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ASEPTIC AND ANTISEPTIC TECHNIQUES

The term aseptic and antiseptic are often used interchangeably. Historically, sterile technique was first carried out with chemicals such as carbolic acid and phenol, which were used on instruments as well as on the skin. This was known as antiseptic technique. With the introduction of steam autoclave and other techniques more effective than chemicals in sterilizing instruments and linens, the term aseptic technique was used to distinguish the newer methods from the older chemical methods. The distinction however, has been lost. Current sterilization techniques rely on both chemical and physical methods.

Aseptic technique then is a body of techniques for ensuring that all bacteria are excluded from the sterile field in which the procedure is done. Although the goal is complete sterility, this is impossible to attain. Every surgical wound is contaminated by at least a few bacteria. These bacteria can come from 5 sources:

1. The operating room physical environment

2. The patient himself

3. The nonscrubbed personnel

4. The scrubbed personnel

5. The operative tools and instruments

Even the most advanced aseptic technique has not yet produced a complete absence of bacteria from the operative environment. Nevertheless, attention to aseptic technique is still of utmost importance in minimizing the risk of infection in all surgical procedures.

The greatest source of contamination in a basically clean operation is the operative environment, a term that covers every other element in the operating room, from the nonscrubbed personnel to the air over the surgical wound.

Studies of operating room during periods of inactivity indicate that although the walls, the floors, and the furniture may contain considerable numbers of bacteria, these organisms do not enter the air of the room. Bacteria do not become airborne unless they are pushed into the air by blast of air or mechanical brushing.

Human activity accounts for most of the organisms in the air of an operating room. Movement or talking leads directly or indirectly to the dissemination of the major portion of bacteria-containing particles in the air. Thus, the rules of behavior in the operating environment come down to simple common sense and strict “surgical conscience”. Movement should be restricted to those functions necessary to conduct the operation. Talking should be minimal. Any break in the aseptic procedures should be reported and corrected immediately, no matter who does it.

Aseptic technique for the operating room environment

1. The operating room should be cleaned and disinfected regularly and as often as necessary, such as after a dirty case. Chemical fogging or fumigation is used as warranted.

2. A supervisor should control the flow of traffic of people entering the operating room, especially visitors, laboratory, x-ray, pathology and other hospital personnel.

3. All persons entering the middle and inner zones of the operating suite should be in proper operating room attire.

4. Proper operating room decorum should be observed, like no eating, no drinking, minimizing talking and unnecessary movement.

Aseptic technique for instruments, sutures, linens, fluids, and other surgical materials

Steam autoclaving

- under pressure

- normal sterilization cycle, 120°C at 20-25 lb pressure for 30 minutes

- sterilization of drapes, gowns, sheets, towels, lap pads, and surgical instruments not damaged by intense heat

1. Ethylene oxide sterilization (gas)

- chemical sterilization under carefully controlled time, temperature, and humidity conditions

- sterilization of heat labile items

- needs aeration

1. Soaking in germicidal solution

- Formalin

- Iodophors

- Benzakonium chloride

- 70% Ethyl alcohol

- Glutaraldehyde

1. Gamma irradiation of sutures

2. Millipore filtration of fluids

Aseptic technique for the nonscrubbed personnel

1. Proper operating room attire

2. Proper operating room decorum, like minimizing talking and unnecessary movement

3. Maintenance of sterility of sterile operative field, sterile personnel, and sterile instruments and objects

Aseptic technique for the scrubbed personnel

1. Proper operating attire

2. Proper operating room decorum

3. Preoperative aseptic technique

- scrubbing

- gowning

- gloving

- prepping and draping of operative field

4. Operative aseptic technique

- use of sterile surgical instruments and materials

- maintenance of sterility of operative field

Proper operating room attire (Fig. 2)

1. Clean scrub suit

2. Clean shoes and slippers

3. Cap

This should cover all strands of hair and beard to prevent nonsterile objects from falling into the sterile field.

