Understanding Surgical Asepsis and Sterile Technique

Surgical asepsis and sterile technique are crucial in medical procedures to prevent infections. Principles, practices, and procedures ensure a sterile environment for invasive procedures. This involves maintaining asepsis and sterile conditions in operating rooms and other medical settings. Healthcare workers must adhere to specific principles to protect patients from infections.

• Surgical Asepsis
• Sterile Technique
• Infection Control
• Operating Room
• Medical Procedures

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1. OR Sitting and Sterile Technique OR Sitting and Sterile Technique Zohair Al aseri, FRCPC (EM&CCM)

2. OR Sitting and Sterile Technique References Bailey and love https://opentextbc.ca/clinicalskills/chapter/sterile-gloving/ https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/ https://opentextbc.ca/clinicalskills/chapter/entering-the-operating- room/#navigation Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014

3. OR Sitting and Sterile Technique OR Sitting and Sterile Technique Objectives Introduction Aware of common sterility definitions Surgical Asepsis and sterile techniques Principles of sterile technique Surgical instruments and disinfection Operating Room Environment Preoperative preparation immediately before surgery Skin preparation PREPPING AND DRAPING

4. Surgical Asepsis and sterile technique Surgical Asepsis and sterile technique Surgical Asepsis and sterile technique Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all microorganisms within any type of invasive procedure. Sterile technique is a set of specific practices and procedures performed to make equipment and areas free from all microorganisms.

5. Surgical Asepsis and the Principles of Sterile Technique Sterile technique: Most commonly practiced in operating rooms, labour and delivery rooms, and special procedures or diagnostic areas. Could be at the bedside, such as inserting devices into sterile areas of the body or cavities: Insertion of chest tube Central venous line Indwelling urinary catheter Used when the integrity of the skin is accessed, impaired, or broken (e.g., burns or surgical incisions).

6. Surgical Asepsis and the Principles of Sterile Technique Principles of Surgical Asepsis All personnel involved in an aseptic procedure are required to follow the principles. It is the responsibility of all health care workers to speak up and protect all patients from infection.

7. Definitions Definitions Aseptic non-touch technique: means maintaining asepsis by not touching sterile equipment or areas with the intent of reducing the risk of transmission of infection to patients Circulating (non-scrubbed) personnel: means staff that work in the periphery of the sterile field. Circulating personnel wear non-sterile scrubs and cover wear to perform duties such as delivering equipment and supplies to the surgical staff, documentation, and specimen handling

8. DEFINITIONS DEFINITIONS Closed gloving Technique: Gloving technique in which the hands are not extended from the sleeves and cuffs when the gown is put on. Instead the hands are pushed through the cuff openings as the gloves are pulled into place. https://www.youtube.com/watch?v=MBXhhFBrxCU Doff means to take off. Don means to put on. Open gloving Technique means a gloving technique in which the scrubbed person s hands slide all the way through the sleeves and cuffs when the gown is put on prior to donning gloves

9. DEFINITIONS DEFINITIONS Product for surgical hand antisepsis: product used for surgical hand preparation with the following characteristics: 1) significantly reduces microorganisms on intact skin, 2) contains a non-irritating antimicrobial preparation with broad spectrum activity. 3) fast acting and persistent. The most commonly used soaps for surgical hand washing contain chlorhexidine or povidone-iodine.

10. DEFINITIONS DEFINITIONS Scrub (scrubbed) personnel means staff who work directly in the surgical field. Scrub personnel perform surgical hand antisepsis before donning a sterile gown and gloves. Sterile field means the area around the site of incision into tissue or site of introduction of an instrument into an orifice that has been prepared for the use of sterile supplies and/or equipment. Strike-through means an event whereby sterile drapes or packages become contaminated due to soaking through or forcing through of moisture or air

11. DEFINITIONS DEFINITIONS Surgical aseptic technique means sterile technique used for invasive procedures Goal of surgical aseptic technique is to maintain the microbial count to an irreducible minimum using: Sterile medical device, sterile equipment, sterile gowns, and gloves Hand scrub Patient skin antisepsis Barriers including sterile gloves, sterile gown, masks and sterile drapes It is essential to prevent surgical site infections (SSI) SSIis defined as an infection that occurs after surgery in the area of surgery . Preventing and reducing SSI are the most important reasons for using sterile technique in any surgical procedure.

