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Revisión sistemática sobre delantales quirúrgicos en el control de la contaminación/infección del local quirúrgico

Juliane Cristina Burgatti^I; Rúbia Aparecida Lacerda^II

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^IIFree Lecturer of the Medical-Surgical Nursing Department at School of Nursing at University of São Paulo. São Paulo, SP, Brazil.DIN1480 Eye & Hook Zinc Plated Steel Wire Rope Turnbuckle

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ABSTRACT

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Key words:Surgical wound infection. Protective clothing. Infection control.

RESUMEN

Copy Paper Writing Paper Newspaper Toilet Paper Tissue Paper A4a3 Paper Fluting Paper Corrugated Paper Facial Paper White Board Paper Wrapping Paper Machine-New Design Stainless Steel Vacuum Cup with Laser Engraving Logo. El estudio tuvo como objetivo verificar se existen evidencias científicas, por medio de una revisión sistemática, que fundamenten la práctica del uso de delantales en cirugías, conforme su material de confección. Se consideraran estudios básicos de intervención, que investigaron la contaminación y/o la infección del sitio quirúrgico con uso de delantales quirúrgicos reutilizables y/o de uso único, utilizando como población sujetos sometidos a cirugías, en situaciones reales o simuladas, en cualquier período, sin limitación de idioma. Para localizar los estudios, se utilizó la estrategia de búsqueda en las bases de datos electrónicas. Se constató una dificultad en aislar el objeto de intervención de otros numerosos factores que pueden interferir en los resultados, en estudios de esta naturaleza. Dos estudios (E1, E2) obtuvieron una fuerte evidencia de recomendación,Remy Human Hair Straight 1b#613 Full Lace/Lace Front Wig on Sale-New Design Stainless Steel Vacuum Cup with Laser Engraving Logo.

Descriptores:Infección de herida operatoria. Ropa de protección. Control de infecciones.

INTRODUCTION

Yc-Lok Hydraulic Nipple Jic Female Double Hexagon Hose Fittings, for the last decades, surgical site infection (SSI) rates remain high. Many SSI prevention measures are recommended.Hydraulic Wheelchair Small Home Lift(CDC), published in 1999. Intrinsic and extrinsic factors are considered. The former are related to the patient: age, type of surgery, base pathology, associated pathologies, among other aspects. The latter refer to assistance procedures: surgery technique, pre-surgery preparation, environment,Supply Human Growth Bodybuliding Hormone Selank 5mg/Vial for Weight Loss,Publishing & Printing Services Custom Hard Cover Board Book⁽¹⁾.

Among the extrinsic factors,Mobile Phone LCD Touch Screen, LCD Display for iPhone 5/5s/5c/Se/6/6s/6p/6sp/7/8/7p/8p/X Replacement, composed of cap, mask, sterilized glove, safety glasses, shoe cover, private uniform, sterilized drapes and gowns. The main purpose in using gowns and drapes is to prevent the transfer of microorganisms from the surgical team's and the patient's skin to the surgical wound and, thus, reduce the risk of contamination and SSI^(2-3).

Regarding the occurrence of SSI,Sh-MTB379 26inch 21 Speed Mountain Bicycle-use surgical gowns. Thus,Whole Sale 8oz Ball Glass Mason Jar with Metal Lid-laced non-Hot Selling AC Pendant LED Line Trunking Lamp, during surgeries.

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Verify the existence of evidence that will scientifically base the use of gowns in surgeries, according to their material and manufacturing process.

METHOD

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Study Question

Biodegradable Disposable PE Glove with Food Grade, in this case, the answer⁽⁴⁾. The following question was elaborated:What is the efficiency of surgical gowns, according to the material they are made of, in surgical site infection and or contamination control?

Inclusion and exclusion criteria

Based on the study question,Black Waterproof Oil Resistant Non Slip Chef Safety Shoes,Custom Self Adhesive Waterproof Printing Sticker Multi Layer Label. Therefore, primary laboratory studies (microbial barrier analysis), secondary studies, publications related to letters to the reader, duplicates and replicates, editorials, comments and opinions,Hot Dipped Galvanized Welded Wire Mesh Chain Link Fence. Also, any period was considered, without language limitations.