4. Mask

This should cover the mouth and the nose to prevent oronasal droplets from reaching the sterile field.

Scrubbing

Scrubbing is done to decrease the bacterial population of the hands.

The important thing about scrubbing is not the duration but a meticulous, systematic way of scrubbing the hands, forearms, and the distal third of the arms. Fig. 3 illustrates an example of systematic scrubbing. It starts from the fingernails, to the hands, wrists, forearms, elbows, and lastly to the distal third of the arms. It divides the various portions of the upper extremities into planes or surfaces, each plane receiving about 15 strokes of the scrubbing brush. Such a systematic meticulous technique usually takes about 10-15 minutes.

Strictly speaking, there is no such thing as short scrub in between 2 clean cases. Except for those using hexachlorophene, the bacterial count rises to initial values after an hour or so after scrubbing. Thus, there is little or no point in reducing the length of the scrub between two clean cases.

Needless to say, in those situations wherein a surgeon or a nurse has to do another case after a dirty case, he or she has to scrub longer. He may even have to take a bath, if necessary.

There are 2 phases of scrubbing: 1) the preliminary mechanical cleansing of surface dirt and oils and 2) the scrubbing proper. Below is a description of the important steps in scrubbing technique:

1. Wet and lather both hands and arms with soap, extend wash about 2 inches above the elbows. This preliminary wash removes all surface dirt and oils.

2. Rinse off lather. Lather both arms and hands with soap again.

3. Begin scrubbing the fingernails. The nails should have been cut short even before scrubbing and dirt underneath should have been cleansed during the preliminary wash. Hold ends of fingers and thumb evenly together. Apply 30 strokes with the brush. One stroke consists of one forward and one backward motion of the brush.

4. From the fingernails, proceed to the fingers, the webs, the hand proper, the wrist, distal 3^rd of the forearm, middle 3^rd of the forearm, proximal 3^rd of the forearm, elbow, and lastly, the distal third of the arm.

5. Consider your fingers as having 4 planes; the hands, 6 planes, two on the palmar surface, two on the dorsal surface, and one on each side; the forearms and arms, 4 planes each. Give each plane 15 strokes. Do not hesitate to give each plane more than the minimum number of strokes. Be sure to overlap from plane to plane.

6. After scrubbing one extremity, repeat the same systematic procedure on the other extremity.

7. After the scrubbing has been completed, discard the brush. You are now ready to rinse your scrubbed hands and arms.

Rinsing after scrubbing (Figs. 4-5)

The scrubbed arms are rinsed one at a time from fingertips to the elbows. The hands must always be positioned above the elbow during and after rinsing so as to let the water flow from the hands down to the elbows and water dripping to the floor from the elbows. In this way, contaminated water from the hands flow from the elbows and not the other way around. The hands should be kept the cleanest because they are the ones that will come into contact with the patient’s tissues during the operation.

Drying the scrubbed hands

Sterile towels are used to dry the scrubbed hands. These towels are discarded after use.

If sterile towels are lacking, the inferior portion of sterile gown may be used. This portion of the sterile gown, whether used for wiping the hands or not, will be considered unsterile right after gowning. Thus, this portion of the sterile gown maybe used for drying the scrubbed hands as long as one takes care not to unsterilize the sleeves and the upper portion of the gown. The help of a scrubbed nurse in sterile gown and gloves is needed in such a situation. She should hold the upper and middle portions of the sterile gown upwards and away from the scrub surgeon who is wiping his hands on the inferior portion of the gown.

The upper extremities are wiped dry one at a time. Different portions of sterile towel are used for each extremity. The fingers, the hands, the forearms, and then the elbow are wiped dry strictly in that order with no going back allowed.

Gowning

A sterile gown must be worn for major, extensive or lengthy operations. It may not be necessary for a short operative procedure and small operative field as long as the surgeon can reasonably preserved the sterility of the field especially from his forearms.

