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Surgical asepsis: Principles and protocols

Article  in  In Practice · January 1996

DOI: 10.1136/inpract.18.1.23

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Operating room protocols

are designed to prevent or
minimise microbiological
contamination of the
surgical wound

Surgical asepsis:
principles and protocols STEPHEN BAINES

WOUND infections have been a major problem since surgery began and, despite improved techniques to
avoid and combat them, they remain an important complication of surgery. This article discusses the
stages in the prevention of wound contamination. The basic principle of aseptic technique is that
microbiological contamination and subsequent infection cannot occur if microorganisms are totally
excluded from a wound. The reality of aseptic technique is a working set of complementary and
independent technologies and operating room protocols designed to prevent or minimise microbiological
contamination of the surgical wound. All items that come into contact with the wound should be sterile.
If an item cannot be made sterile, it is rendered surgically clean by washing with antiseptics or
disinfectants which destroy most, but not all, microorganisms. Stephen Baines
graduated from
Cambridge University
SOURCES OF CONTAMINATION unless one of the barriers fails to function as expected. in 1990. He is resident
in small animal soft
All items of surgical equipment should be rendered tissue surgery at
Bacterial contamination may arise from the following: sterile prior to surgery. Air in contact with the surgical Liverpool University
* the surgical team; wound is the most common vehicle for delivering bac- and holds the RCVS
certificates in
* surgical equipment; teria into the wound. The bacteria in the air are usually veterinary radiology
* the operating theatre environment; from the animal and any non-scrubbed personnel in the and small animal
surgery. His current
* the patient. operating theatre; the concentration of bacteria in the air interests include all
The most common source of contamination is the is directly related to the number of people present and aspects of soft tissue
surgery, particularly
animal's endogenous microbial flora. Prevention of the degree of activity. oncologic and
exposure to this population of bacteria is important at A number of phases are important in the prevention reconstructive
the time of surgery, and the preoperative preparation of wound contamination (see table, below left). Most surgery.
of the patient is concerned with reducing the likelihood bacterial contamination occurs at the time of surgery.
of contamination from this source.
In the presence of a properly prepared patient, most
particulate material and bacteria come from the surgical Definitions
team. Modem aseptic techniques are effective in reduc-
* Antisepsis Prevention of sepsis by the destruction or inhibition of micro-
ing contamination by exogenous bacteria. A scrubbed
organisms using an agent that may be applied safely to living tissue
surgeon, correctly attired, rarely contaminates a wound
* Antiseptic Chemical agent that either kills pathogenic microorganisms, or

inhibits their growth as long as the agent and microorganism remain in contact;
this term is reserved for agents applied to the body
Preoperative Patient selection * Asepsis Absence of pathogenic microbes in living tissues

* Disinfectant Germicidal chemical substance that kills microorganisms in

Perioperative Preparation of personnel
Sterilisation of surgical equipment
Maintenance and design of the operating
theatre
Preparation of the patient
lntraoperative Aseptic operative technique
inanimate objects, such as items of surgical equipment
* Disinfection Removal of microorganisms, but not necessarily their spores
* Sepsis Presence of pathogens or their toxic products in the tissues of a
patient
* Sterilisation Complete elimination of microbial viability, including both

Postoperative Suitable postoperative care vegetative forms of bacteria and spores, by physical or chemical means

In Practice c JANUARY 1 996 23

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Wound contamination and infection
There is no such thing as sterile surgery
- veterinary surgeons are not pre-
sented with germ-free patients in a
sterile environment. All surgical
wounds are contaminated by bacteria.
However, not all surgical wounds
become infected when they are con-
taminated. A critical level of contam-
ination is required before wound infec-
0 6
IMPAIRED HOST
DEFENCES
Old age
Poor physical condition
Malnutrition
Systemic disease
Drug therapy
tion results. This level is generally
accepted to be 105 organisms per gram
of tissue. Various factors determine
whether wound infection will result.
These relate to the host's resistance to
bacterial infection, the characteristics
of the bacterial contamination, and
the interaction between the host and
the bacteria.
S .
.
BACTERIAL INOCULUM
Number of bacteria
Virulence
Time since contamination
NON-STERILE BARRIERS
Scrub suit
A scrub suit is an occlusive, but not impermeable, barrier
to microorganisms, the aim of which is to reduce partic-
ulate shedding in the operating theatre. These clothes
should not be worn outside the operating theatre, or for
procedures which carry an increased risk of contamina-
tion (eg, dressing changes and patient examination), if
further surgery is scheduled.
Surgical head covers
Hair is the primary source of bacterial contamination
from the surgical team and should therefore be covered.
Hoods are more effective than caps. The item chosen
should cover the occipital and temporal regions, should
be durable and comfortable to wear and should not shed
lint into the wound.
Shoes and shoe covers
The aim of these items is to prevent bacteria from out-
door shoes contaminating the operating theatre. There
appears to be no difference in the effectiveness of theatre
boots/clogs and outdoor shoes with properly fitted cov-
ers with respect to reduction of bacterial contamination.

