OR Sitting and Sterile Technique: Zohair Al Aseri, FRCPC (EM&CCM)

OR Sitting and Sterile Technique
Zohair Al aseri, FRCPC (EM&CCM)

References
• Bailey and love
• https://opentextbc.ca/clinicalskills/chapter/sterile-gloving/
• https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/
• https://opentextbc.ca/clinicalskills/chapter/entering-the-operating-ro
om/#navigation
• Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et
al., 2014; Rothrock, 2014
Objectives
• Introduction
• Aware of common sterility definitions
• Surgical Asepsis and sterile techniques
• Principles of sterile technique
• Surgical instruments and disinfection
• Operating Room Environment
• Preoperative preparation immediately before surgery
• Skin preparation – ‘PREPPING’ AND DRAPING
Surgical Asepsis and sterile technique
Surgical Asepsis and sterile technique

• Asepsis refers to the absence of infectious material or infection.
• Surgical asepsis is the absence of all microorganisms within any type

of invasive procedure.
• Sterile technique is a set of specific practices and procedures

performed to make equipment and areas free from all
microorganisms.
Surgical Asepsis and the Principles of Sterile Technique
Sterile technique:
• Most commonly practiced in operating rooms, labour and delivery
rooms, and special procedures or diagnostic areas.
• Could be at the bedside, such as inserting devices into sterile areas of
the body or cavities:
• Insertion of chest tube
• Central venous line
• Indwelling urinary catheter
• Used when the integrity of the skin is accessed, impaired, or broken
(e.g., burns or surgical incisions).
Principles of Surgical Asepsis

• All personnel involved in an aseptic procedure are required to follow
the principles.
It is the responsibility of all health care workers to

speak up and protect all patients from infection.
Definitions
• Aseptic non-touch technique: means maintaining asepsis by not

touching sterile equipment or areas with the intent of reducing the risk
of transmission of infection to patients
• Circulating (non-scrubbed) personnel: means staff that work in the

periphery of the sterile field.
• Circulating personnel wear non-sterile scrubs and cover wear to

perform duties such as delivering equipment and supplies to the
surgical staff, documentation, and specimen handling
DEFINITIONS
• Closed gloving Technique: Gloving technique in which the hands are not
extended from the sleeves and cuffs when the gown is put on. Instead
the hands are pushed through the cuff openings as the gloves are
pulled into place.
https://www.youtube.com/watch?v=MBXhhFBrxCU
• Doff means to take off.

• Don means to put on.
• Open gloving Technique means a gloving technique in which the
scrubbed person’s hands slide all the way through the sleeves and cuffs
when the gown is put on prior to donning gloves
DEFINITIONS
Product for surgical hand antisepsis: product used for surgical hand
preparation with the following characteristics:
1) significantly reduces microorganisms on intact skin,
2) contains a non-irritating antimicrobial preparation with broad spectrum
activity.
3) fast acting and persistent.
The most commonly used soaps for surgical hand washing contain
chlorhexidine or povidone-iodine.
DEFINITIONS
• Scrub (scrubbed) personnel means staff who work directly in the surgical
field.
• Scrub personnel perform surgical hand antisepsis before donning a sterile gown and
gloves.
• Sterile field means the area around the site of incision into tissue or site of
introduction of an instrument into an orifice that has been prepared for the
use of sterile supplies and/or equipment.
• Strike-through means an event whereby sterile drapes or packages become

contaminated due to soaking through or forcing through of moisture or air
DEFINITIONS
Surgical aseptic technique means “sterile technique” used for invasive procedures
• Goal of surgical aseptic technique is to maintain the microbial count to an
irreducible minimum using:
• Sterile medical device, sterile equipment, sterile gowns, and gloves
• Hand scrub
• Patient skin antisepsis
• Barriers including sterile gloves, sterile gown, masks and sterile drapes
• It is essential to prevent surgical site infections (SSI)

• SSI is defined as an “infection that occurs after surgery in the area of surgery” .
• Preventing and reducing SSI are the most important reasons for using sterile
technique in any surgical procedure.
DEFINITIONS
• Surgical drape means material intended for use on a sterile field that provides an
• adequate barrier to microbes, particulate matter and fluids;
• tear and puncture resistant
• flexible
• moisture repellent
• low linting
• antistatic, flame retardant
• free of noxious odors.
• Surgical hand antisepsis means the process of removing debris and transient