The gowns are folded in such a way that the surface that a surgeon will be grasping with his scrubbed hands, if there is no scrub nurse to assist him, is the inside part or the part that will eventually become unsterile upon gowning. After grasping the sterile gown from the sterile instrument table, the surgeon should keep the gown high above the ground, away from the sterile table. He should not contaminate areas of the gown that should remain sterile after gowning. Grasping the backside of the neck edge, the surgeons let the gown unfold. He looks for the armholes and put his arms through the sleeves at the same time. A circulating nurse then secures the neck and back closure.

If a double-tie gown is used (Fig. 6), after putting his arms into the sleeves, the surgeon wears his gloves first, unties the bow-knot at the side of the gown, and then lets the nurse with sterile gloves hold on to the tie as he rotates his body to permit the gown to cover the back. He then gets the tie back from the sterile nurse and reties a knot at the side of the gown. This completes the tying of the sterile gown.

After gowning, only portions of the gown that can be easily seen are considered sterile and should be maintained sterile throughout the operation. These areas are the hands, that is, after the sterile gloves are worn, the sleeves up to the front of the gown just below the neck to the waistline or table level. (Fig. 7)

Gloving

There are two techniques of gloving: 1) the open technique and 2) the closed technique. In the open technique, the gloving is done with the hands protruding out of the sleeves (Fig.8). In the closed technique, the gloving is done with the hands still inside the sleeves (Fig. 9). The latter technique is harder but better in terms of less chances of contamination by the unsterile though clean hands.

Sterile powder may be used to facilitate gloving. However, care must be taken so that powder touched by the clean hands does not spill over the sterile gown. This is easier said than done. Thus, a recommendation is, if a surgeon will use powder to facilitate his gloving, he does so after drying his hands and before putting on the sterile gown.

Sterile gloves are folded in such a way that the parts grasped by the hands in an open technique become the unsterile parts (Fig. 8). Proper gloving not only entails proper aseptic technique but also using the proper-sized gloves with absence of wrinkles.

All gloves must be immediately changed once punctured or unsterilized. A circulating nurse should remove the unsterilized gloves making sure she does not touch the sterile surface of the gown of the surgeon.

If both gloves and gown need to be changed, the gown is always removed before the gloves.

Prepping the operative field

The operative field is prepared through the following aseptic technique: 1) mechanical cleansing and scrubbing using detergents and 2) sterilization using antiseptic solution like iodophors or benzalkonium chloride. Body surface hairs encroaching upon the operative procedure should be removed either by shaving or depilation a few hours or minutes before the operation.

The extent of preparing depends on the proposed operative field, as well as the areas of possible extension. As a rule, it is better to overprep than to underprep. Fig. 10 illustrates some examples of the area of prepping for several types of operation.

The duration or time that maybe considered as adequate prepping with an antiseptic solution is 5 minutes. Residual bacterial count drops markedly during the first minute and progressively less during the second and third minute. After 5 minutes the count will be minimal.

The direction of prepping with an antiseptic solution begins at the areas where the incision will be made and gradually goes outward or peripherally (Fig. 11). Where there is a dirty area to be prepped, the clean area is prepped first and the dirty area last (Fig. 12).

Draping the operative field

The proposed field that has been previously prepped is enclosed using sterile towels each folded one-third back on itself. The towels are then stabilized with clips or sutures (Fig. 13).

To minimize the contamination of sterile operative field as well as the sterile gowns of sterile personnel, the rest of the patient’s body and the whole operating table are covered with sterile drapes. It is only after this has been done that the surgeon and his assistants wearing sterile gowns can go near the operating table. Although the patient and the whole table are covered with sterile drapes, only the top surface of the drapes and the area above the table level are considered sterile. Thus, sterile instruments, sterile sleeves and gloves should always be kept above the table level.

A sterile operative field (Fig. 14) is thus surrounded by sterile towels and drapes, sterile instruments, and the surgeon and his assistants with sterile gowns and gloves. The sterile field must be maintained sterile throughout the operative procedure. Any break in the aseptic technique should be corrected.