Definition:

Sterilization : Processes by which all pathogenic & non pathogenic microorganisms, including spores, are killed.

Disinfection: Chemical or physical process of destroying all pathogenic microorganisms, except spore bearing ones; used for inanimate objects, but not on tissues.

Definition:

Decontamination : Process or method by which all contaminated materials that can cause diseases are removed.

Aseptic techniques : Methods by which contamination with microorganisms is prevented.

Antiseptic techniques: Prevention of sepsis by the exclusion, destruction, or inhibition of growth and multiplication of microorganisms from body tissues and fluids.

Historical backgrounds :

Ignas Sammelweis (1818 - 1865)Puerperal fever increased maternal mortalityHand scrub with chlorinated-lime solution prior to

examination.Father of nosocomial infection.

Louis Pasteur (1860)Discover the process of fermentation by microorganismsGerm theory: against spontaneous generation theory.

Historical backgrounds :

Joseph Lister (1865)Use carbolic acid solution on surgical dressing in the

operating room mortality (Listerization)Father of modern surgery (Antiseptic technique)

Ernst Von Bergmann (1886)Introduced “steam sterilizer”Basic of sterilization aseptic techniqueLater: “pressure & vacuum steam sterilizer” was developed

Methods of Infection control

Anti septic techniques

Design and traffic patterns of the operating theatre

Sterilization

The objective of modern surgery For inanimate objects Problem :

Some items are not heat resistance

Techniques of Sterilization

Physical:HeatRadiation/ ultraviolet rayBoiling waterUltrasound

Chemical:LiquidGas

Heat Sterilization

Dry : Commonly cause damageFor powder, oils, and jelly

Moist :SteamHigh pressure spores Vacuum constant temperatureAutoclave

Chemical Sterilization

Generally as disinfection Mechanism of action :

Protein coagulationEnzyme denaturation in cellsLysis

Depend on : number of microorganisms, soiling, concentration, and temperature.

Solutions

Jodium and JodophorGood bactericide, but irritantMixture : povidone-jodine 10%

Alcohol Solution of 70% or 90%

Glutaraldehyde (Formaldehyde Sol. in Alcohol 2%)Spores are killed within 3 hours

Solutions

Hexachloropene (Halogenated phenol)Bacterio-static, particularly Gram (+) bacteriaFor scrubbing

Chlorhexidine gluconateBactericide : Gram (+) & (-).Good for antiseptic

Gas Sterilization

Formaldehyde Ethilene-oxide - propionolactone

Boiling Water

Mild boiling Vigorous boiling

More active, if 2% sodium-carbonate or 0,1 % sodium-hydroxide being added

The Operating Theater

Sterilecore

Clean Zone

Transitional Zone Restricted area

Semi – Restricted Area

SCRUB SUIT

Traffic patterns of Operating Theatre

The use of aseptic principles requires regulation of traffic and flow patterns of the personnel, patient, equipment, and supplies in operating theatre

Aims : to protect the safety and privacy of patients and the cleanliness and integrity of the environment.

unrestricted area

A. OUTERZONE - Areas for receiving patients messengers, toilets, administrative function,Corridors outside surgical suite

unrestricted area

Entrance

Reception desk

Patient suite

Transitional Zone (Video)

Locker room

Dressing room

Clean Zone

Changing room

Patient transfer area

Stores room

Nursing staff room

Anaesthetist room

Recovery room

ASEPTIC ZONE

•Scrub area

•Preparation room,

•Operation theatre,

•Area for instrument packing

and sterilization.

Sterile Core

DISPOSABLE ZONE

Area where

used equipment

are cleaned

and

biohazardous

waste is

disposed

FORMALDEHYDE FUMIGATION

Commonly used to sterilize the OR.