12. DEFINITIONS DEFINITIONS Surgical drape means material intended for use on a sterile field that provides an adequate barrier to microbes, particulate matter and fluids; tear and puncture resistant flexible moisture repellent low linting antistatic, flame retardant free of noxious odors. Surgical hand antisepsis means the process of removing debris and transient microorganisms from the nails, hands, and forearms; reducing the resident microbial count to a minimum; and inhibiting regrowth of microorganisms.

13. Surgical Asepsis and the Principles of Sterile Technique Safety considerations: Health care providers who are ill should avoid invasive procedures or, if they can t avoid them, should double mask.

14. Surgical Asepsis and the Principles of Sterile Technique Hand decontamination Wash hands prior to each operation using antiseptic surgical solution, with a single-use brush for the nails. six-step hand hygiene technique is now widely adopted Hospitals will have policies for which antiseptic agents are used.

16. Surgical Asepsis and the Principles of Sterile Technique Skin preparation Antiseptics such as chlorhexidine or povidone-iodine applied to the surgical site prior to incision reduce the number of resident organisms Antiseptics containing alcohol must be allowed to evaporate completely before using diathermy.

17. Surgical Asepsis and the Principles of Sterile Technique Surgical instruments Use only sterile or disposable, single-use instruments. Sterile Services Departments (SSD) and is the process for complete destruction of all microorganisms, including spores for reusable instruments . First thoroughly washed in automated washer disinfectors that reach temperatures of 85 95 C (thermal disinfection), remove organic matter and kill most microorganisms except spores. Instruments can then be packed and processed in a steam steriliser or autoclave to destroy any remaining microorganisms and their spores. Pressures above atmospheric are used so that higher temperatures can be achieved (e.g., 121 C for 20 minutes; 134 C for 5 minutes).

18. Surgical Asepsis and the Principles of Sterile Technique Check packages for sterility by assessing intactness, dryness, and expiry date prior to use. Any torn, previously opened, or wet packaging, or packaging that has been dropped on the floor, is considered non-sterile and may not be used in the sterile field. 1. All objects used in a sterile field must be sterile.

19. Surgical Asepsis and the Principles of Sterile Technique Whenever the sterility of an object is questionable, consider it non-sterile. Fluid flows in the direction of gravity. 2. A sterile object becomes non-sterile when touched by a non-sterile object. Keep the tips of forceps down during a sterile procedure to prevent fluid travelling over entire forceps and potentially contaminating the sterile field.

20. Surgical Asepsis and the Principles of Sterile Technique Keep all sterile equipment and sterile gloves above waist level. 3. Sterile items that are below the waist level, or items held below waist level, are considered to be non-sterile. Table drapes are only sterile at waist level. 4. Sterile fields must always be kept in sight to be considered sterile. Never turn your back on the sterile field as sterility cannot be guaranteed.

21. Surgical Asepsis and the Principles of Sterile Technique Set up sterile trays as close to the time of use as possible. 5. When opening sterile equipment and adding supplies to a sterile field, take care to avoid contamination. Place items on the sterile field using sterile gloves or sterile transfer forceps. Sterile objects can become non- sterile by prolonged exposure to airborne microorganisms.

22. Surgical Asepsis and the Principles of Sterile Technique 6. Any puncture, moisture, or tear that passes through a sterile barrier must be considered contaminated. Keep sterile surface dry and replace if wet or torn. 7. Once a sterile field is set up, the border of one inch at the edge of the sterile drape is considered non- sterile. Place all objects inside the sterile field and away from the one-inch border. 8. If there is any doubt about the sterility of an object, it is considered non-sterile. Known sterility must be maintained throughout any procedure.