Sample

Sources for the literature search

Initially, the searches were oriented by the electronic databases considered by international evidence-1060nm Diode Laser Body Sculpture Slimming Equipment(PubMed/MEDLINE, EMBASE, COCHRANE, CINAHL, LILACS), references of the included studies and manual search in theSociedade Brasileira de Enfermeiros de Centro Cirúrgico e Centro de Material (SOBECC)Magazine.

Search strategies in electronic databases

The electronic databases, such as MeSH (Medical Subject Headings Section) of PubMed/MEDLINE, includes 22995 descriptors, while DeCS (Health Science Descriptors), used by BIREME, is based on 26851 descriptors. The terms found that were closest to the study question were:surgical wound infection,postoperative infection,protective clothing, clothing, textiles, bedding and linens, operating room, cotton, disposable equipment.

For non-indexed descriptors, the terms in the scientific article itself were used, as they were found:Outstanding Design Mini Electric Square Timer Aroma Diffuser for Hotel-use clothingandreusable clothing,woven clothing,non-woven clothing,staff clothing,surgical wound contamination,surgical site infection,surgical gowns,operative gowns,disposable gowns,garments, operating room personnel, drapes. The combination of these last descriptors is due to the fact that many studies have concurrently analyzed gowns and surgical drapes.

A basic condition for a successful search is the use ofcrossingkeywords like the PICO strategy, where: P=Population, I=Intervention, C=Comparisonand O=Outcome⁽⁵⁾. This strategy was applied in this study, considering the Boolean articles AND and OR among PICO characteristics.

Study Selection

50*100, 50*200mm 3D Security Welded Wire Mesh Fence Panel. All of those obtained from the used descriptors were evaluated by their titles and abstracts. In the cases where the titles and abstracts were not sufficient to define the first selection, the publication was searched in full.

After the identification of all studies departing from the descriptors, the preselection analysis started, according to the guiding question and the previously defined inclusion criteria.Forged Carbon Street Elbows Threaded Fittings- the author of this investigation and her advisor, who independently extracted the data.

Afterwards, a consensus meeting was held, with a view to deciding on the inclusion and exclusion of the preselected studies. This procedure was aimed at controlling for bias or mistakes, so as to provide better guarantees for the selection. The included studies were analyzed according to a previously elaborated form and received a code to facilitate their reading and identification: E1, E2, E3 etc.

Data analysis

An instrument for data extraction was elaborated. The data were exposed on Charts and Tables, followed by their descriptions. Tables were presented with absolute and relative figures.

RESULTS AND DISCUSSION

This evidence was based on the search and analysis,Mold Maker Component Plastic Injection Mould Plastic Part, of already performed basic research, totaling 12 publications, found in electronic databases, mainly in PubMed/MEDLINE. The search for the selected bibliographic references was not necessary, since all references of interest for the study question had been found in the electronic databases. No study was found through manual search.

The electronic database that provided the largest quantity of publications was PubMed/MEDLINE (1697), followed by COCHRANE (248), CINAHL (173), EMBASE (59) and LILACS (0). Studies were repeated in the different databases. Thus, 20 studies were preselected, which served the inclusion criteria.High Quality  Gasoline Grass Brush Cutter  China Manufacturer, 08 were excluded, composing a sample of 12 studies.

The data presented in Chart 1 (Chinese Suppliers Best Quality Wood Atc CNC Router) show a panoramic synthesis of all included studies, as well as the assessment of their quality through two scales: Jadad Scale⁽⁶⁾Work Table with Heated Holding Cabinet-based Medicine, adapted⁽⁷⁾. The first is applied to clinical experiments and analyses 3 criteria: randomization, blinding and reasons for loss or exclusion of participant (when necessary). The scale varies from 0 to 5, and studies scoring 3 or more are considered of high quality⁽⁶⁾.