For an area of 1000 cubic feet

REQUIREMENT

• 500 ml of 40% formaldehyde in one

litre of water

• Stove or hot plate for heating

Formalin

• 300 ml of 10% Ammonia

PROCEDURE

COMMERCIALLY AVAILABLE DISINFECTANT

•Bacillocid special Is a surface and environmental disinfectant• Has a very good cleansing property along withbactericidal, virucidal , sporicidal and fungicidalActivity

CompositionEach 100 g contains:• 1.6 Dihydroxy 11.2G( Chemically bound formaldehyde)• Glutaraldehyde 5.0g• Benzalkonium chloride 5.0g• Alkyl urea derivatieves 3.0g

MOPPING OF FLOORS

3 bucket system

1st Bucket with water :-dirty mop is rinsed

2nd Bucket with fresh water for rinsing ;-Mop rinsed again in this water

3rd Bucket with low level disinfectant -Mop is immersed in the solution and the floor mopped liberally .

ULTRA VIOLET RADIATION

• Daily U.V. Irradiation for 12 -16 hrs

•To be switched off 2 hrs before Surgery

ULTRA SONIC CLEANER USED FOR

-Cleaning of micro surgical instruments and instruments with hinged areas and

serrated Edges

PRINCIPLE

Sound waves pass at a frequency of 100,000hz or more in the liquid.These

waves generate submicroscopic bubbles, which then collapse creating a

negative pressure on the particles in the suspension.

ARRANGEMENT OF INSTRUMENTS AND PACKING

•Arrange the instruments in trays

•Place heavy instruments at the bottom of the tray

•Place a signolac indicator inside the tray

•Double wrap the instruments set with linen

•Apply a signolac indicator with a dated label out side

the pack also.

STERILIZATION

Sterilization is a complete destruction of all microorganisms,

(both the vegetative forms and their spores.)

Sterilizing agents available

•Steam under pressure [AUTOCLAVE]

•Ethylene oxide [ E.T.O. ]

•High-level disinfectant

•Irradiation

AUTOCLAVE Steam sterilization: Autoclaving is suitable for sterilization of most metallic ophthalmic instruments, except sharp knives and finescissors.

Autoclaving at 121°C for 20 minutes at 15 lbs psipressure effectively kills most microorganisms &spores

Types of autoclaves

•Gravity displacement type• Pre vacuum type.• Vertical or horizontal type

AUTOCLAVE (VERTICAL

WORKING OF AN AUTOCLAVE

Various stages in the process of autoclaving

1. Loading 5. Holding2. Closing 6. Exhaust3. Air removal 7. Drying4. Steam exposure 8. Unloading

Autoclaving at 121 degree C/ 15 lbs for 20 min effectively kills micro organisms and their spores.

FLASH STERILISATIONEmergency sterilization132º C at 30 lbs of pressure for 3mnts

ETHYLENE OXIDE (E.T.O.)

• Kills micro organisms by altering their DNA

by alkylation.

•Widely used for resterilising ‘ packaged heat sensitive

devices’ like sharp knives and blades.

• Effective and safe for heat labile tubings, vitrectomy

cutters, cryoprobes, light pipes, laser probes, diathermy

leads.

ETHYLENE OXIDE (E.T.O.)

A typical ETO sterilization cycle includes:

1. Packing of the articles to be sterilized.

2. Arranging and loading the sterilizer

3. Air removal with a vacuum pump

4. Heating to the required temperature, ( 45 C– 55 C )

5. Steam humidification maintained at a relative humidity

of 60 % E.T.O

Exposure to the ETO at 5 psi for 12 hours or 10 psi for 6 hours

6. Gas removal by 70 psi vacuum.

7. Air flush by filtered air repeated 4 times to reestablish

atmospheric pressure

8. Aeration to elute residual ETO .

GLUTARALDEHYDE ( 2%)

•Suitable for Instruments that cannot be autoclaved .

•Sharp cutting instruments, plastic & rubber items , Endoscopes.

•Effective against Vegetative pathogens in 15 mts and resistant

pathogenic spores in 3 hrs.

Caution

should be thoroughly rinsed serially 2 to 3 times in trays filled with

sterile water.

