Aseptic Technique

I. Terminology1. Microbe – microorganism too small to be seen with the naked eye

a. Exogenous – environmentb. Endogenous – inside the body

2. Pathogen – microbe capable of causing disease3. Infection – the relationship between a pathogen and its host4. Resistance – the ability of a patient to overcome invasion of pathogen5. Sepsis – presence of pathogens6. Asepsis – complete absence of pathogens7. Sterile – condition of any item that has undergone a cleansing procedure and results in

absence of microbes8. Surgical Asepsis – to maintain an object or area free of microbes9. Medical Asepsis – reduce the number of microbes in general10. Disinfectant – an agent that destroys bacteria or inactivates viruses; used on inanimate

objects11. –cidal – refers to agents that kill microbes

a. Microcidalb. Virocidalc. Germocidal

12. –static – refers to agents that inhibit the growth of microbesa. Microstaticb. Virostaticc. Germostatic

II. Methods of Sterilization1. Filtration – separate particulate material from liquids or gases; used commonly on

medication to sterilize2. Radiation – destroys microbes without causing any temperature elevation; used

commonly on suture and gloves3. Cold Sterilization – soaking instruments in a disinfectant solution (example:

Chlorahexadine or glutaraldehyde). The instruments used for minor procedures or endoscopic equipment.

4. Thermal energy – Autoclavea. Dry heat – used to sterilize materials that cannot tolerate moist heat. Examples

include oils, powders, petroleum productsb. Moist heat – most common for surgical instruments and cloth materials

Temperature: 121.5 C or 250 F

Pressure: 17 psi in SLC (increase 1 psi for every 1000 ft above sea level)

Time: 45 minutes (30 minutes for pre-warmed autoclave)

c. Flash Sterilization used for items that cannot stand the temperature or moisture for long periods of time (Example: drills, syringes). Place the items in a prewarmed autoclave for 10-15 minutes and remove the items.

d. Sterilization indicators:1. Tape – tan with black stripes when sterilized. Place the tape over the pack and

put the date, name of item and initials of the person who wrapped the pack.

2. Chemical sterilization indicators that turns black inside the pack.

5. Gas Sterilization (ETOH) – used on equipment that cannot tolerate moisture or heat. Ethylene Oxide is a colorless gas that is flammable, explosive, and toxic. This gas penetrates paper and plastic film to kill microbes. It takes 24 hours to allow the gas to penetrate each item in the bag. Another 24 hours to air out the packs afterwards before they can be used. Care needs to be taken that there is no moisture left on the items prior to sterilizing because it will create antifreeze.

a. Sterilizer Indicator: tape that is green with red stripes that turn yellow when sterilized.

III. Storage of sterile packs

Item Closed Cabinet Open CabinetSingle wrapped items 1 week 2 days

Double wrapped items 7 weeks 3 weeks

Paper/plastic pouches 1 year 1 year

IV. Common Antiseptic and Disinfectant Agents

Agent Examples Common Uses Spectrum of Activity

Povidone-Iodine Betadine, Iodine Preoperative Scrubs, wounds

Bacteria, virus, fungi, protozoa, yeast

Chlorhexidine Nolvasan , Surgical Scrub, Hibiclens

Preoperative Scrubs, wounds

Bacteria, virus, fungi, yeast

Alcohol Preoperative Scrubs, disinfectant, do not use on open wounds

Bacteria, some fungi

Phenols Hexachlorophene

Lysol

Preoperative hand scrubInanimate objects

Bacteria

Bacteria, virus, fungi, yeast

Quarternary Ammonium

Rocal Used on inanimate objects

Bacteria

Chloride Bleach Disinfectantf Bacteria, virusAldehyde Formaldehyde

Glutaraldehyde

Tissue specimen Antimicrobial

V. Patient Preparation1. Shave the area using a #40 blade and remove the shaved hair by hand or vacuum.2. Surgical Scrub

Start in the center of the incision area and in a circular motion working from the inside out, scrub with iodine or chlorahexadine. Then with the same technique, scrub

with alcohol. Repeat this rotation 3 times. Never go back into the center of the incision area from the outside.

Some clinics will spray iodine over the incision area after the surgical scrub prior to making the incision.