microorganisms from the nails, hands, and forearms; reducing the resident microbial
count to a minimum; and inhibiting regrowth of microorganisms.
Safety considerations:
Health care providers who are ill should
avoid invasive procedures or, if they can’t
avoid them, should double mask.
Hand decontamination
• Wash hands prior to each operation using antiseptic surgical solution,
with a single-use brush for the nails.
• ‘six-step hand hygiene technique’ is now widely adopted
• Hospitals will have policies for which antiseptic agents are used.
Skin preparation
• Antiseptics such as chlorhexidine or povidone-iodine applied to the
surgical site prior to incision reduce the number of resident organisms
• Antiseptics containing alcohol must be allowed to evaporate

completely before using diathermy.
Surgical instruments
• Use only sterile or disposable, single-use instruments.
• Sterile Services Departments (SSD) and is the process for complete destruction of
all microorganisms, including spores for reusable instruments .
• First thoroughly washed in automated washer disinfectors that reach
temperatures of 85–95°C (thermal disinfection), remove organic matter and kill
most microorganisms except spores.
• Instruments can then be packed and processed in a steam steriliser or autoclave to
destroy any remaining microorganisms and their spores.
• Pressures above atmospheric are used so that higher temperatures can be
achieved (e.g., 121°C for 20 minutes; 134°C for 5 minutes).
• Check packages for sterility by assessing intactness,

1. All objects used in a dryness, and expiry date prior to use.
sterile field must be • Any torn, previously opened, or wet packaging, or
sterile. packaging that has been dropped on the floor, is
considered non-sterile and may not be used in the
sterile field.
Whenever the sterility of an object is

questionable, consider it non-sterile.
2. A sterile object becomes non-sterile Fluid flows in the direction of gravity.

when touched by a non-sterile object. Keep the tips of forceps down during a
sterile procedure to prevent fluid
travelling over entire forceps and
potentially contaminating the sterile
field.
Keep all sterile equipment and

3. Sterile items that are below sterile gloves above waist
the waist level, or items held level.
below waist level, are
considered to be non-sterile. Table drapes are only sterile at
waist level.
4. Sterile fields must always be Never turn your back on the

kept in sight to be considered sterile field as sterility cannot
sterile. be guaranteed.
• Set up sterile trays as close to the
time of use as possible.
5. When opening sterile equipment • Place items on the sterile field
and adding supplies to a sterile field, using sterile gloves or sterile
take care to avoid contamination. transfer forceps.

• Sterile objects can become non-
sterile by prolonged exposure to
airborne microorganisms.
6. Any puncture, moisture, or tear

that passes through a sterile barrier Keep sterile surface dry and replace if
must be considered contaminated. wet or torn.
7. Once a sterile field is set up, the

border of one inch at the edge of the Place all objects inside the sterile
field and away from the one-inch
sterile drape is considered non- border.
sterile.
8. If there is any doubt about the Known sterility must be maintained

sterility of an object, it is considered throughout any procedure.
non-sterile.
9. Sterile persons or Front of the sterile gown is sterile between the

sterile objects may only shoulders and the waist, and from the sleeves to two
contact sterile areas; inches below the elbow.
non-sterile persons or Non-sterile items should not cross over the sterile
items contact only non- field. For example, a non-sterile person should not
sterile areas.
reach over a sterile field.
• Do not sneeze, cough, laugh, or talk over the sterile field.
10. Movement • Maintain a safe space or margin of safety between sterile and
around and in the non-sterile objects and areas.
sterile field must not
• Refrain from reaching over the sterile field.
compromise or
contaminate the • Keep operating room (OR) traffic to a minimum, and keep
sterile field. doors closed.
• Keep hair tied back.

Operating Room Environment
• The OR environment has sterile and non-sterile areas, as well as

sterile and non-sterile personnel.
• It is important to know who is sterile and who not, and which areas in

the OR are sterile or non-sterile.
The Operating Room Environment
Sterile OR Personnel: Non-sterile OR Personnel:

• Surgeon •Anesthesiologist
•Circulating nurse
• Surgical assistant
•Technologist, student, or observer
• Scrub nurse
PREOPERATIVE PREPARATION IMMEDIATELY BEFORE
SURGERY
Preoperative checks with the patient

• Patient’s name
• Condition
• Consent – mark side
• All investigations available
• Sepsis
• Pre-existing complications
SURGERY
Theatre team’s preparation for the operation

• Theatre team should be given as much notice as possible for the
proposed operation.
• Children are usually put first on operating lists to reduce the anxiety
created by waiting.
• Diabetics and other patients whose conditions are potentially labile

should also be put early on the list.
SURGERY
The theatre list

• Theatre list should have as a header the date and the details of the
theatre, surgeon and anaesthetist.
• For each operation the patient’s name and number, the ward that
they will be coming from, the operation title and the side of surgery, if
appropriate, should be given.
SURGERY
The theatre list

• Anaesthetist should be aware of the operative procedure to estimate
the effect on the physiology of the patient.
• Need for preoperative prophylactic antibiotics should be discussed in

advance.
• Possible requirements such as blood transfusion, platelet infusion or

antihaemophiliac fraction before starting the operative procedure.
SURGERY
Types of scrub disinfectant solutions
Chlorhexidine gluconate
• Has a residual effect and is effective for more than 4 hours.
• It has potent antiseptic activity against Gram- positive and Gram-

negative organisms and some viruses.
• Only moderate activity against the tubercle bacillus.