GAMMA IRRADIATION

•Cold sterilization

•High penetrating power

•Lethal to DNA

•No appreciable rise in temperature

•Most useful for disposable & rubber items as well as ringer

lactate

MICROBIOLOGICAL MONITORING

Swabbing and culture for bacteria in ORFrequency -Once a monthAreas swabbed – In all ORs1. Operation table at the head end2. Over head lamp3. Four Walls.4. Floor below the head end of the table5. Instrument trolley6. AC duct7. Microscope

MICROBIOLOGICAL MONITORING

Quality of air in OR

Settle plate method

Frequency ( Once a month)

Procedure

One plate of blood agar and sabourauddextrose agar (SDA) is placed in the centerof the OR (Close to operation table) and thelid is kept open for 30 min.

Bowie–Dick tapes(signolac)This watermark does not appear in the registered version - http://www.clicktoconvert.com

Putting on surgical attire

In the semi & restricted area:

Scrub suit : shirt & trousersHair covering: surgical cap/hoodMasks : disposable/ re-useableGoggle (optional): protective eyewearShoe covers

are compulsory

Surgical attire

Male personnel

Female personnel

Personnel with veil

Surgical Instruments in the Operating Theatre

Critical items :Sterile, because of being used for penetrating skin or

mucosa

Semi critical items :In contact with skin or mucous membrane

Non critical items :

PREOPERATIVE PREPARATION

PRINCIPLES OF STERILE TECHNIQUE The patient is the center of the sterile field. It

includes the areas of the patient, the operating table and furniture covered with sterile drapes, and the personnel wearing the OR attire.

Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects one’s surgical concience.

If the principles are understood, the need for their application becomes obvious. The sterile technique is the basis of modern surgery.

1. ONLY STERILE ITEMS ARE USED WITHIN THE STERILE FIELD.

If you are in doubt about the sterility of anything consider it not sterile.

Known or potentially contaminated items must not be transferred to the field.

a. If sterile package is found in a nonsterile workroom.

b. If uncertain about actual timing or operation of sterilizer.

c. If unsterile person comes into close contact with a sterile table and vice versa.

d. If sterile table or unwrapped sterile items are not under constant observation.

e. If sterile package falls to the floor; it must then be discarded.

2. GOWNS ARE CONSIDERED STERILE ONLY FROM THE WAIST TO THE SHOULDER LEVEL, IN FRONT AND THE SLEEVES.

When wearing a gown, consider only the are you can see down the waist as the sterile area. The following practices must be observed:

a. Sterile persons keep hands in sight or above waist level.

b. Hands are kept away from the face. Elbows are kept close to sides. Hands are never folded under arms.

c. If a sterile person must stand on a platform to reach the operative field, the area of the gown below waist must not brush against sterile tables or draped areas.

d. Items dropped below the waist level are considered unsterile and must be discarded.

3. TABLES ARE STERILE ONLE AT TABLE LEVEL.a. Only top of a table with sterile drape is

considered sterile. Edges and sides of drape extending below the table level are considered unsterile.

b. Anything falling or extending over table edge, such as a piece suture, is unsterile. Scrub nurse does not touch the part hanging below that level.

c. In unfolding sterile drape, the part that drops below table surface is not brought back up to the table level.

4. PERSONS WHO ARE STERILE TOUCH ONLY STERILE ITEMS OR AREAS; PERSON WHO ARE NOT STERILE TOUCH ONLY UNSTERILE ITEMS OR AREAS.

a. Sterile team members maintain contact with sterile field by means of gowns and gloves.

b. Nonsterile, circulating nurse does not directly come into contact with the sterile field.

c. Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile package.

5. UNSTERILE PERSONS AVOID REACHING OVER A STERILE FIELD; STERILE PERSONS AVOID LEANING OVER AN UNSTERILE AREA.

a. Unsterile circulating nurse never reach over a sterile field to transfer sterile items.

b. In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area.

c. Scrub nurse sets basins or glasses to be filled at edge of the sterile table.

d. Circulating nurse stands at a distance from the sterile field.

e. Surgeon turns away from sterile field to have perspiration removed from brow.