Face masks
LOCAL FACTORS Of all the traditional attire worn to promote asepsis in
the operating room, face masks contribute the least. A
Necrotic tissue single mask does not reduce the level of environmental
Haematoma bacterial contamination - droplets and microorganisms
Dead space shed from the naso- and oropharynx are directed to the
Reduced blood supply sides and bottom of the mask and ultimately reach the
Foreign material surgical environment. During breathing or quiet talking
there is, in fact, little or no expulsion of bacteria-laden
Modified from particles.
Smeak and Olmstead However, the evidence at present does not support the
(1984)
total abandonment of face masks. Their main function is
to protect the wound from droplets (5 to 30 .tm in diam-
eter) of saliva expelled during talking. Some smaller
Consequently, the perioperative and intraoperative phas- particles (less than 2 to 3 pm diameter) may still pass
es are traditionally regarded as the mainstays of asepsis. through the mask, but particles of this size do not fall
readily on their own into the wound during surgery. The
use of surgical hoods may improve the efficacy of mask-
PATIENT SELECTION wearing by allowing the edges of the mask to be covered
by the headgear.
Evaluation of the patient for suitability for surgery
should be comprehensive, to assess its overall state of PREPARATION OF THE SURGEON'S SKIN
health, determine the risk of surgical wound infection It is not possible to sterilise the surgeon's skin. Rather
and to guide the preoperative preparation. Important the aims of the scrubbing protocol (described below) are:
considerations are the patient's physical condition, the * the mechanical removal of gross dirt from the hands
presence of intercurrent disease and any evidence of a and foreanns;
remote site of infection. * a reduction in the transient microbial count to as close
It is a myth that animals are more resistant to infec- to zero as possible;
tion than humans. Operative invasion of normal tissue * a prolonged depressant effect on the resident
should only be undertaken if postoperative infection will microflora of the hands and arms.
not threaten the animal's well-being or life. 'Transient' flora are organisms isolated from the skin,
but not demonstrated to be consistently present in the
majority of people; they do not multiply and are pre-
PREPARATION OF PERSONNEL sumed to be deposited on the skin from the mucous
membranes or the environment. 'Resident' flora, on the
Non-sterile barriers such as scrub suits, masks and caps other hand, are organisms consistently isolated from the
will decrease, but not eliminate, the shedding of particu- skin of most people; they are permanent residents of the
late matter (including microorganisms). Preparation of skin and are able to multiply within the skin. The
the surgeon's skin reduces the likelihood of bacterial mechanical action of washing removes most of the tran-
contamination, and sterile barriers such as gowns and sient bacteria by friction. The resident population is
gloves further reduce contamination. killed by antiseptic solutions.

24 In Practice * JANUARY 1 996

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Scrubbing protocol any contaminated case or break in the surgery schedule,

Many different scrub routines are described and no
single technique is necessarily more effective than any
other. One method should be chosen and adhered to
strictly. It should not be excessively time consuming and
the antiseptic should not irritate the skin with repeated
use.
The scrub protocol is based anatomically on either a
timed procedure or the counted brush stroke method.
The hands and arms should be divided into the four sides
of each finger and thumb, the back of the hand, palm,
wrist and the forearm. The counted brush stroke method
uses a specified number of strokes for each area (usually
30 for the nails and 20 for each of the skin areas). The
timed scrub uses a specified time for each area (such as
30 seconds for each nail, repeated once, and three min-
utes for each hand and forearm).
Present opinion recommends a surgical scrub which
lasts no longer than five minutes for the first case or after
Properties of an hdal skin
* Wide spectrum of antimicrobial activity
* Ability to decrease microbial count quickly
* Quick application
* Long residual lethal effect
* Active in the presence of organic matter
* Safe to use without skin irritation and
sensitisation
* Economical
and three minutes for subsequent cases. Particular atten-
tion should be paid to the nails, subungual and interdigi-
tal areas, bearing in mind that any cuts and abrasions
may harbour bacteria. Throughout the scrub the hands
and forearms should be held higher than the elbows and
out from the surgical attire to prevent contamination and
to allow water to run away from the cleanest area. The
brush should be of a good quality soft nylon bristle to
prevent excoriation, and should be sterile. The practice
of storing brushes in dishes of antiseptic solution should
be avoided since bacteria may multiply freely, particu-
larly in a more dilute solution, and may be transferred to
the patient by the surgeon.
Surgical scrub solutions
The ideal properties of a surgical scrub solution are
described in the box on the left, while the various scrub
solutions available and their characteristics are listed in
the table below.
STERILE BARRIERS
Gloves
Sterile surgical gloves should be wom to reduce further
the risk of bacterial contamination. Closed gloving -
where the hands are kept inside the sleeves of a sterile
gown while the gloves are put on - is preferred to
decrease contamination. Various studies have shown that
a large percentage of surgical gloves appear to have
minor perforations by the end of an operation. For this
reason, the hands should always be scrubbed properly,
and the method chosen should achieve both an immedi-

IA:;i 16's ; 'I

Agent Example Mechanism of Activity Speed of action Characteristics Side effects Recommended
(Trade names) action uses
Quatemary Benzalkonium Cationic surface Broad-spectrum Slow Inactivated by Pseudomonas Cleaning non-
ammonium chloride (Roccal; agents bactericidal soaps and organic infections sterile surfaces
compounds Sterling Change cell wall (mainly Gram- material Ulceration if
Winthrop) permeability positives) Bacteria survive undiluted
Neutralise Some viruses under film
phospholipids
Chlorinated Hexachlorophene Inhibit electron Bacteriostatic Slow Require repeated Neurotoxicity None - other
phenol (Ster-Zac; transport and (Gram-positives application agents more
derivatives Hough, membrane bound only) Must use alone effective
Hoseason) enzymes Not sporicidal
Aliphatic 70 per cent ethyl Damage lipids in Broad-spectrum Rapid Some residual Skin irritation Routine skin
alcohols alcohol cell membrane bactericidal action Tissue necrosis in preparation,
Protein Improved activity open wounds combined with
precipitation when used with other agents
chlorhexidine or
povidone-iodine
Diphenyl ethers Triclosan Disrupt bacterial Broad-spectrum Intermediate Some residual Routine skin
(Manusept, cell wall bactericidal action preparation
Aquasept; Hough, (not some Active in the
Hoseason) Pseudomonas presence of
species) organic matter
Poor fungicide
lodophors Povidone-iodine Damage cell wall Broad-spectrum Rapid Slow release of Relatively high Routine skin
(Pevidine; BK) Form reactive bactericidal active iodine incidence of skin preparation
(Betadine; Napp) ions and protein Fungicidal Minimal residual reactions
complexes Virucidal action
Sporicidal with Inactivated by
prolonged contact organic material
Bisdiguanide Chlorhexidine Alter cell wall Broad-spectrum Rapid Good residual Occasional skin Routine skin
compounds (Hibitane, permeability bactericidal (not action reactions and preparation
Hibiscrub; ICI) Protein some Pseudo- Active in the photosensitivity
precipitation monas species) presence of
Minimal action organic matter
against spores
and viruses

In Practice JANUARY 1 996 25

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ate antibacterial effect and a prolonged residual activity.