SURGERY
Iodine
• Has some residual effects but these are not sustained for more than 4 hours.
• It is highly bactericidal, fungicidal and viricidal.
• Has some activity against bacterial spores and good activity against tubercle
bacillus.
• Penetrate cell walls to produce anti-microbial effects.

SURGERY
Alcohols
• Highly effective
• rapidly acting anti-microbial agents with broad-spectrum activity.
• Effective in destroying Gram-positive and Gram-negative bacteria,
fungi, viruses and tubercle bacilli, but are not sporicidal.
SURGERY
Operating room/theatre
Temperature and humidity
Patients are at risk of becoming hypothermic during prolonged operations. Paralysis,

cool intravenous fluid and large exposed wounds all add to this potential problem.
To prevent such hypothermia ambient temperatures of between 24 and 26∞C are

recommended.
However, most surgeons find such temperatures uncomfortable and fatigue quickly.
Ideal working temperatures for surgeons are between 19 and 20∞C.
SURGERY
Operating room/theatre
Temperature and humidity
For prolonged operations patient-warming blanket should be used.
This is especially important in small children.
Relative humidity in theatres should be capable of adjustment in the range

40–60%.
SURGERY
Illumination
The light source in theatre should not produce shadow.
It should be capable of producing a minimum of 40 000

lux at the incision site.
SURGERY
Ventilatory system
Airflow system
• keeps air fresh
• It is measured by air changes per hour.
Minimum standard number of airflow changes allowed in operating rooms in

the is 17 per hour.
Laminar flow will generally provide 100–300 air changes per hour and is used
in operations in which airborne infection must be avoided at all costs
(operations involving implants).
SURGERY
Movement
• All staff should enter the theatre through the entry zone, which is used for
scrubbing and gowning.
• Amount of movement in and around the operating room and table itself should
be kept to a minimum.
• There should be doors clearly marked for entry and exit, as one-way traffic will
minimise the risk of contamination.
SURGERY
Airborne contamination
Airborne bacteria in the theatre originate almost exclusively from
personnel within the theatre.
Person may shed from 3000 to 50000 micro-organisms per minute.
The major source is the skin, which is often contaminated with

Staphylococcus aureus and other coagulase -Ve staphylococcal species.
Bacteria also disperse from the upper respiratory tract.

SURGERY
Airborne contamination
Avoid:
• Excessive or unnecessary movements,
• Operating room/theatre overcrowding,
• Poor scrubbing up, gowning and gloving technique,
• Poor airflow and inappropriate temperatures and humidity
SKIN PREPARATION – ‘PREPPING’ AND DRAPING
Skin preparation before surgery (often shortened to ‘prepping’)
Aim:
• Reduce the microbial count on the patient’s skin to the minimal level
possible
• Inhibit microbial regrowth and contamination of the wound itself during
surgery.
Achieved with soaps or detergents and water in the ‘pre-prep’ phase.
Disinfection destroys micro-organisms provided that it comes into contact

with them for long enough.
Skin preparation
‘Pre-prep’
Skin of the patient must be prepared before formal surgical skin preparation to
remove soil and debris.
If a plaster of Paris cast has just been removed, the skin should be washed with soapy
disinfectant and then washed down with water or saline followed by application of
surgical disinfectant (‘prep’) prior to the main prep.
For patients under- going elective surgery, a shower on the day of surgery with a
soapy disinfectant should suffice.
Skin preparation
Skin preparation solution – ‘prep’
The solution used may have an aqueous or alcohol base.
Care must be taken that the solution does not pool

under the patient
pooling can cause a chemical burn.
Preparing the patient’s skin (‘prepping’)

•Performed by staff who are scrubbed up
•Use aqueous solutions for open wounds, alcohol for intact skin
•Work from the incision site outwards
•Repeat at least twice
•Clean heavily contaminated areas last and then discard the prep sponge
•Remove excessive prep solution with a dry swab
Draping of the operative area
• The purpose of surgical draping is to create and maintain a

protective zone of asepsis, called a ‘sterile field’
• Surgical draping involves covering with sterile barrier material,