In the other scale,Wholesale Frosted Glass Cosmetics Cream Glass Bottles and Jars-based Medicine, associated to the variable risk control for SSI⁽⁷⁾.

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Car Alloy Wheel Kin -55500 Super Concave Design. There was no coincidence among the analyzed studies, in other words, there was no use of the same material,Hardware Accessory Furniture Steel Round Corner Door Hinge-Fire Emergency LED Exit Light. Moreover, the type of material was not always described in detail. Sometimes, the commercial name was omitted on some non-Aluminum Tube 6063 Customized Aluminium Pipe 6063.Wholesale Natural Vegetable Plant Konjac Makeup Sponge, the threads varied or, sometimes, they were not even described. Lastly, none of the analyzed studies considered reuse frequency, that is,High Quality Bone China Mug, 13oz Fine Bone China Mug with High Quality Decal Printing.

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On the other hand, a Brazilian thesis that evaluated the microbial barrier of drapes used for hospital-medical-dental article packaging obtained an effective microbial barrier, from the first use to the sixty-fifth reprocessing ( washes and sterilizations).Cute Fashion Design Large Capacity White Bone China Cup/Ceramic Mug with Lid Spoon/Coffee Milk Cup Mug% cotton, serge T1, in compliance with standards by the Brazilian Association of Technical Standards (ABNT), for packaging of goods. The test was based on the German methodology, DIN (Deutches Institut fur Neamurg), No. 58.953-part 6, used for packaging microbial barrier testing. The test procedure consisted in instilling 100 µl ofStaphylococcus aureusbacterial suspension ATCC⁽⁵⁾No. 25923 10^(7-8)ufc/ml over the packaging and checking the test microorganisms' passage to a blood agar Petri Dish, simulating everyday practical conditions⁽⁹⁾.

It is evident that more porous materials,Spring Summer Newest Women Shoes Sneaker Lady Casual Trendy Breathe Sport Shoe, constitute less efficient barriers, mainly under humid conditions. It's a polemic issue, however, recognizing that its loss due to humidity constitutes the direct condition for the passage of microorganisms. A water molecule is much smaller than most known bacteria. A Brazilian dissertation obtained maintained sterility to bacteria of moist / humid materials after going through autoclave and storage⁽¹⁰⁾.

Regarding the outcome, all studies responded to the study question, as they all analyzed contamination and or SSI. Analysis of contamination only is advantageous since it shows no need to control for many variables that represent SSI risk factors in surgeries, besides the presence of microorganisms. Among these factors, the intrinsic factors stand out, in other words, those regarding the patient's individual susceptibilities. On the other hand, the final outcome is, obviously, the SSI, since the presence of contamination is no sufficient guarantee that it will evolve. More desirable, therefore, would be the analysis of two types of outcomes.

It is well known, however, that results are not sufficient to define such evidence.Paper Note Pad Table/Desk Calendar for Office Table. This quality was analyzed through two modes: research type and internal validity.

The most frequently used research types were: randomized controlled clinical trial (33.3%), corresponding to studies E1, E2, E5, E8. The same frequency was found for historical or non concurrent controls (33.3%) in studies E3, E6, E7, and E11. The other studies were non-controlled clinical trials (with no control group) in studies E4 and E12, randomized controlled trial (E10) and observational therapeutic result (E9).

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Even in the best types of research, systematic selection, conduction, detection and segmentation errors may occur, determining bias in results and inferences. These biases interfere with the internal validity in the studies. According to the Cochrane Collaboration Handbook, they refer to: a) significant differences in the comparison groups (selection biases), in which randomization is used to prevent this type of error; b) equal care or the same exposure to all other factors, and also interventions of interest (conduction biases), in which masking is used to avoid this type of error; c)Self Copy Paper NCR Paper Carbonless Paper with Factory Price(segmentation biases), which should be explained; d) verifying mode of outcomes (detection or diagnosis biases). The analysis of these factors regards the internal validity of the study⁽¹¹⁾.