If such a practice is adopted, minor punctures in gloves .f Instrun
Steam sterIsatIoO
are not associated with a significant increase in wound
infection rates. Cleaning
Gross contamination must be removed as a first
Gowns step, regardless of the sterilisation technique used.
Sterile surgical gowns are used as a further barrier Dried blood conceals microbes, particularly in the
between the surgical team and the patient. Gowns should less accessible parts of the instruments, and renders
be made of a material that establishes such a barrier sterilisation more difficult. Instruments should be
(thus eliminating the passage of microbes), that is resis- cleaned as soon as possible after use. Immediately
tant to blood and aqueous fluids and that is free from after surgery they should be rinsed in cold water to
linting, eliminating the number of airborne particles. remove blood and debris. If there is a delay before
Disposable, single-use gowns have superior barrier final cleaning, they should be immersed in warm
properties, particularly with respect to fluid absorption. water containing an effective detergent.
Studies have shown that non-woven disposable gowns Manual cleaning is best achieved using a hand
greatly reduce the number of airborne particles and brush with soft bristles. Abrasive cleaners should be
wound infection compared with cloth gowns, although avoided, as should ordinary soap which leaves
this difference is much less marked for clean procedures. behind an insoluble film. A washer-steriliser cleans
Reusable gowns result in less waste and are cheaper instruments in an agitated detergent bath before
to use. However, the price differential is somewhat automatic steam sterilisation. However, this results
smaller when the time, effort and cost of laundering and in unwrapped instruments, and is not suitable for
sterilising the gowns is taken into account. Cloth gowns routine sterilisation of surgical supplies. Ultrasonic
lose all their barrier properties when wet. In addition, cleaners clean via the process of cavitation. Minute
each time the gown is laundered the pores in the fabric gas bubbles are formed by ultrasound waves which
widen, further decreasing the barrier properties. These expand until they are unstable, then collapse.
gowns must be regularly inspected for holes. It should be Implosion of these bubbles creates a minute vacu-
noted that mending of gowns by sewing results in many um which is responsible for removing tightly bound
needle holes much bigger than the natural pores in the soil. Instruments should be loaded with all box
material. locks open.
Gowns with integral or added impervious sleeves
should be used if the gown above the glove is subjected Preparation of packs
to moisture. Gloves should cover the elasticated cuff of Instruments and supplies are segregated according
the gown. to their intended use. Materials are positioned
within packs to allow complete steam penetration.
Instruments should be sterilised with their box locks
STERILISATION OF SURGICAL EQUIPMENT open and complex instruments, such as Balfour
retractors, should be disassembled. Containers such
All instruments, implants and equipment which are to be as kidney dishes are positioned such that the open
used during surgery must be sterilised before use. There end is facing down or horizontally. Instrument
are several different methods of sterilising available (see packs should be packed on edge vertically, in longi-
below). The choice of method will depend on: tudinal rows within the steriliser so that they are
oriented in the direction of the steam flow. A small
amount of space should be left between each pack.
63~~~ ~~~~~~~~~~~~~~~~~~~~~ 0
Linen packs should be positioned such that their
layers are oriented vertically, so that air and steam
Physical Chemical travel downwards to escape between the layers.
Heat Gaseous Care should be taken to prevent overloading and
Steam Ethylene oxide blocking of the inlet and exhaust valves.
Moist heat (boiling) Formaldehyde
Dry heat Beta-propiolactone
Autoclave operation
Irradiation Liquid A number of minimum time-temperature standards
Gamma irradiation Alcohols (ethyl alcohol, isopropyl alcohol)
Ultraviolet light Aldehydes (formaldehyde, glutaraldehyde) have been established for the routine sterilisation
High energy electrons Chlorhexidine of packs (see table, page 27). It is generally agreed
lodophors that 13 minutes at 1200C is a safe minimum stan-
Phenols
Quaternary ammonium compounds dard; five to 10 minutes at this temperature will
destroy most resistant microbes, while the addition-
0__ 0 03 *~ '*0
al time provides a margin of safety. Emergency ster-
ilisation is carried out at 1310C for three minutes.
Steam Dry heat Ethylene oxide The sterilising time begins when the temperature
Instruments Glassware Fibreoptic equipment of the exhaust gases reaches the desired level.
Therefore, the cycle time includes this heat up time,
Drapes, gowns, swabs Cutting instruments Plastic catheters and syringes as well as the sterilising time, and generally lies
Most rubber articles Ophthalmic instruments Anaesthetic tubing in the range of 15 to 45 minutes. The time taken
to heat up the steriliser is much reduced in pre-
Glassware Drill bits Optical instruments
vacuum and pulsing type units.
Some plastic goods Powders and oils High speed drills and burrs