‘drapes’, the area immediately surrounding the operative site.
• Drape materials should resist penetration of microscopic
particles and moisture, limiting the migration of micro-
organisms into the surgical wound.
• Drapes should be handled only by personnel wearing sterile gloves.
• Disposable drapes are a more effective barrier to fluid penetration

(‘strike-through’) and therefore prevent secondary ingress of micro-
organisms.
• Draping should allow access to the whole surgical incision and allow
for extensile exposure if this is possibly going to be needed.
Exposed skin around the incision area itself may be
covered with a self-adhesive transparent drape,
Diathermy and sucker must be firmly attached to the

drapes with enough slack to allow free movement.
Outer ends of each are then passed off the operating

table and from this point are regarded as unsterile.
Objectives
• Introduction
• Aware of common sterility definitions
• Surgical Asepsis and sterile techniques
• Principles of sterile technique
• Surgical instruments and disinfection
• Operating Room Environment
• Preoperative preparation immediately before surgery
• Skin preparation – ‘PREPPING’ AND DRAPING
Thank you
Q&A
References
• Bailey and love
• https://opentextbc.ca/clinicalskills/chapter/sterile-gloving/
• https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/
• https://opentextbc.ca/clinicalskills/chapter/entering-the-operating-ro
om/#navigation
• Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et
al., 2014; Rothrock, 2014

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OR Sitting and Sterile Technique

Zohair Al aseri, FRCPC (EM&CCM)

Surgical Asepsis and sterile technique

• Surgical asepsis is the absence of all microorganisms within any type

• Sterile technique is a set of specific practices and procedures

Principles of Surgical Asepsis

It is the responsibility of all health care workers to

• Aseptic non-touch technique: means maintaining asepsis by not

• Circulating (non-scrubbed) personnel: means staff that work in the

• Circulating personnel wear non-sterile scrubs and cover wear to

• Doff means to take off.

• Strike-through means an event whereby sterile drapes or packages become

• It is essential to prevent surgical site infections (SSI)

• Surgical hand antisepsis means the process of removing debris and transient

• ‘six-step hand hygiene technique’ is now widely adopted

• Antiseptics containing alcohol must be allowed to evaporate

• Check packages for sterility by assessing intactness,

Whenever the sterility of an object is

2. A sterile object becomes non-sterile Fluid flows in the direction of gravity.

Keep all sterile equipment and

4. Sterile fields must always be Never turn your back on the

6. Any puncture, moisture, or tear

7. Once a sterile field is set up, the

8. If there is any doubt about the Known sterility must be maintained

9. Sterile persons or Front of the sterile gown is sterile between the

• Do not sneeze, cough, laugh, or talk over the sterile field.

• Keep hair tied back.

• The OR environment has sterile and non-sterile areas, as well as

• It is important to know who is sterile and who not, and which areas in

Sterile OR Personnel: Non-sterile OR Personnel:

Preoperative checks with the patient

Theatre team’s preparation for the operation

• Diabetics and other patients whose conditions are potentially labile

The theatre list

The theatre list

• Need for preoperative prophylactic antibiotics should be discussed in

• Possible requirements such as blood transfusion, platelet infusion or

Types of scrub disinfectant solutions

• It has potent antiseptic activity against Gram- positive and Gram-

• Only moderate activity against the tubercle bacillus.

Types of scrub disinfectant solutions

• It is highly bactericidal, fungicidal and viricidal.

• Penetrate cell walls to produce anti-microbial effects.

Types of scrub disinfectant solutions

Patients are at risk of becoming hypothermic during prolonged operations. Paralysis,

To prevent such hypothermia ambient temperatures of between 24 and 26∞C are

Temperature and humidity

For prolonged operations patient-warming blanket should be used.

This is especially important in small children.

Relative humidity in theatres should be capable of adjustment in the range

It should be capable of producing a minimum of 40 000

Minimum standard number of airflow changes allowed in operating rooms in

Person may shed from 3000 to 50000 micro-organisms per minute.

The major source is the skin, which is often contaminated with

Bacteria also disperse from the upper respiratory tract.

Achieved with soaps or detergents and water in the ‘pre-prep’ phase.

Disinfection destroys micro-organisms provided that it comes into contact

The solution used may have an aqueous or alcohol base.

Care must be taken that the solution does not pool

Preparing the patient’s skin (‘prepping’)

• The purpose of surgical draping is to create and maintain a

• Surgical draping involves covering with sterile barrier material,