Asepsis and antisepsis, disinfectans and sterilization

The major theatre

Although aseptic surgery has been done in a tent, under a tree, or on a kitchen table, it is safer if it is done in a room which has been designed to preserve the sterility of the surgical field, to make surgical routines easier, and to prevent mistakes.

Asepsis

The most serious sources of infection in a theatre are bacteria from:

The pus and extcreta left behind by previous patient

The clothes, hands, skin, mounths of the staff

The patient himself

Keeping the theatre as clean as possible, so that the pus and excreta of previous patients are removed

Making sure that the autoclaving is done conscientiously

Minimize the risk of infection by:

Following the rules about the indications for operating, the timing of operations, wound closure, and careful tissue handling

Creating and maintaining the sterile zone

Minimize the risk of infection by:

Sterile zone

The sterile zone

Has to be created anew for each patient in a theatre in which the risk of infection has been reducted as much as possible

Its creation starts when a nurse swabs the top of troley with antiseptic, puts two sterile towels on it and lays out sterile gowns and gloves

The sterile zone

The operations site joins the sterile zone as it is prepared with an antiseptic solution and draped

Nothing which is contaminated must touch anything in this zone until the end of the operation

The sterile zone

If the technique of the team is poor, the sterile zone becomes smaller and smaller as he operation proceeds.

Should be as small as possible . It consist:

Yourself the surgeon

Your assistant, when you need one

The scrub nurse responsible for the instruments

The circulating nurse to fletch and carrry

The anaesthetist

His assistant, if he has one

Operative team

The theatre charge nurse responsible for organizing the theatre

Theatre dresser , who is less educated, but unlike the nurses who come and go, has spent his whole career in the theatre, and so knows its routines and where things are

Two other people are important

Aseptic technique

Entering the theatre:

Anyone entering the theatre must change, in the changing room, into clogs or sandals and into a suit.

Decide which operations nedd gowns, gloves or masks.

Scrubbing up:

Adjust the elbow taps to deliver water at a comfortable temperature

Wet your hands, apply a little soap or forearms to 5cm above your elbows for one complete minute

Wash your forearms

Aseptic technique

Scrubbing up:

Then take a sterile brush and put soap on it

Scrub the lateral side of your left thumb, then its medial side, then the lateral and medial aspects of each succeive finger

Scrub your nails, and then the back and front of your left hand

Do the same with your right hand

Scrub for 5 minutes in all

Aseptic technique

Scrubbing up:

Rinse the suds from your hands while holding them higher than your elbows

Turn off the taps with your elbow

Dry your hands with a sterile towel before you put on a sterile gown

Dry your hand first, then your forearms

Aseptic technique

Scrubbing up:

Grasp the folded towel with the fingers of both hands, then step clear, so that you don´t touch anything with the open towel

Blot your hands on one corner, then dry your forearms

Try not to bring a wet (unsterile) part of the towel back to a dry area

Aseptic technique

Gowning:

Hold the gown away from your body, high enough to be wel above floor

Allow it to drop open, put your arms into the arm holes while keeping your arms extended

Then flex your elbows and abduct your arms

Aseptic technique

Gowning:

Wait for circulating nurse to help you

She will grasp the inner sides of the gown at each shoulder and pull them over your shoulders

Aseptic technique

Gloving:

Dust your hands with powder and rub them together to spread it

Be careful to touch only the inner surface on the gloves

Grasp the palmar aspect of the turned down cuff of a glove and pull it on to your opposite hand

Leave its cuff for the moment

Aseptic technique

Gloving:

Put the fingers of your already gloved hand under the inverted cuff of the other glove, and pull it on to your bare hand

It is a good routine to wash your gloved hands sterile water to remove powder

Now help the next person who has gowned on with their gloves

Aseptic technique

Trauma

The operation site

Shaving:

The operation site should be socially clean before the operation, and you may have to check this

There is usually no need to shave a patient

If you shave him, do so on the morning of the operation, or as part of the operation

The operation site

Shaving:

If you shave him a day or two before , minute abrasions in his skin will become infected and the risk of wound infection will increase

If hair is going to get in the way, all you need to do is to clip it short immediately before the operation

The operation site

Preparation:

Do this as soon as the patient is anaesthetized

Start with a soapy solution, and follow this with spirit, or better if there is a low sensitivity to iodine in the community , usealcoholic iodine

Take a sterile swab on a hoder, start in the middle of the opertion site, and work outwards

The operation site

Preparation:

Discard both swab and holder, and repeat the proces with the second swab

The spirit will evaporate to leave the skin dry

Some surgeon consider thie over-elaborate, and merely use a single application of iodine

