉佴谹a虯矷酵釓珜 2 墊橶慞陓橏完橔迋﹦朝蒶橧谹苂湆忭均я牶樿矷

4.      侁埏廙癟迋”牷ˍ駖把朝膋憸樿矷●廙暽鉖驗﹥體ъ芷邯℅谹侁埏廙癟 佸谹 園珝涷蒘魨酵抉餌嫗犖靾餑涫駁嫘呯供筵酵扭體Ж盓廙癟迋”牷ˍ駖彤矷轄腕扳  ●寥蚋疻橏岐谹湧Ъa虯矷襲蓍廙癟體狶避 廙癟萃擏廘魰驗 墊橶避 質畛谹 侜悝避 扯畛墊橶避 a芩谹 a狶瓚 1.30 境煬 廙癟屣嫩碳 勣抉佴谹a虯矷酵釓珜 2 墊橶 a狶瓚 1 境煬

5.      體狶寥蚋眝矷漺邃呯寥赸侜例◆籤繒婩Э找誥樿矷慞凅呯避迋蹙駔晪﹊骳a虯矷鉌趨

6.      譜蹊棺陎悝轂蒶樨捘槽妧譎鉲凱郯 煬鳼錘酷芫鄋郪祂創體狶避

7.      廙癟避秅繳 2 襖

8.      鉡郯芶橏岐谹鉌醮阬℅谹煤擏 2 a狶 苂湆譜棋睿 咍狶例△捚鉣蝖寥苂    漺邃呯避迋蹙魰佴谹矷 靾頠譜弅嘗谹

 

 

 

 

遄蝥撙 樑 Mask 芫鄐譙駖宏譜棋

憾筵Ⅰ鉌郪祂紩嫩佴谹矷 

諦﹋稱魨瓚廙癟萃擏廘頠籤臏谹勣抉佴谹矷 5 珝桮畛C暽腴

 

 

 

遉橏隞豐嘔俁嘈樿尬骳萃  避芛桄廷竻豐頩隞湧珗佴橏  忭均я疰迡挹a虯矷 譜и坎樿矷轄庍謎捗×箋忑樿   呯畛侁埏潮砫芰期谹 Sterile

 Scrub Nurse 佬侁埏抌扼呯

 

 

 

鄋蝝避俁呯慬擏  譜и妒畟潮畛疺捘槽吽挹鉌郪 慞陏陎悝寥茖牷屣飽譜鉥蝜隞嗨﹤勻郯竻避

 

 

 

 

 例★桄嗽袡襖鄋頩鉥埡 呯畛侁埏臾 Sterile

Scrub Nurse 佬岆薊奡 Sterile 慞凅抌嗟岐谹蒶  例★桄嘈遽僱捚蒶歖譏繙鏑苂  譜侞骳均疰照潸珛挬靾銴Ы墓避俔賓堙鞁曋涷識﹥鏑 鉆郯竻例﹛疰潸珛挬境嗶狳轅匹畛臥暽遄埭H暽 鉖忸駖慞  Bacteria 迗走祫潸珗鉌郪芞骳萃棹矷轄照蒶 Contaminated

 

C暽腴飽疰棻慞樑暺駍轉避駖轄勣弄樿尬骳萃氮瓚÷藩矷樊г塾

 

1.      鉡郯芞湇餉Ъ轄勣弄樿尬骳萃 壇珘疻佸谹鄖橏佴橏煬駎樿尬骳萃捶郱恁煉翹湇餉Ъ 廜邿茧嫩竻 慞倇鏑狶匹畛尺暽鄐癒挹樑暺駍 慞陔橏翹湇餉ЪH暽鉬饕芧卄弄樿尬骳萃

2.      鉬纓餔嫩忑樿潮珝涷樑暺駍邃抌轄例△痋迋◎桄弄蟈 蠅褻盓臾揪桄嫘 鉧郯芼樿均揤÷繭埭鄋郪芛涷迗巡埭轄×箋忑樿潮珝涷蒘餑狳牷檠繒矷呯竻潸珛挬蠅褶桄抉擋駖匹畛酷芫檐邃飽疰膋歖勻郯竻膋毈蕞橏 漺穡凅芷潮牶竻呯竻潸珛挬勿媮蒶橧埭肴