6. EDGES OF ANYTHING THAT ENCLOSES STERILE CONTENTS ARE CONSIDERED UNSTERILE.

a. In opening sterile package, ends of flaps are secured in hand so they do not dangle loosely.

b. Flaps on the peel open packages should be pulled back, not torn to expose sterile contents. Contents should be lifted upward or flipped.

c. After bottle is opened contents must be used or discarded.

d. If a sterile wropper is used as a table cover, it should cover aply the entire table surface. Only the interior and surface level of the cover are considered sterile.

7. STERILE FIELDS ARE CREATED AS CLOSE AS POSSIBLE TO TIME OF USE.

Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment. Precautions must be taken as follows:

a. Sterile tables are set up justprior to the opertation.b. If is difficult to uncover a table. Therefore it is not

recommended for later use.

8. STERILE AREAS ARE CONTINUOUSLY KEPT IN VIEW.

Inadvertent contamination of sterile areas must be readily visible. To ensure this principle:

a. Sterile persons face sterile areas.b. When sterile packs are opened in a room,

or a sterile field is set up, someone must remain in the room to maintain vigilance.

9. STERILE PERSONS KEEP WELL WITHIN THE STERILE AREA.

Allow a wide margin of safety when passing unsterile areas and follow these rules:

a. Sterile persons stand back at a safe distance from the OR table when draping the patient.

b. Sterile persons pass each other back to backc. Sterile persons turns back to nonsterile person or

area when passing.d. Sterile persons face sterile are to pass it.e. Sterile persons asks nonsterile individual to step

aside rather than risk contamination.f. Sterile persons stay within and around a sterile

field.g. Movement within and around a sterile area is kept

to a minimum to avoid contamination of sterile items or persons.

10. STERILE PERSONS KEEP CONTACE WITH STERILE AREAS TO A MINIMUM

Sterile persons do not lean on sterile tables and on the draped patient.

Sitting or leaning against a nonsterile surface is a break in technique.

11. UNSTERILE PERSONS AVOID STERILE AREAS. A wide margin of safety must be maintained when

passing sterile areas by ff. these rules:a. Unsterile person maintains at least 1foot (30cm)

distance from any sterile area.b. Unsterile persons face & observe a sterile area when

passing to be sure they do not touch it.c. Unsterile persons never walk between two sterile areas.d. Circulating nurse restricts to a minimum all activities

near sterile field.

12. DESTRUCTION OF INTEGRITY OF MICROBIAL BARRIERS RESULT IN CONTAMINATION.

Integrity of a sterile package of sterile drape is destroyed by perforation, puncture or strike-through. Strike through is soaking of moisture through unsterile layers to sterile layers or vice versa.

Ideal barrier materials sre abrasion resistant, impervious to permeation of fluids or dust that transport microorganisms.

The integrity of a sterile package, its expiration date and appearance of process monitor must be checked for sterility just prior to opening.

To ensure sterility:a. Sterile packages are laid on dry surfaces. b. If sterile package becomes damped or

wet, it is re-sterilized or discarded. c. Drapes are placed on a dry field.d. If solution soaks through sterile drape to

nonsterile area, the wet area is covered with impervious sterile drape or towels.

e. Sterile items are stored with clean dry hands.

f. Undue pressure on sterile packs is avoided to prevent forcing sterile air out and pulling unsterile air into the pack.

13. MICROORGANISMS MUST BE KEPT TO AN IRREDUCABLE MINIMUM.

Perfect asepsis in an operative field is an ideal to be approached; it is not absolute. All microorganisms cannot be eliminated, but this does not obviate necessity for strict sterile technique. It is generally agreed that:

a. Skin cannot be sterilizedb. Some areas cannot be scrubbedc. Infected areas are grossly contaminatedd. Air is contaminated by dust and droplets

THE OPERATING ROOM ATTIRE Consists of the scrub dress, head cover, mask and

shoes or shoe cover. Sterile gown and gloves are added for srubbed team.