The operation site

Preparation:

Be sure to prepare a wide enough area of skin

In an abdominal, operation this should extend from the patient´s nipple line to below his groin

The operation site

Draping:

Wait until he is anaesthetized

Place the first towel across the lowe end of the operation site

Palce another across its nearer edge

Apply a towel clip at their intersection

Place another towel across the opposite edge of the site, and finally one across its upper edge

The operation site

Draping:

Clip them at their intersections

If necessary, grip his skin with the clips, or secure the towels with a stitch

Alternatively , drape him with two longutidunal towels clipped at each end, with a towel above and below

The operation site

Draping:

Then, in an abdominal operation cover his whole abdomen with an abdominal sheet with a narrow quadrangular hole in it

If important areas near the surgeon become contaminated, cover them with fresch sterile towels

The operation site

Swabs and packs:

Use 10 cm gauze squares on spongeholding forceps (swabs on sticks)

You wil also need abdominal packs

The operation site

Cleaning the theatre:

Clean it thoroughly after each day´s list, and completely every week

Cleaning instruments:

Use an old nail brush

Open hinged instruments fully, scrub them, and take special care to clean their jaws and serrations

Boiling and autoclaving

Sterilization is the total desctruction of all forms of life, including bacterial spores

It is best done with heat, either dry heat in an oven, or steam under pressure in an autoclave

Processes (usually chemical) which do not destroy spores are termed „disinfection“

Boiling and autoclaving

The basis of aseptic surgery is to kill all micro-organisms on all instruments and dressings, preferably by exposure to steam under pressure

If this is impractical, imerssion in boiling water for 10 minutes at sea level will kill all viruses and all vegetative bacteria, but not spores, particularly those of tetanus and gas gangrene

Autoclaves

The sterilize is effectively, if there is killing all spores

Autoclaves : simple walled autoclaves

double walled autoclaves

Autoclaves

Autoclaves

Disinfectants and antiseptics

Although heat is the best way of killing micro-organisms, you will have to use chemicals to kill them on a patient´s skin, or on anything which heat might harm, such as drains or some suture materials.

Antiseptics and disinfectants

Skin:

Any alcoholis solution will do

Alcoholic iodine is best:

Use it routinally, except in children, on the scrotum, and in allergic patients

0,5% chlorhexidine in spirit is a less satisfactory alternative

Apply it to skin after removing all traces of soap

Antiseptics and disinfectants

Wounds:

There is no substitude for scrubbing brush, plenty of water from a jug, and a thorough surgical toiler

Chlorhexidine is useful for cleaning the skin round a wound

Antiseptics and disinfectants

Instruments , suture materials and drains:

The following agent are effective against HIV and HBV in addition to the classical pathogens

2% alkaline buffered glutaraldehyde is the best

5% fromlain in 70% spirit

0,5% solution of chlorhexidine in 70% spirit with 0,5% sodium nitrite

Plain 70% spirit

Antiseptic and disinfectants

10 minutes is the absolute minimum time in these soutions, 24 hours is safer

Ideally nothing should be considered sterilized until it has been immersed for 24 hours

Wash all equipment well before using it

Antiseptic surgery

This used to be standard practice before aseptic methods made it obsolete

Aim to sterilize everything coming into contact with the wound by soaking it for a sufficien time in an antiseptic solution

Antiseptic surgery

Antiseptic solutions:

Use chlorhexidine 5% concentrate to make two solutions:

1. A weak solution of 1/2000 of the active agent in water, use this for soakng towels

2. Make up small quantities of solutions frequently, make them up hot, and clean out the containers well between batches

Antiseptic surgery

Sterilizing equipment and drapes:

Soak everithing which will come into contact with the wound in one of these solutions for at least 30minutes.

Soak sutures and gloves in the solutions

Use monofilament for ligatures and sutures, and the minimum number of simple instruments.

Antiseptic surgery

Sterilizing equipment and drapes:

The most appropriate drape, for a tubal ligation, for example , may be a single solution soaked plastic sheet long enough, and widw enough, to cover the whole patient, with a hole in the middle through which to operate.

Antiseptic surgery

Perioperative antibiotics:

For rutine use in antiseptic surgery

Some operators have given their patients antibiotics prophylactically

Antiseptic surgery

While operating:

Treat the patient´s skin with the solution for at least five minutes before the operation

Wash your hands as usual and put on the wet gloves

If you are not using gloves, soak your hands in solutions for five minutes

Antiseptic surgery

After operating:

Rinse everything free of blood

Rinse the instruments, and put them away

If possible carry nothing over to the next operation

Thank you for your attention!