26 In Practice * JANUARY 1996

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Types of autoclave
Vertical pressure cooker
The vertical pressure cooker is a simple machine
which operates by boiling water in a closed contain-
er, like a household pressure cooker. It usually has an
air vent at the top, which is closed once the air has
been evacuated, allowing the pressure (15 psi) to
build up. However, since steam is less dense than air,
there is a danger that some air will be trapped under
a layer of steam within the steriliser. In addition, the
manual operation of such a machine leaves room for
human error in the sterilisation cycle.
Gravity or downward displacement autoclave
The gravity or downward displacement autoclave is
the most common type in use. Steam is introduced
under pressure at the top of the sterilising chamber,
compressing the air to the bottom, where it is vented
to the outside. Once the air is eliminated, the tem-
perature rises. The coldest steam, or steam with the
highest air content, continues to be discharged, and
a thermometer placed at this exit registers the tem-
perature of the coldest area of the chamber.
Many of these machines are designed for loose
instrument sterilisation only, rather than packs, as
they have insufficient drying cycles. Packs may
appear dry, but remain damp, allowing entry of
microorganisms during the storage period. This type
of machine is not suitable for a busy surgical unit
needing to autoclave a large number of instruments,
gowns and drapes.
Pre-vacuum steriliser
The pre-vacuum steriliser uses a vacuum pump to
evacuate air from the chamber before steam is
admitted. This eliminates the time lag required in
gravity displacement autoclaves, thus decreasing the
total cycle time, and reduces the probability of air
entrapment within packs. These machines allow
emergency sterilising ('flashing') of surgical instru-
ments and materials. They are fully automatic with
fail safe mechanisms, and their efficacy and reliability
outweigh other types. However, they are larger and
more sophisticated and purchase and maintenance
costs are higher.
Steam pulsing systems
Steam pulsing systems decrease the need for the
development of a high pre-vacuum and, hence, are
cheaper. A steam pulse increases the pressure within
the chamber to a set level, whereupon the chamber
is vented to a minimum pressure preceding the next
pulse. The cycle time is shorter than that of gravity
displacement units.

W I 1. f-II tol 1. i ial death occurs at a lower temperature and in a shorter

time (bacterial spores killed after 15 minutes exposure to
Temperature (C) Pressure (psi) Sterilising time (minutes)
steam at 121 °C will only be destroyed after one hour in a
121 15 15 hot air oven at 160°C, for example).
126 20 10 * STEAM. Sterilisation with saturated steam under pres-
sure is the most dependable and most widely used means
134 30 3-5 for the destruction of microbial life. Steam penetrates
each surgical pack and porous articles, and gives up its
heat by condensation. Steam sterilisation depends on
* the amount and type of equipment to be sterilised; direct contact, and therefore certain items such as oils/
* financial constraints; greases and items sealed in completely non-porous
* available space. containers, such as a stoppered tube, will not be ster-
Each has its advantages and disadvantages, and ilised. Heat-sensitive items which may be damaged
usually several methods will be used for all the equip- include fibreoptic equipment, lenses and some plastic
ment required. The table at the foot of page 26 lists the goods, particularly those designed to be disposable.
method of choice for the sterilisation of various articles. Air present in steam sterilisers is the principal factor
Physical methods of sterilisation are generally more which reduces the efficacy of the process by limiting the
reliable, and steam is the most frequently used. Chemical diffusion of steam and its condensation as well as the
sterilisation is achieved primarily with ethylene oxide; attainment of a high temperature. Modem steam sterilis-
other agents are rarely used. Failure of instrument sterili- ers (autoclaves) differ chiefly in the mechanisms by
sation usually results from inadequate maintenance of which they evacuate air from the sterilising chamber (see
the equipment or attempts to modify sterilising proce- box above).
dures without careful attention to detail. The procedure for steam sterilising instruments is
outlined in the box on page 26.
PHYSICAL METHODS OF STERILISATION * MOIST HEAT (BOILING). Boiling cannot be guaranteed
Heat to kill all microorganisms and spores because the
The temperature range within which microorganisms are maximum temperature of 100°C is insufficient to kill
able to survive is determined largely by the thermal via- spores. It should, therefore, not be considered a method
bility of their protein and nucleic acids, and denaturation of sterilisation.
of cell proteins appears to be the principal means by * DRY HEAT. Dry heat kills microorganisms by causing
which heat destroys microbes. There is no one tempera- oxidative destruction of bacterial protoplasm. The range
ture at which all microorganisms are killed. The thermal of equipment which may be sterilised in this way is
destruction of bacteria is time- and temperature- restricted; fabrics, rubber goods and plastic are easily
dependent; in addition, when moisture is present, bacter- damaged.
In Practice * JANUARY 1 996 27
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__33 Ll I*
during the cycle. Instruments should be clean and dry
Item Temperature (C) Time (minutes)
before undergoing sterilisation, since grease and protein
will slow the process and water will react with the gas.
Glassware 180 60 Occlusive bungs and caps should be removed to allow
Non-cutting instruments 180 60 penetration of the gas. Individually packaged items are
Powders, oils
placed in a polythene liner bag. Many packaging materi-
160 120
als may be used, with the exception of nylon autoclave
Cutting instruments 150 180 tape, which does not allow good penetration by the gas
(see later). A glass ampoule containing ethylene oxide is
placed within the liner bag, which is then sealed. The
The table above lists recommended time and temper- glass vial is snapped open within the bag to release the
ature settings for dry heat sterilisation. Hot air ovens are gas. The steriliser unit is closed and the ventilation
small but economical in terms of purchase and running turned on. After sterilisation, the container is aerated and
costs, but have largely been superseded by the autoclave, the item should be left in a well-ventilated room for 24
which has the advantages of being larger and suitable for hours to allow the ethylene oxide to dissipate. However,
most types of equipment. In addition, a long cooling it may take up to six days for the gas to be completely
period is necessary before the items may be used. High removed from certain plastic and rubber items.
vacuum-assisted ovens reduce the sterilising time to 15 Ethylene oxide is effective for the sterilisation of
minutes for most articles and convector ovens incorpo- many types of equipment, but its use is limited by the
rate a motor to circulate air through the unit. However, size of the sterilising chamber, the duration of the cycle
neither type is commonly used in veterinary medicine. and concerns regarding its toxicity. This method is there-
fore restricted to items damaged by heat. It should not be
Irradiation used to sterilise any object previously sterilised by irra-
Microorganisms can be destroyed by exposure to gamma diation, particularly those made from PVC, because this
rays, ultraviolet light or by high-energy electrons. may result in the formation of highly toxic ethylene
Gamma irradiation is the most effective of these meth- chlorhydrin, which is difficult to elute.
ods, enabling a measured dose to be given most easily.
Many pre-packaged items such as catheters, syringes and Cold sterilisation
suture material are sterilised this way. Ultraviolet light Cold sterilisation refers to the soaking of instruments in
has poor powers of penetration and is rarely a true steril- disinfectant solutions. This method should really only
ising agent. High-energy electrons, meanwhile, are more be considered a means of disinfection, although some
suited to the sterilisation of small articles, such as manufacturers guarantee sterilisation following pro-
adhesive dressings or syringes. longed immersion (usually 24 hours). Occasionally, cold
sterilisation is used for articles that cannot be exposed to
Filtration steam, such as anaesthetic accessories, or to disinfect
Filtration may be used to remove microbes from liquids lensed instruments such as endoscopes.
or gases; for example, when preparing solutions of heat- Disinfectants should play no part in the sterilisation
labile substances which cannot be sterilised by any other of critical instruments (ie, those that potentially may be
method, or preparing large volumes of sterile water. Its introduced beneath the surface of the body). However,
principal use is in the removal of bacteria from the air in should there be no alternative but to cold sterilise an arti-
surgical suites. cle, a 2 per cent buffered aqueous solution of glutaralde-
hyde has been recommended as a true sterilising solu-
CHEMICAL METHODS OF STERILISATION tion; such a solution is bactericidal and virucidal in 10
Gas or liquid agents may be used for sterilisation. These minutes, and sporicidal in three hours. This agent is
methods were developed to sterilise materials damaged extremely irritating to tissues and articles must, there-
by wet or dry heat. Ethylene oxide is the only gaseous fore, be rinsed with sterile saline before use. The chemi-
agent in general use. cal solution and the article to be sterilised should be
placed in a tray or bowl, preferably with a lid, to prevent
Ethylene oxide evaporation or contamination by microorganisms.
Ethylene oxide is capable of destroying all known bac-
teria, spores and fungi, and at least the larger viruses. It STERILISATION INDICATORS
inactivates cellular DNA and prevents cell reproduction. It is important to monitor the efficacy of the method of
Concerns have been expressed regarding its use, since it sterilisation, and to be able to tell whether an item has
is toxic, irritant to tissues and inflammable except when been sterilised. The various means of doing so are out-
mixed with carbon dioxide. Several factors influence the lined briefly below. Indicators, however, should not be
ability of ethylene oxide to destroy microbes, including relied on too heavily. Exact standards for preparing,
temperature, pressure, concentration, relative humidity packaging and loading of supplies are the best guaran-
and time. As the temperature increases, its ability to pen- tees of the effectiveness of the procedure.
etrate increases and the time required for sterilisation
decreases. However, the only system available in the UK Chemical indicators
operates at room temperature for 12 hours. Chemical indicators undergo a colour change when a
The machine used in ethylene oxide sterilisation con- certain temperature is reached or when exposed to a cer-
sists of a plastic container with a ventilation system to tain chemical. They provide no indication about the time
prevent gas entering the work area. It should be kept in a of exposure to a given sterilant and, if placed on the
clean, well-ventilated location away from the work area; surface of a package, do not indicate that the contents
the temperature of this location should be at least 20°C have been sterilised. Hence, for this reason, they should