VI. Sterile Fields/Sterile Packs1. Sterile Fields

a. Patient – where the area is shaved and scrubbed or draped

b. Personnel – in front of the gowned person between the waist and shoulders

2. Opening a sterile PackOpen the packs by pulling each tab away from the center. Be careful not to

touch the items in the pack or reach over the pack when opening.

VII. Surgical InstrumentsAvailable in a variety of grades or quality according. German is the top quality and Pakistan is the lower quality. Higher quality instruments may have gold plates and made out of tungsten carbide.

General parts of instruments:a. boxlock – hingeb. ratchet mechanismc. jawsd. finger rings

A. Scapel blades

B. Needle Holders:1. Mayo-Hegar2. Olsen-Hegar3. Mathieu

C. Scisssors1. Operating scissors

a. Mayo: used for dissection and cutting tough tissueb. Metzenbaum: used to cut delicate tissuesc. General surgical scissors

2. Non-operating scissorsa. Bandage scissorsb. Suture removal scissorsc. Surgical wire cutting scissors

D. Thumb ForcepsDesigned to hold tissues with a simple motion and quick release. 1. Brown-Adson: minimal tissue trauma; more delicate tissues

2. Rat-Tooth tissue forceps:more traumatic; used on tough or fibrous tisssues

3. Adson-Hudson : smaller version of a rat tooth tissue forcep

4. Standard thumb forceps : general purpose

E. Tissue ForcepsUsed to clamp blood vessels, tissue stumps and other tissues1. Mosquito: used on delicate tissue

2. Crile: used on tougher tissue

3. Kelly forceps: identical to Crile but serrations only extend distal half of the jaws

4. Rochester-Pean: similar design to Crile but larger and more rugged

5. Rochester-Carmalt: longitudinal grooves with cross grooves at the tips; used for gripping large tissue bundles with crushing action.

6. Allis tissue forceps: relatively traumatic to tissue

F. Towel Forceps1. Backhaus towel clamps

2. Jones towel clamps

G. RetractorsUsed to facilitate exposure of the operating field1. Hand-held retractors

a. Army-Navy retractor

b. Senn retractor

c. Spay hook

2. Self-retaining retractorsa. Gelpi

b. Weitlaner

VIII. Suture Material

A. Terminology1. Suture: material to hold tissues together or provide hemostasis

2. Ligature: a strand of suture material used to tie-off blood vessels to prevent hemorrhage or to isolate a tissue mass to be excised.

3. Approximation: the bringing together of tissue edges

4. Tensile strength: the amount of weight or pull necessary to break suture material

5. Multifilament suture: made up of smaller strands braided or twisted together

6. Monofilament suture: one strand

B. Uses of suture material:1. Opposing the edges of a wound or incision

2. Eliminate dead space

3. Tightening and stabilizing joints that have sustained ligament injury

4. Strengthening or replacing weakened tissue – hernias

5. Ligating blood vessels or tissues

C. Suture sizeThe larger the number the larger the suture material size. A number with a “-0” indicates a smaller suture size.

Smallest--------------------------------------------------Largest10-0, 4-0, 3-0, 2-0, 1-0, 0. 1, 2, 3, 4

D. Types of suture material1. Absorbable: material that is broken down with hydrolysis or body enzymes.

Generally most absorbable material loses their tensile strength within 60 days.

a. Surgical Gut: derived from intestinal mucosa of sheep, pigs, or cows

b. Vicryl (Polygalactin): synthetic polyester

c. PDS (Polydioxanone): similar to Vicryl

2. Nonabsorbable: retains strength for greater than 60 days. Needs to be removed.

a. Silk

b. Nylon

c. Polypropylene

d. Stainless steel

E. Suture Reactiona. Infection/abscessb. Inflammationc. Rednessd. Lump over the incision sitee. Tissues pull apart from the suture

F. Suture Needles1. Types of needles

a. Swagged on needle: suture material attached by manufacture to the needle

b. Taper Point: Least traumatic to the tissues; used in soft tissue not skin.

C. Cutting: triangle point; used on tougher tissue

d. Reverse cutting: cuts better and does not tear compared to the cutting