Provides effective barriers that prevent the dissemination of microorganisms to the patients and to protect personnel from infected patients.

1. Scrub dress – worn only in the operating suite.2. Head cover – is used to cover hair completely.3. Shoes – should be clean and conductive washable

and soft soled covered by shoe covers.4. Mask – is put on by all personnel before coming

into the OR and must be worn over nose and mouth.

5. Sterile gown – are worn over scrub attire.6. Sterile gloves – are worn to complete the attire for

srcubbed members.

POSITIONS FOR SURGERY Surgical positioning is the practice of placing

a patient in a particular physical position during surgery. The goal in selecting and adjusting a particular surgical position is to maintain the patient's safety while allowing access to the surgical site. Often a patient must be placed in an unnatural position to gain access to the surgical site.

The selection of a surgical position is made after considering relevant physical and physiological factors, such as body alignment, circulation, respiratory constraints, and the musculatory system to prevent stress on the patient. Physical traits of the patient must also be considered including size, age, weight, physical condition, and allergies.

The type of anesthesia used also affects the decision.

Changing Positions If the patient has been immobilized, it may be

important to change the patient's position periodically to prevent blood pooling, to stimulate circulation, and to relieve pressure on tissues.

The patient should not be placed in unnatural positions for an extended period of time. After anesthesia, the patient's inability to react to movements may damage joints and muscle groups. Considerations should be taken not to damage these muscle groups by, for example, moving both legs simultaneously.

Risk for Extremities The most common nerve injuries during

surgery occur in the upper and lower extremities. Injuries to the nerves in the arm or shoulder can result in numbness, tingling, and decreased sensory or muscular use of the arm, wrist, or hand. Many operating room injuries could be solved by simply restraining the arms and legs. Other causes of nerve or muscular damage to the extremities is caused by pressure on the body by the surgical team leaning on the patient's arms and legs. The patient's arms can be protected from these risks by using an arm sled. 

Positions

Supine position - The most common surgical position. The patient lies with back flat on operating room bed.

Trendelenburg position - Same as supine position but the upper torso is lowered.

Reverse Trendelenburg position - Same as supine but upper torso is raised and legs are lowered.

Fracture Table Position - For hip fracture surgery. Upper torso is in supine position with unaffected leg raised. Affected leg is extended with no lower support. The leg is strapped at the ankle and there is padding in the groin to keep pressure on the leg and hip.

Lithotomy position - Used for gynecological, anal, and urological procedures. Upper torso is placed in the supine position, legs are raised and secured, arms are extended.

Fowler's position - Begins with patient in supine position. Upper torso is slowly raised to a 90 degree position.

Semi-Fowlers position - Lower torso is in supine position and the upper torso is bent at a nearly 85 degree position. The patient's head is secured by a restraint.

Prone position - Patient lies with stomach on the bed. Abdomen can be raised off the bed.

Jackknife position - Also called the Kraske position.

Patient's abdomen lies flat on the bed. The bed is scissored so the hip is lifted and the legs and head are low.

Knee-chest position - Similar to the jackknife except the legs are bent at the knee at a 90 degree angle.

Lateral position - Also called the side-lying position, it is like the jackknife except the patient is on his or her side. Other similar positions are Lateral chest and Lateral kidney.

Kidney position - The kidney position is much like the lateral position except the patient's abdomen is placed over a lift in the operating table that bends the body to allow access to the retroperitoneal space. A kidney rest is placed under the patient at the location of the lift.

Sims' position - The Sims' position is a variation of the left lateral position. The patient is usually awake and helps with the positioning. The patient will roll to his or her left side. Keeping the left leg straight, the patient will slide the left hip back and bend the right leg. This position allows access to the anus.

Setting Up An Unsterile Table As A Sterile Field

The scrub person drapes an unsterile table toward self first to protect the gown. Gloved hands are protected by cuffing a drape over them.

The scrub person stands back from the unsterile table when draping it in order avoid leaning over an unsterile are.