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not be over-interpreted. Their main value is in informing * LINEN SHEETS are strong, conforming and reusable,
personnel that a pack has been exposed to a sterilising but are permeable to moisture. Therefore, a double wrap
process, not that sterilisation has been achieved. of linen is covered by a waterproof, paper-based wrap
Chemical indicators include chemical indicator strips, for surgical packs.
tubes full of a liquid which changes colour on exposure * METAL DRUMS with steam vents in the side, which are
to heat (Browne's tubes), indicator tape which is impreg- closed after sterilisation, are often used with small,
nated with chemical stripes which change colour on portable autoclaves (for instruments, gowns, drapes, etc).
exposure to heat or ethylene oxide (Bowie-Dick indica- However, they are often multi-use, so there is a degree
tor tape), and inks impregnated on the surface of a pack of environmental contamination each time the drum is
which change colour on exposure to heat or ethylene opened. There is also a risk of contamination through
oxide. items touching the edge or outside of the drum. They are
relatively expensive, but long-lasting.
Biological indicators * BOxES AND CARTONS made from cardboard may be
Biological indicators consist of bacterial spores which used for gowns, drapes or packs. They are relatively
are more resistant to the sterilant than those agents likely cheap and may be reused.
to be present as contaminants. Tubes or strips containing Sterile packs should be stored in closed cabinets,
the spores are included within the sterilising vessel and rather than on open shelves; safe storage times are sig-
are then incubated for a number of days. Biological indi- nificantly longer in cabinets and there is less risk of
cators have the advantage that they provide absolute items getting wet. All packs should be dated, preferably
proof that sterilising conditions have been met. with an expiration date.
However, the results are not available for one to seven
days, and false positives may still occur with an auto-
clave if the steam is not properly saturated. Properly MAINTENANCE AND DESIGN OF THE
applied chemical methods in conjunction with regular OPERATING THEATRE
maintenance of the equipment should obviate the need
for biological indicators. Despite improvements in operating theatres, sterility
remains difficult to achieve. The design, construction
Temperature/pressure recordings and layout of an operating theatre, as well as operating
Larger autoclaves have visible temperature and pressure room protocols, will affect how readily the principles of
gauges, and these variables may be plotted on a record- aseptic technique may be applied.
ing chart during the operation of the machine.
Thermocouples can be used to record the temperature DESIGN
within the sterilising chamber for the duration of the The operating room should be situated in a convenient
cycle to ensure that the time and temperature require- location for work, but out of the general 'traffic flow'.
ments are met. The use of an end room with a single door will minimise
traffic, as will only having necessary personnel enter
PACKING SUPPLIES FOR STERILISATION the room. To decrease contamination further, only
Various materials are available for packaging supplies correctly attired personnel should be allowed in the
for sterilisation, and several factors influence which room at any time, and the room should not be used for
material is chosen. The material must be resistant to other purposes, such as examination or treatment of
damage when handled. The sterilant must be able to pen- animals.
etrate the material chosen during sterilisation, and be The room should be large enough to accommodate
easily exhausted from the pack once sterilisation is com- the surgical team, patient and ancillary equipment, but
plete. Microorganisms must not be able to penetrate the small enough to facilitate cleaning and reduce bacterial
outer surface of the wrapper. The size of the sterilising contamination, and to discourage the storage of redun-
chamber and the items to be sterilised may also have a dant items. The airflow should move from the area
bearing, as may cost and personal preference. of least to the area of greatest contamination. The air
* NYLON FILM designed for use in an autoclave is avail- within the operating room should be at a mild positive
able in a range of sizes, is reusable and is transparent, pressure, so that air flows out when the door is opened.
allowing the contents of the pack to be seen without The windows should be prevented from opening to
breaking the seal. However, it becomes brittle after prevent contamination from outside. A minimum of
repeated use, resulting in the development of tiny holes 25 air changes per hour is required if the air is recir-
and therefore contamination of the pack. It may be diffi- culated, or 15 if it is vented to the outside. Fan heaters
cult to remove sterile items without contaminating them should be avoided since they cause air and dust
on the edges of the bag. movement.
* SEAL-AND-PEEL POUCHES are disposable bags consist- The operating room should be constructed so that it is
ing of a paper back and a clear plasticised front with a easily cleaned and the potential for harbouring micro-
foldover seal. They are available in a wide variety of organisms is reduced. The walls and floors should be
sizes and are suitable for steam or ethylene oxide sterili- constructed of impervious, non-staining materials with-
sation. The risk of contamination during opening is out seams, and the walls and ceiling painted with a light-
small. Double wrapping decreases the risk of contamina- coloured waterproof paint. The comers and edges of
tion during storage. walls should be coved to allow easy cleaning. The room
* PAPER may be used as an outer layer for packs. The should contain as little furniture as possible. What furni-
most suitable type is crepe-like (ie, slightly elastic and ture there is should ideally be constructed from stainless
conforming). Although it is frequently reused, it is steel and glass, as this is easier to clean and disinfect.
intended to be disposable. Cabinets should have tight-fitting doors; recessed cabi-