23. Surgical Asepsis and the Principles of Sterile Technique Front of the sterile gown is sterile between the shoulders and the waist, and from the sleeves to two inches below the elbow. 9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non- sterile areas. Non-sterile items should not cross over the sterile field. For example, a non-sterile person should not reach over a sterile field.

24. Surgical Asepsis and the Principles of Sterile Technique Do not sneeze, cough, laugh, or talk over the sterile field. Maintain a safe space or margin of safety between sterile and non-sterile objects and areas. 10. Movement around and in the sterile field must not compromise or contaminate the sterile field. Refrain from reaching over the sterile field. Keep operating room (OR) traffic to a minimum, and keep doors closed. Keep hair tied back.

25. Operating Room Environment The OR environment has sterile and non-sterile areas, as well as sterile and non-sterile personnel. It is important to know who is sterile and who not, and which areas in the OR are sterile or non-sterile.

26. The Operating Room Environment Sterile OR Personnel: Non-sterile OR Personnel: Anesthesiologist Surgeon Circulating nurse Surgical assistant Technologist, student, or observer Scrub nurse

27. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Preoperative checks with the patient Patient s name Condition Consent mark side All investigations available Sepsis Pre-existing complications

28. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Theatre team s preparation for the operation Theatre team should be given as much notice as possible for the proposed operation. Children are usually put first on operating lists to reduce the anxiety created by waiting. Diabetics and other patients whose conditions are potentially labile should also be put early on the list.

29. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY The theatre list Theatre list should have as a header the date and the details of the theatre, surgeon and anaesthetist. For each operation the patient s name and number, the ward that they will be coming from, the operation title and the side of surgery, if appropriate, should be given.

30. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY The theatre list Anaesthetist should be aware of the operative procedure to estimate the effect on the physiology of the patient. Need for preoperative prophylactic antibiotics should be discussed in advance. Possible requirements such as blood transfusion, platelet infusion or antihaemophiliac fraction before starting the operative procedure.

31. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Types of scrub disinfectant solutions Chlorhexidine gluconate Has a residual effect and is effective for more than 4 hours. It has potent antiseptic activity against Gram- positive and Gram- negative organisms and some viruses. Only moderate activity against the tubercle bacillus.

32. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Types of scrub disinfectant solutions Iodine Has some residual effects but these are not sustained for more than 4 hours. It is highly bactericidal, fungicidal and viricidal. Has some activity against bacterial spores and good activity against tubercle bacillus. Penetrate cell walls to produce anti-microbial effects. They may be irritating to the skin or cause allergic reactions.

33. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Types of scrub disinfectant solutions Alcohols Highly effective rapidly acting anti-microbial agents with broad-spectrum activity. Effective in destroying Gram-positive and Gram-negative bacteria, fungi, viruses and tubercle bacilli, but are not sporicidal.

34. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Operating room/theatre Temperature and humidity Patients are at risk of becoming hypothermic during prolonged operations. Paralysis, cool intravenous fluid and large exposed wounds all add to this potential problem. To prevent such hypothermia ambient temperatures of between 24 and 26C are recommended. However, most surgeons find such temperatures uncomfortable and fatigue quickly. Ideal working temperatures for surgeons are between 19 and 20C.

35. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Operating room/theatre Temperature and humidity For prolonged operations patient-warming blanket should be used. This is especially important in small children. Relative humidity in theatres should be capable of adjustment in the range 40 60%.

36. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Illumination The light source in theatre should not produce shadow. It should be capable of producing a minimum of 40 000 lux at the incision site.

37. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Ventilatory system Airflow system keeps air fresh It is measured by air changes per hour. Minimum standard number of airflow changes allowed in operating rooms in the is 17 per hour. Laminar flow will generally provide 100 300 air changes per hour and is used in operations in which airborne infection must be avoided at all costs (operations involving implants).

38. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Movement All staff should enter the theatre through the entry zone, which is used for scrubbing and gowning. Amount of movement in and around the operating room and table itself should be kept to a minimum. There should be doors clearly marked for entry and exit, as one-way traffic will minimise the risk of contamination.

39. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Airborne contamination Airborne bacteria in the theatre originate almost exclusively from personnel within the theatre. Person may shed from 3000 to 50000 micro-organisms per minute. The major source is the skin, which is often contaminated with Staphylococcus aureus and other coagulase -Ve staphylococcal species. Bacteria also disperse from the upper respiratory tract.

40. PREOPERATIVE PREPARATION IMMEDIATELY PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY BEFORE SURGERY Airborne contamination Avoid: Excessive or unnecessary movements, Operating room/theatre overcrowding, Poor scrubbing up, gowning and gloving technique, Poor airflow and inappropriate temperatures and humidity

41. SKIN PREPARATION SKIN PREPARATION PREPPING AND DRAPING PREPPING AND DRAPING Skin preparation before surgery (often shortened to prepping ) Aim: Reduce the microbial count on the patient s skin to the minimal level possible Inhibit microbial regrowth and contamination of the wound itself during surgery. Achieved with soaps or detergents and water in the pre-prep phase. Disinfection destroys micro-organisms provided that it comes into contact with them for long enough.

42. SKIN PREPARATION SKIN PREPARATION PREPPING AND DRAPING PREPPING AND DRAPING Skin preparation Pre-prep Skin of the patient must be prepared before formal surgical skin preparation to remove soil and debris. If a plaster of Paris cast has just been removed, the skin should be washed with soapy disinfectant and then washed down with water or saline followed by application of surgical disinfectant ( prep ) prior to the main prep. For patients under- going elective surgery, a shower on the day of surgery with a soapy disinfectant should suffice.

43. SKIN PREPARATION SKIN PREPARATION PREPPING AND DRAPING PREPPING AND DRAPING Skin preparation Skin preparation solution prep The solution used may have an aqueous or alcohol base. Care must be taken that the solution does not pool under the patient pooling can cause a chemical burn.

44. SKIN PREPARATION SKIN PREPARATION PREPPING AND DRAPING PREPPING AND DRAPING Preparing the patient s skin ( prepping ) Performed by staff who are scrubbed up Use aqueous solutions for open wounds, alcohol for intact skin Work from the incision site outwards Repeat at least twice Clean heavily contaminated areas last and then discard the prep sponge Remove excessive prep solution with a dry swab

45. Draping of the operative area Draping of the operative area The purpose of surgical draping is to create and maintain a protective zone of asepsis, called a sterile field Surgical draping involves covering with sterile barrier material, drapes , the area immediately surrounding the operative site. Drape materials should resist penetration of microscopic particles and moisture, limiting the migration of micro- organisms into the surgical wound.

46. Draping of the operative area Draping of the operative area Drapes should be handled only by personnel wearing sterile gloves. Disposable drapes are a more effective barrier to fluid penetration ( strike-through ) and therefore prevent secondary ingress of micro- organisms. Draping should allow access to the whole surgical incision and allow for extensile exposure if this is possibly going to be needed.

47. Draping of the operative area Draping of the operative area Exposed skin around the incision area itself may be covered with a self-adhesive transparent drape, Diathermy and sucker must be firmly attached to the drapes with enough slack to allow free movement. Outer ends of each are then passed off the operating table and from this point are regarded as unsterile.

48. OR Sitting and Sterile Technique OR Sitting and Sterile Technique Objectives Introduction Aware of common sterility definitions Surgical Asepsis and sterile techniques Principles of sterile technique Surgical instruments and disinfection Operating Room Environment Preoperative preparation immediately before surgery Skin preparation PREPPING AND DRAPING

49. Thank you Q&A

50. References Bailey and love https://opentextbc.ca/clinicalskills/chapter/sterile-gloving/ https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/ https://opentextbc.ca/clinicalskills/chapter/entering-the-operating- room/#navigation Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014