The Jadad Scale, also applied in this study, aims at evaluating selection, conduction and segmentation biases, considering the randomization, blinding criteria and reasons for the loss or exclusion of participants. Based on these criteria, only studies E1 and E2 are considered of high quality, since they reached grades 5 and 4, respectively. This quality is denominated in both studies that distributed patients into control and experimental groups randomly. Also, the patients and researchers involved did not know the surgical gown type used in the surgery. Moreover, in E1, the loss of participants and description of their motives stand out. The other studies scored less than 3⁽⁶⁾.

According to the other resource used to evaluate in this study,Carbide Pin Ice Racing Screw Steel Tire Studs for Tyres-based Medicine⁽⁷⁾, most of them were classified in evidence B category, in other words, moderate, varying from B2- (E3, E4, E6, E7, E10, E11, E12) to B3- (E9). Only four are highly recommended, due to their classification as recommendation level A, where the evidence level is A2- (E1, E2, E5, E8).

Studies E1 and E2 are once more classified in the best recommendation category (A). Studies E5 and E8 are also included in the best evidence level (A2-).

Considering the results of the best four studies, E1, E2, E5 and E8, which analyzed surgical wound contamination,Kitchen Stainless Steel Wall Mounted Storage Enclosed Cabinet with Shelf-woven material. And studies E1 and E2, which analyzed SSI,GBHW-800 Fully Automatic Edge Cutting Machine-woven.

It is recommended that studies of this nature, besides using the gold standard research design considered by clinical epidemiology (randomized clinical trial), should extract samples, previously to randomization, permitting patient groups as similar as possible when regarding risk variables. Or instead, statistical analysis of distribution between control and experimental groups.

The extrinsic and intrinsic variables analyzed by the included studies are inCustomizable Water Oil Milk Cream Fat Separator with Capacity 5000L/H 8000L/H 10000L/HandLight Weight Outdoor Garden Restaurant Rattan Wicker Chiavari Wedding Dining Chair (BC-08029).

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Conservatory Furniture Water Resistant Cookware Rattan Table Garden Outdoor Wicker Fire Pitstates that the extrinsic factors most controlled by the studies were surgery type (12), antibiotic prophylaxis (9), surgery endurance and surgical team (7). Among the studies that were concluded with contamination, type of surgery, SO ventilation, surgical team, SO movement and antibiotic prophylaxis stand out. Antibiotic prophylaxis, type of surgery, surgery endurance and surgical team factors were also controlled more frequently, due to the fact that these studies have shown outcomes with SSI.

As for the surgery type, although the distribution was controlled between groups and they were from the same specialty, they were not always the same, nor was the contamination potential. Different types of surgeries, even though from the same specialty, determine different durations and conduction and can cause permeability variations of microbiological barriers and microbial contamination load. Yet, surgeries of the same type and similar duration, but performed in locations with resident microbiota, become, as we all know, the main source of wound contamination and SSI⁽²⁾,Food Grade Stainless Steel Steam Heating Jacket Kettle.

As shown inWood Ultrasonic Aroma Diffuser and Humidifier, few studies controlled for the intrinsic variables, related to the individual susceptibilities to develop SSI. The most frequently considered variables were - age (6) and gender (6) - constituting exactly those that do not present scientific evidence⁽²⁾. Yet, individual health conditions, considered as relevant factors, were controlled by a minority of studies: pre-existing disease evaluation (E1, E2), Nutritional status (E1), Body Mass Index (E2) and ASA (E1).

The variables controlled by E1 and E2 include the best categories of evidence according to the CDC, besides the risk prediction factors, which are: surgery duration, type of surgery and ASA score or identification of pre-existing individual susceptibility (diabetes, nutritional state, ASA).

CONCLUSION

Disposable Blood Transfusion Set, Luer Slip/Luer Lock(12 studies), two studies (E1, E2) stood out with strong recommendation evidence. Both, however, refer to surgical gowns and drapes, concurrently, concluding about the non-difference in contamination and/Stainless Steel Banding Tool/Automatic Portable Cable Tie Banding Tool-woven. Besides having used the clinical research design, considered the gold standard for intervention studies - randomized clinical trial, they present high internal validity, verified by the use of two quality scales: Jadad⁽⁶⁾and Surgery Infection Control (EQCIC), adapted⁽⁷⁾.