3.      酵冓轂嘟檠噯堌佴悝疑婄Ё煬閮郱蚍骳萃 慞郅譜и菠÷轔暸觴邯﹞識擏  蠅鍵辣盓÷繭蠅京芮÷繩豻勻郯竻佹畟疑婄Ё煬閮邾骳萃棗骳嗨△樿弄譙俔錘 (恍畟佸谹〥  遉骳佸谹庈熅)

4.      墓樑暺駍轉a皊樿尬骳萃 鉡郯虰埰悜倘彄溘懥湧蒶樲疰虴挹匹畛贊樨痋寣頛湇餉Ъ慞橶併孚荂疰諦□堌佴悝鉧郯

v   ±供捶蚢Л彸閫吽酵﹌譙侲臥樿熁內譎鉲頃堌佴悝煬閮郱蚍骳萃

v   霽來嘎嫩臥樿熁仄涷疑婄Ё樊г塾孚涷佬照潸珛挬蒶歖侜谹寥苂煬駔奡

v   覲甄桄均疰鄖譎冢菠算窖竻鄋郪俋瓣疑婄Ё樊г塾孚涷佬照潸珛挬

4.      蓍 ̄博煬閮凄★Ⅰ疑婄Ё煬閮郱蚍骳萃握Ы照漺轉券皊寥珝涷樑撉蚢珥慞陏釓挬譜и 匹繩虓涷呯竻潸珛挬佸谹∟芧÷羹骳萃港錘境嫩塽駖夾牷÷轎★Ⅰ迗邢赶呯遄埭碳氮敷 庠閫佬鉬蝜獌÷妢赶呯遄埭÷繭埭鄋郪俔湧

5.      鉡郯籵挬瑁瓞湇餉Ъ弝佸挹照潸珛挬鈱梒疑樿轍體 鄖橏佴橏煬鋡竻呯竻潸珛挬佬照÷藩矷照匹畛庈迗智堌佴悝疑婄Ё煬閮郱蚍骳萃 ÷蹴纔矷寥蚋砳飽疰諦□堌佴悝匹辭芷寥蚋珝涷迋_溢婖﹊橏 (broad range) 慞迮樿找錘鉬蝜戰伂駖鏡狶÷ 菟竻譜и均疰彄樲皊譙矷疰彄樨疰照匹畛庈迗 寥蚋珝涷墊臏膋歖芾

§       7.5 % povidone iodine scrub 鉬蝜 intermediate level 轅譟詳懠飽疰勻芮勿媮鄋郪俔湧﹊橏坎й 廘鳼錘弅轄繹照籤薹銓鏈 蓍 ̄博煬頛湇餉Ъ彄 iodine 迗巡樿扼芷寥蚋珛捚邰頩

§       4 % chlorhexidine scrub 鉬蝜 low level 靾駔畛疰須蚥畟妡芤 TB 慞凈Ы捗 廘頝蚥畟廕仄淀譏轍 ̄褽ョ銧暾捸я砡 ̄豁

6.      ÷藩矷樊г塾孝樿尿矷疑婄Ё﹊橏抉擅禮憩菔矷疰潸珛挬侜捸鉣涷禮÷羶嫩閤樿麂牷疑婄Ё靾駔倰珒慞迮樿尿矷蒶憿①狶﹊骳÷羶椇橏sterile 鉆郯竻例﹠狳轅÷璽覲滯竻潮珝涷障蓍4 潸珛挬

7.      ÷藩矷樊г塾孝樿孚蚗畟蒫橨郕 aseptic technique 阹說籀懠飽疰諦□堌佴悝菟竻潸珗÷疆骳鄋郪俉體 慞邾湇照÷藩矷樊г塾孝樿扼抌嗟岐谹 sterile

8.      ÷藩矷樊г塾孝樿抉譎餑疑婄Ё煬閮陓岐桭潸珛挬 ( incision ) ∟芧慞橶諦﹠矷隞煤擏庋坎橏弄譙籵郈矷鉬蝜ロ迋∩領朝襖 境 5 境煬 慞橶鄋蝝諦廷稱駖矷蒶殧呯把朝鄋蝝例◇譎鉲雪涷照潸珛挬∟芧 慞橶併抉芰棵駍嗶郯僱駖 漺邈錘膋曌橏煬魰閤樿嫗體ы韶芰景譎鉲雪涷庈迗氮瓚靾頞椇橏隞轄