In Practice * JANUARY 1996 29

Downloaded from inpractice.bmj.com on July 26, 2011 - Published by group.bmj.com
nets, extending from floor to ceiling, are preferable. A
pass-through port from the preparation room to the oper-
ating theatre improves efficiency and minimises traffic.
There should be no open drains present in the operating
room.
USE
Clean operations should be perfonned first - particularly
when implants are used and contaminated surgery last.
There should be a separate room for dirty procedures.
An operation list should be kept so that if any sepsis
problems arise, the cause may be identified.
MAINTENANCE AND CLEANING
A routine cleaning programme in the operating theatre is
essential if a high standard of asepsis is to be achieved.
At the start of each day, all the furniture and surfaces
should be damp-dusted with a dilute disinfectant solution
(dry dusting would simply moxve dust around the room).
In between cases, the operating table, equipment and
surfaces. including the floor, should be cleaned if soiled.
At the end of the day, all floors should be vacuumed to
remove debris and loose hair, and then cleaned with dis-
infectant. All waste material should be removed. Surface
equipment, lights and scrub sinks should be disinfected.
Once weekly, there should be a more thorough clean-
ing session in which all equipment is removed from the
room, and the floors and walls are scrubbcd. A disinfec-
tant with detcrgent properties which will remove organic
matter, and which is active against a wide range of bac-
teria, including Pseudotnonas species, should be used.
After removing excess solution, the disinfectant should
be allowed to dry to provide a longer residual activity.
All equipment should be meticulously cleaned.
All cleaning utensils should be designated specifical-
ly for use in the operating room, kept clean and stored
away from the sterile area.
PREPARATION OF THE PATIENT
The skin and hair of the patient harbour a significant
reservoir of bacteria. Endogenous bacteria originate from
within the body; exogenous bacteria are found on the
surface of the animal and include environmental
contaminants. Bacteria normally residing on canine skin
include Staphlvlococcus. Micrococcu.s, Streptococcui.s,
A4cinetobacte,, Clostridiunm and Bacillus species as well
as some Gram-negative bacilli and diphtheroids.
Preoperative preparation of the patient entails remov-
ing hair from the proposed surgical site and adjacent
areas, cleansing and the use of antiseptic agents and
aseptic draping of the surgical site. Some patients may
require preoperative bathing if gross contamination is
present.
HAIR REMOVAL
Hair removal is required for most surgical procedures.
This may be carried out beforc anaesthesia or while the
patient is anaesthetised. Removal of hair before anaes-
thesia results in a shorter anaesthetic time, and most of
the loose hairs are shed before surgery reducing the
potential for contamination. Removal of the hair from
the patient while it is anaesthetised takes less time and
may be necessary if the site is painful. However, all
methods of hair removal cause some degree of trauma to
30
the skin. Any injury to the skin's barrier properties will
be followed by rapid bacterial colonisation. The inci-
dence of post surgical wound infection increases with
the time interval between hair removal and surgery. Hair
is, therefore, generally removed immediately before
surgery.
Shaving
Shaving removes hair with minimal stubble, but causcs
multiple small lacerations and skin erosions that arc
rapidly colonised by bacteria. Shaving is no longer rec-
oimmended because it has been associated with up to a
10-fold increase in post surgical wound infection rates.
Depilatories
Depilatories, although an atraumatic method of hair
removal, have not gained popularity in veterinary prac-
tice because they are less effective on the coarse hair of
animals and are expensive. They may also produce skin
reactions.
Clipping
Clipping is the recommended technique for hair
removal. Sharp blades (without missing teeth) and
liberally applied lubricants and coolants minimise
the propensity for skin trauma. Nicks in the skin may
harbour bacteria and cause irritation, leading to post-
operative self-trauma. The clipper blades should be
cleaned in between cases and may need to be sterilised
after clipping contaminated sites. Clipping should be
performed away from the operating theatre to minimisc
contamination.
A minimum of 15 cm each side of the proposed inci-
sion site should be clipped. If multiple procedures are to
be performed, all sites should be clipped at the same
time. For procedures on the limbs, hair on the entire limb
is clipped as far as the dorsal midline. Paws are difficult
areas to clip without causing trauma and have a higher
resident bacterial population. If access to the paw is not
required, it can be covered by an impermeable material
to obviate clipping. Contamination of open wounds by
loose hair and dander can be minimised by covering the
area with saline-moistened gauze swabs or applying ster-
ile water-soluble gel and clipping away from the wound.
A vacuum should be used to remove hair and debris
from the clipped area and adjacent table surfaces imme-
diately after clipping.
PREPARATION OF THE PATIENT'S SKIN
The patient's skin cannot be completely sterilised. The
aim of preoperative preparation is to reduce the numbers
of bacteria without damaging the skin. The transient bac-
teria on the skin surface can be killed with antiseptic
solutions, but the resident bacteria in the hair follicles
and sebaceous glands cannot be destroyed. The level of
resident bacteria may be reduced with adequate prepara-
tion but, during the operation, they come to the surfacc
of the skin and are a source of contamination. Surgical
scrub solutions are formulated with antiseptic and deter-
gent properties, and are applied first. An antiseptic solu-
tion (water- or alcohol-based) is then applied to give
residual bactericidal activity.
Skin preparation agents
Various skin preparation agents are available (see table,
page 25). The ideal agent is a broad-spectrum bacterici-
In Practice * JANUARY 1996
 Downloaded from inpractice.bmj.com on July 26, 2011 - Published by group.bmj.com