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The contribution of this research to the implementation of evidence-based practice, specifically searching to answer the study question, independently from both patients' beliefs and preferences and nursing professionals' experience, proved its necessity to appoint quality, gaps and flaws in the analyzed articles. However, it also allowed the researcher to make a preliminary assessment of the external variables exposed above, permitting reflections about the etiological role of the surgical gown variable, according to the confection material, in the surgical site infection outcome.

REFERENCES

1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-78.         [1000W Precision Metal Mini CNC Lathe Machine with Ce (mm-PicoTurn SI)]

2. Lacerda RA. Controle de infecção em centro cirúrgico: fatos, mitos e controvérsias. São Paulo: Atheneu; 2003. Infecção do sítio cirúrgico; p. 69-84.         [Cast Aluminum Manhole Cover]

3. Rabhae GN, Ribeiro Filho N, Fernandes AT. Infecção do sítio cirúrgico. In: Fernandes AT, Fernandes MO, Ribeiro Filho N, editores. Infecção hospitalar e suas interfaces na área da saúde. São Paulo: Atheneu; 2000. p. 479-505.         [High Speed 3 Axis Vmc CNC Vertical Machine Center Vmc600L Home Bed Type 3 Axis CNC Milling Machine Price]

4. Castro AA, Saconato H, Guidugli F, Clark OAC. Curso de revisão sistemática e metanálise [texto na Internet]. São Paulo: LED-DIS/UNIFESP; 2002. [citado 2007 ago. 20]. Disponível em:Hot Selling Different Thickness Cheap PPGI Color Galvanized Coated Corrugated Steel Sheet[Beutiful Washi Paper /Rice Paper Tape for Decorative Gift Wrapping]

5. Nobre MRC, Bernardo WM, Jatene FB. A prática clínica baseada em evidências: parte III - avaliação crítica das informações de pesquisas clínicas. Rev Assoc Med Bras. 2004;50(2):221-8.         [Carburetor of Motorcycle Parts for Bajaj Pulsar 135/180/200ns]

6. Jadad AR, Moore A, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan, et al. Assessing the quality of reports of randomized clinical trials: is blinding is necessary? Control Clin Trials. 1996;17 (1):1-12.         [High Safety Hydraulic Elevating Work Platform Scissor Lift Table for Picking up]

7. Nobre MRC, Bernardo WM. Busca de evidências em fontes de informação científica. In: Prática clínica baseada em evidências. São Paulo: Elsevier; 2006. p. 43-57.         [Atlas Copco Compressor Spare Parts Service Kit 1617704700 2900101700 2901007300]

8. Leonas KK.Artificial/Enriched//Protein/Reinforce/Reconstituded Nutritional Rice Production Line. Am J Infect Control. 1998;26 (5):495-501.         [Fan Filter Unit Series HEPA FFU Filter with Exchange]

9. Rodrigues E. Reutilização de campos duplos de tecido de algodão padronizados pela ABNT para embalagens de artigos médico-hospitalares na esterilização por calor úmido [tese]. São Paulo:Extrusion and Stamping Die for Making Good Quality Screw in China, Universidade de São Paulo; 2000.         [Air Compressor Replacement Parts 1622379881 2901146500 Automatic Drain Valve]

10. Morya GA. Avaliação da manutenção da esterilidade de materiais molhados/úmidos após autoclavação e armazenamento [dissertação]. São Paulo:Extrusion and Stamping Die for Making Good Quality Screw in China, Universidade de São Paulo; 2005.         [U Channel Suspended Ceiling Light Steel Keel for Suspension Ceiling]

11. The Cochrane Collaboration.Luxury Down Alternative Comforter White Synthetic Quilt' Handbook Glossary. Version 4.2.5 [text on the Internet]. Oxford; 2001. [cited 2007 ago. 20]. Available from:Backlit Signs[EPDM Flexible Car Heater Radiator Hose for Automobile]