9.      ÷藩矷樊г塾孝樿抉芰景譎鉲雪涷諦∼呯庈迗氮瓚慬擏鉆郯竻例﹋疰鄐轅煬頛岏苂湆蓍寥蚋瓵矷覲坐坐橏彤狳∟俁呯遄埭÷邊佹毈湧佸谹迗兒餌嘟郯俔蕞橏蓍 ̄博煬魬芷鄐譙駖夾淶靽輸

蓍÷蹴腕梒謎堌佴悝樑暺駍邃呯﹊橏抉擅禮憩塾暽菟竻太墅序骳÷羹骳萃揪墊晶桄馱谹迖鞀 佬銧歖腕梒謙郪僩涷潸珛挬蒶樴鏑芩  檠噸涷慲揮鉬蝜萃е鎔狶÷蹴腕梒購駍飾竻鏡狶÷繚涷佬潸珛挬 煬魬芷箄苂煉彤芤懧蜓埭啎抇 

 

                                                            

         Back and Spinal surgery              Shoulder and Arm         Flank and Anterior approach to the spine     Elbow to hand

  

 

 

                                                               

       

 

                   Hip and Thigh                               Knee                                         Leg to foot

 

 

鉡郯芛荂疰鉞譏臏樊г塾坎竻樑暺駍轉譏繙鏑苂慞橶 鉡郯芘盓C暽腴飽疰障潮珨證例﹤臥樿鉧郯芞骳萃 鉆郯竻例﹥漱煬鈱梒轅匹畛弅轄繹煬閮  Diapedesis  潸珗潮珨椇骳萃期砪湧 漺轉忠眓園瓞橏塾暽鉬梒〞嵙鍍瓚譜覆鉲籤煬魬芷潸珛挬境  煉屁觴碳攣樿尬骳萃棹芤懧蜓埭啎抇銧曋荂疰酵陔堙蛙膋曊塈嬝疺菠﹜境氬阰頩赸遠赶呯酵疿例﹤臥樿慞邿蚆珨棓樿嫘匱橏障潸珛挬噥я狺й薊郪嫗瓚寥虓涷遄埭蓍疑婄Ё潸珛挬靾隢祫襲隞勣抉菅禮蠅褻盓彸閫吽酵”牷鉞梒均蝔冓a疺湆疑婄Ё潸珛挬銧樲牷H暽

 

 

 

 

 

 

 

 

         潮砫閣癒例﹛疰體狶廒                                    抌Л煬駖蹙魬菟嬝疺菠★橔庠謎骳嫣錘銧

 

÷繩茪й購倰珒呯竻潸珛挬

呯竻潸珛挬鉬蝜妎珗煬駔茪悜蓍÷繩荂疰潸珛挬 ÷繩茪й購倰珒呯竻潸珛挬併抉餌嘟婰廷茪悜 煤擏塹曀樿坐襖漱臢褻盓÷繩茪й購倰珒萃擏廘餖陔苤駖匱骳萃 4郱蚍骳萃 譜侞骳均疰照潸珛挬證繕駖證 鉡郯侲岋蝔彸暽÷羹骳萃氬嫗菔瓚и 腋芫邦÷繩茪й購倰珒蓍 ̄博煬餑捸疰照潸珛挬樑暺駍繕埭鄋郪

 

÷繩茪й購倰珒蓍腴嫩芷牷駖飽疰照潸珛挬

- ÷蹴芰晰茪й購倰珒 阹說籀 鄐譙駖扼芷蓍呯竻潸珛挬 鄋頩疑婄Ё漟縟潸珛挬 股暽遄蝥卄 靽抌竻潸珛挬 菱 X Ray 慞冓芰晾瓞塾妥橶 70 % alcohol  庠閫轅譟詳鼒蚥畟鄋郪俔湧椎 弅轄繹照籤轍漱煬鈱梒 ̄捘瘉  ̄捘驕 TB 慞 鞁識  廘鳼錘弅轄繹照籤薹銓鏈 ÷繩茪й購倰珒佬膋橶堋 spray 佸谹膋曌橏臾 alcohol鄋蝝慞橶酷駖邃呯 alcohol 慬擏閟找錘匹辭芷潮砡呯抉芰毯塽駖夾牷 alcohol 佬迋_溢婖銧暾淀避駖譜鉖邈韶竻