There Is No Compromise with

SterilityIt’s Considered Sterile

or Unsterile.

The OR Scrub

The Surgical Scrub

Definition.The surgical scrub is the process of

removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in a surgical procedure.

Despite the mechanical action and the chemical antimicrobial component of the scrub process, skin is never sterile.

The Methodology of the Scrub

The Timed Method

All surgical scrubs are 5 minutes in length.All are performed using a surgical

scrub brush and an antimicrobial soap solution.

Surgical Scrub Procedure1. Wet the hands and

forearms2. Apply antiseptic agent

from the dispenser to the hands.

3. Wash the hands and arms thoroughly to 2 inches above the elbows, several times. Rinse thoroughly under running water with the hands upward, allowing water to drip from the flexed elbows.

4. Take a sterile brush or sponge (from a package or dispenser) and apply an antiseptic agent ( if it is not impregnated in the brush). Scrub each individual finger, including the nails, and the hands, a half minute for each hand.

5. Hold the brush in one hand and both hands under running water, and clean under the fingernails with a disposable plastic nail cleaner. Discard the cleaner after use.

6. Again scrub each individual finger, including the nails and the hands with the brush, half a minute for each hand.

The Final Rinse1. Be sure to keep both arms

in the upright position (careful not to touch the faucet!) so that all water flows off the elbows and not back down to the freshly scrubbed hands. Bring arm through the water once, starting with the fingers, then pull the arm straight out. Do not let water run down to hands, must drip off elbows

7. Rinse the hands and brush, and discard the brush.

8. Reapply the antimicrobial agent and wash the hands and arms, applying friction to the elbows, for 3 minutes. Interlace the fingers to clean between them.

9. Rinse the hands and arms as described in the previous slide.

Drying the Hands and Arms

1. Reach down to the opened sterile package containing the gown, and pick up the towel. Be careful not to drip water onto the pack. Be sure no one is within arm’s reach.

2. Open the towel full-length, holding one end away from the nonsterile scrub attire. Bend slightly forward.

3. Dry both hands thoroughly but independently. To dry one arm, hold the towel in the opposite hand and, using the oscillating motion of the arm, draw the towel up to the elbow.

4. Carefully reverse the towel, still holding it away from the body. Dry the opposite arm on the unused end of the towel.

Gowning and Gloving Techniques

1. Reach down to the sterile package and lift the folded gown directly upward.

2. Step back away from the table into an unobstructed area to provide a wide margin of safety while gowning.

3. Holding the folded gown, carefully locate the neckline.

4. Holding the inside front of the gown just below the neckline with both hands, let the gown unfold, keeping the inside of the gown toward the body. Do not touch the outside of the gown with bare hands.

5. Holding the hands at shoulder level, slip both arms into the armholes simultaneously.

6. The circulator brings the gown over the shoulders by reaching inside to the shoulder and arm seams. The gown is pulled on, leaving the cuffs of the sleeves extended over the hands. The back of the gown is securely tied or fastened at the neck and waist, touch the outside of the gown at the line of ties or fasteners in the back only.

Gloving by the Closed Glove Technique

1. Using the right hand and keeping it within the cuff of the sleeve, pick up the left glove from the inner wrap of the glove package by grasping the folded cuff.

2. Extend the left forearm with the palm upward. Place the palm of the glove against the palm of the left hand, grasping in the left hand the top edge of the cuff, above the palm. In correct position, glove fingers are pointing toward you and the thumb of the glove is down

3. Grasp the back of the cuff in the left hand and turn it over the end of the left sleeve and hand. The cuff of the glove is now over the stockinette cuff of the gown, with the hand still inside the sleeve.

4. Grasp the top of the left glove and underlying gown sleeve with the covered right hand. Pull the glove on over the extended right fingers until it completely covers the stockinette cuff.

5. Glove the right hand in the same manner, reversing hands. Use the gloved left hand to pull on the right glove.

Gloving the Right Hand

Scrubbing, Gowning, and Gloving Complete