dal compound that rapidly kills accessible microorgan-
isms. These criteria are currently best fulfilled by
chlorhexidine and povidone-iodine. Although some stud-
ies comparing the efficacy of these two agents have
demonstrated that chlorhexidine is more effective, other
studies have failed to document a significant difference
in bacterial kill rates or in postoperative wound infec-
tion. The use of either agent is justified, although
chlorhexidine has the advantages of prolonged residual
activity, continued activity in the presence of organic
matter and reduced incidence of skin reactions.
It is important to note that Gram-negative bacteria,
particularly Pseudomonas species, can live and multiply
in some dilute antiseptic solutions. For this reason, such
solutions should be dispensed freshly from concentrated
stock solutions into sterile containers. Dilute solutions
should be discarded after 48 hours.
Skin preparation protocol
The initial surgical site preparation is performed outside
the operating theatre. The wearing of surgical gloves
during preparation decreases the risk of contamination
by the operator's hands; the gloves do not need to be
sterile during these initial stages of the procedure.
Antibacterial detergents are usually applied to the skin
with wet, lint-free gauze swabs. It has been reported that
a gloved hand may be as effective in decreasing total
bacterial numbers. Scrub brushes should be avoided as
they can cause excessive skin trauma.
Both the detergent's lather and the scrubbing action
are important for the mechanical removal of debris and
bacteria. Excessive vigour should be avoided because it
brings bacteria within the follicles to the surface and
causes irritations or abrasions that are rapidly colonised
by bacteria. There should be just sufficient water to
produce a good lather. Too much water will result in
dilution of the agent, and hence reduced efficacy, and
wetting of the patient, potentiating both heat loss during
the surgery and moist contamination ('strike through')
of surgical drapes.
Once the scrub is completed, an antiseptic such as 70
per cent ethyl alcohol, or a mixture of ethyl alcohol and
chlorhexidine or povidone-iodine, is applied or sprayed
on to the proposed surgical site. A sterile drape may be
placed over the prepared area and the animal is trans-
ported to the operating theatre.
Once within the operating theatre, a similar, but
pIf
Advantages Disadvantages
Disposable Excellent water repellent Expensive
properties May be less conforming
Always in good condition
Large stock required
Labour saving
Less laundry
Can be obtained pre-sterilised
Reusable Cheaper Poor barrier properties
Less waste
with respect to fluids -
leading to break in asepsis
Laundry and preparation
time consuming
Threads may detach and
gain access to wound
Reduced quality with
repeated washing
32
shorter surgical scrub, this time using sterile swabs and
gloves is advocated by some authorities. Alternatively,
the surgeon may apply antiseptic solution to the surgical
site using sterile swabs on sponge-holding forceps.
DRAPING THE PATIENT
Draping maintains asepsis by preventing contamination
of the surgical site by hair and the immediate environ-
ment. The drapes should cover the entire patient and
table, leaving only the surgical site exposed. The ideal
material will provide a barrier to bacteria and debri$
from non-sterile areas for the duration of the surgery. It
should be easy to sterilise, economical and retain its bar-
rier properties under the conditions in which it is used. It
must remain securely fastened to the patient during
manipulation. Both reusable and disposable type drapes
are available; their relative advantages and disadvan-
tages are considered in the table (below left).
Four drapes may be used to isolate a rectangle con-
taining the proposed surgical site or, alternatively, a sin-
gle fenestrated drape. Each corner of the draped square
is secured to the patient's skin by towel clamps, Michel
clips or sutures. Penetration of the drape by a clamp will
destroy the barrier at that point. In addition, clamps are
considered contaminated after making contact with the
patient's skin and so a new clamp should be used if the
drape is repositioned. If four single drapes are used, a
second draping layer, consisting of a large, single sheet
with a central opening, may be used on top of the first
layer. A waterproof disposable drape between the two
layers will improve the effectiveness of the barrier if
cloth drapes are used. Additional drapes or towels may
be used during surgery to protect the tissues when there
is an increased risk of contamination, for instance during
enterotomy. Another method, useful for orthopaedic pro-
cedures on limbs, is to cover the limb with a double lay-
ered orthopaedic stockinette and suture it to the wound
edges. This technique allows the entire limb to be
draped, while still permitting manipulation. The inclu-
sion of a plastic layer underneath the stockinette
improves its barrier properties.
Adhesive barrier drapes have been recommended as a
solution to the problems inherent in current draping tech-
niques. They are waterproof and their adhesive nature
allows rapid application, without the need for additional
skin attachment. The incision is made directly through
the drape, and their transparency aids orientation and
identification of landmarks. Significant reductions in the
numbers of bacteria in surgical wounds at closure have
been documented using these drapes, although this has
not been reflected in a significant decrease in wound
infection rates for clean and clean-contaminated proce-
dures in man. Acceptance of these drapes in veterinary
surgery is low due primarily to their cost, the unreliable
adherence of the drapes to the area adjacent to the surgi-
cal site and studies questioning their effectiveness in
human surgery.
ASEPTIC OPERATIVE TECHNIQUE
Good technical surgery is concerned with maintaining
asepsis, as well as obtaining haemostasis, producing
adequate exposure and manipulating tissues with care.
Asepsis is maintained by having a well prepared envi-
ronment and preventing breaks in aseptic technique.
In Practice * JANUARY 1996
 Downloaded from inpractice.bmj.com on July 26, 2011 - Published by group.bmj.com