- ÷蹴芰晰茪й購倰珒鉞梒尬骳萃氬飽籀梫涷鉭眓卄抉菅禮潸珛挬照湧Ъи妠媥婄氻Ы膋 1 % chlorhexidine solution 照匹畛庈迗毯擋駖識﹎疺檠麩竻и妠崳呯之溯

- ÷繩茪й購倰珒擋暽呯竻

1 % VIRKON ( chlorine ) 鄋蝝照匹畛庈迗晷郪嫖朝靾韏樿抉芰氮呯

 

÷繩茪й購倰珒蓍4郱蚍骳萃

蓍 ̄博轅鉣谹森譙虮婰坐挬侜桎孝﹋湆擋暽 蒶撽桭寥蚋 1% VIRKON 襲犒鉣谹森譙虮婰坐挬侜桎 慞橶膋憿譜棍刐狶й孚挹 鉧郯肏挹鉣谹暑譜轄 10 л境煬 例★桄嫘抌嗟岐谹庈迗毯芰氮體Л赸遠婩扼僎塈Ⅹ凊揮

 

÷繩茪й購倰珒蓍譜侞骳孚蚍骳萃

- 鄋蝝照匹畛庈迗氯虛邾骳萃 慞冓菅禮潸珛挬 鄋頩鉥梒ョ挹蓍腴嫩芷牷駖嫩譎餑潸珛挬

- ÷繩茪й購倰珒擋暽靾魬芷靾憿й ﹊珒擋暽鉧證虼郱赶呯諍頩諷擏 ̄虼畟 膋曌橏鄋蝝擋暽臾犒橔觴 1 % VIRKON鄋蝝 ﹊珒蠅疑Щ鉎扞佹迋℅瓴鏑芩×

 

÷繩茪й購倰珒鉡郯侲岋蝔彸暽÷羹骳萃氬嫗菔瓚и

- 照匹畛庈迗棹婸 ̄喬菔狶 蓍呯竻潸珛挬 湧Ъ寥蚋 1 % VIRKON 慞橶鄋蝝蒶殧呯

- 照匹畛庈迗晷郪僑橶繒橔暱謎妨恁諦﹥體И棫畛湧Ъ寥豻酷骳邦庈迗氮體ч芰氬呯慬擏

 

÷繩茪й購倰珒蓍 ̄博煬餑捸疰潸珛挬樑暺駍繕埭鄋郪

侜悝照潸珛挬樑暺駍繚涷轅÷繭埭鄋郪迋瞄樿妥橶 bactyl spray 酵釓珜 15 20 境煬 例★桄嫩芰晰茪й購倰珒呯竻慞倰婸 ̄喬 鄐譙駖扼芷湧Ъ寥蚋 1% VIRKON 煤擏塹曌湇餉Ъ煬餑捸疰菠毯臥樿佬照潸珛挬鉬蝜 證薹奡琿畟卄弄樿

 

 閟﹋疰俛狶邴 

        1       Orozco R. Asepsis in Surgery:It special application in Orthopedic

2         Sterile precautions. In : Russell RCG, Williams NS and Bulstrode CJK, ed. Bailey & Loves Short practice of surgery, 23rd ed: Arnold publishers, 2000: 120-4.

3         Wound infection. In : Russell RCG, Williams NS and Bulstrode CJK, ed. Bailey & Loves Short practice of surgery, 23rd ed: Arnold publishers, 2000: 87-98.

4         Prevention of infection. In: EFtekhar NS, ed. Total hip arthroplasty. Vol.1. St.Louis, etc: Mosby-Year book Inc, 1993: 341-94.

5         Gristina AG, Schuler T, Giridhar G. In: Hughes S and McCarthy I, ed. Sciences basic to Orthopedics. London, etc: Saunders, 1998: 117-27.   

6        鈱喧 迗京疻 . ( 2540 ).  ÷臘觴碳韁狶呯竻潸珛挬 ( 戰謙鴗識擏煬 2 ).  ̄塈鈮懍: 熁屁埡樺臾褸媮帊 ̄喬÷蹴﹎腕慬閫酵冓溜銩.

7       熁屁觴碳襯媜疻均籀. ( 2544 ). universal precaution ( 戰謙鴗識擏煬 2 ).  ̄塈鈮懍:           疑埩挶墊К藤薄疰戰謙 ( 酵冓溜銩 ) 來×.

8       AORN (1999 ). Standards, Recommended Practices, and Guidelines. Denver.