CREATING THE STERILE FIELD Surgical team members should approach the sterile
The sterile field, an area of asepsis creating by unwrap- field face first to maintain asepsis and prevent con-
ping a large sterile pack onto an instrument trolley, is set tamination. Movement around the sterile field should
up as near to the time of surgery as possible and moni- be limited to avoid compromising sterility. Sterile
tored to avoid contamination. The instruments should be team members remain near the sterile field, and non-
laid out by an individual wearing a sterile gown and sterile personnel remain away from it, to avoid accidental
gloves. It is bad practice for an unscrubbed person to contamination. No non-sterile personnel should reach
complete this arrangement using Cheatle forceps, across the sterile field. During the procedure, contam-
because of the greater risk of contamination occurring inated instruments should not be retumed to the sterile
when ungloved hands are moved to and fro across a ster- table. Reference
ile table. All items within this field are sterile and a new SMEAK, S. D. & OLMSTEAD,
M. L. (1984) Infections in clean
set of sterile instruments should be used for each proce- wounds: the role of the
dure. Sterile items added to the sterile field must not POSTOPERATIVE CARE surgeon, environment and host.
touch non-sterile areas, such as the hands of the person Compendium on Continuing
Education for the Practicing
opening the package or the edges of wrappers and pack- Aseptic technique does not finish at the end of the surgi- Veterinarian 6, 629-633
ages. The patient becomes the centre of the sterile field cal procedure. In the postoperative period, sterile dress-
through placement of sterile drapes that protect the sur- ings need to be maintained and changed using aseptic Further reading
gical site from contamination and establish a work area technique. Indwelling catheters and surgical drains need BRIGDEN, R. J. (1988) Operating
Theatre Technique, 5th edn.
for the surgical team. to be attended to similarly. Incorrect patient management Edinburgh, Churchill
All packages of sterile items should be inspected for in the postoperative period can reduce the benefits of Livingstone
CHITWOOD, L. B. & SWAIN, D.
perforation, permeation by liquid or outdated sterilisa- minimising or preventing bacterial contamination in the C. (1992) Perioperative Nursing.
tion dates, indicating that the item is no longer sterile. pre- and intraoperative phases. Philadelphia, Springhouse
Notes
KYLE, J. & HARDY, J. D. (1981)
MAINTAINING THE STERILE FIELD Scientific Foundations of
The sterile field encompasses the sterile table containing SUMMARY Surgery, 3rd edn. London,
William Heinemann
the items necessary for the procedure, the draped patient SABISTON, D. C. (1991)
and the surgical team members wearing sterile gowns. The various protocols for achieving surgical asepsis dis- Textbook of Surgery: The
Biologic Basis of Modern
The front of the gown from chest to table level and the cussed in this article may be adapted according to the Surgical Practice, 14th edn.
sleeves from above the elbow to the cuff are considered facilities available at the individual practice or hospital, Philadelphia, W. B. Saunders
TRACY, D. L. & WARREN, R. G.
sterile. The back of the gown, neckline, under the arms economic necessity and personal preference. Under all (1983) Small Animal Surgical
and the gown below table level are considered non-ster- circumstances, however, the highest standards of asepsis Nursing. Missouri, Mosby
ile. Gowns and gloves that become punctured or tear, or should always be sought and maintained. An inability to VASSEUR, P. B., LEVY, J.,
DOWD, E. & ELIOT, J. (1988)
that become permeated by liquid must immediately be achieve these is soliciting failure. Surgical wound infection in
replaced or reinforced. Any other break in asepsis should The most common reasons for breaks in aseptic tech- dogs and cats: data from a
teaching hospital. Veterinary
immediately be noted and rectified. nique are summarised in the box on the left. Surgery 17, 60-64

..................................................................................................................................

Common breaks In aseptic

technique
Operating team Veterinary report of a
* Exposed hair

* Active respiratory infection

procedure
* Dermatitis altering the natural
* Loose-fitting mask

* Soiled scrub suit

conformation
Scrub procedure of a dog
* Rings and bracelets left on
* Long or dirty fingernails
This certificate has been produced with
* Improper scrub sequence, duration or technique
the Kennel Club and the Royal College
* Gowning or gloving with wet hands
of Veterinary Surgeons
Touch contamination break Pads of 10 sets of certificates are available
* Sterile team member having front to back

contact with another sterile member

* Any contact with non-sterile surface, usually
Price £5.00
during draping to BVA members
* Hands held below table level
from TGS Subscriber Services, 6 Boume
* Torn glove
Enterprise Centre, Wrotham Road, Borough
Technique breaks Green, Kent TN15 8DG, telephone 01732
* Drapes soaked by blood or solutions 884023, fax 01732 884034
* Opening of contaminated viscus

* Unnecessary conversation
Payment with order please
* Non-sterile person leaning over sterile field

In Practice a JANUARY 1 996 33

 Downloaded from inpractice.bmj.com on July 26, 2011 - Published by group.bmj.com

Surgical asepsis: principles and protocols

Stephen Baines

In Practice 1996 18: 23-33

doi: 10.1136/inpract.18.1.23

Updated information and services can be found at:

http://inpractice.bmj.com/content/18/1/23

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