Surgical Asepsis and Antisepsis

Surgical Asepsis (Sterile Technique)

Aseptic technique is defined as methods and practices that prevent cross contamination in surgery. Microorganisms have access to the inner tissues, whenever dermal integrity is disrupted, such as during surgery.

The bacteria that contaminate surgical wounds generally originate from the operating room personnel, and from the environment. Rules of aseptic technique must be followed to prevent wound contamination.

The Sterile Field

1. Sterile field is a microorganism-free area, including free of spores.
2. To maintain an area free of microorganisms, sterile gloves, gowns and drapes are used to create a barrier between the environment (including members of the team) and the client.
3. Established by using the innermost side of a sterile wrapper or by a sterile drape.  Sterile supplies and solutions may be placed on it. 

Principles and practices of surgical asepsis–

Start with sterile equipment and set up the sterile field.

1. All objects used in a sterile field must be sterile.
2. Confirm sterility of the package. – Check expiration date and ensure package is clean and dry.
3. Open the package – place in center of table; top flap open away from you; touch only outside of wrapper; side flaps open with each hand; 4^th flap toward you making sure it does not touch your uniform.  If the inner surface touches any unsterile article it is contaminated.
4. Opening a wrapped package while holding it: same as above.
5. Using a drape to establish a field; with one hand pluck the corner of the drape that is folded back on the top.
   • Lift the drape out of the cover and allow it to open freely without touching any objects. 
   • Lay the drape on a clean dry surface, placing the freely hanging side farthest from you (nurse should not lean over sterile field).

If there is any doubt about the sterility of an object consider it unsterile. Eg, the package falls on the floor or has evidence of damage or moisture, even dried moisture.

Maintain the sterile field from start to finish–

1. The skin cannot be sterilized and is unsterile.
2. Sterile persons and items contact only sterile areas, unsterile persons and items contact only unsterile areas.
3. Sterile objects become unsterile when touched by unsterile objects.
4. Sterile objects can become unsterile by prolonged exposure to airborne microorganisms.  Do not cough, sneeze, or talk excessively over a sterile field.
5. Use a sterile package immediately once it has been opened. Leftover sterile solutions are no longer sterile and should be discarded.
6. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile. Sterile areas are continuously kept in view.
7. Always face a sterile field. If you turn your back on a sterile field, you cannot guarantee its sterility.
8. Movement within and around a sterile field must be such as not to cause contamination of that sterile field.
9. Fluids flow in the direction of gravity. Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action.
10. The edges of sterile containers are not considered sterile once the package is open.  The one inch margin around the edge of the sterile field is considered contaminated.
11. Sterile gowns are considered sterile in front, shoulder to table level.  The sleeves are also sterile.
12. Tables are sterile only at table top level.
13. Whenever bacterial barriers are permeated, contamination occur.
14. Articles of doubtful sterility are considered unsterile.
15. Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis.

Sterile Supplies

1. Open each wrapped package as describe above.
2. With free hand, grasp the corners of the wrapper and hold them against the wrist of the other hand (the unsterile hand is now covered by the sterile wrapper).
3. Place the sterile item on the field by approaching from an angle rather than holding the arm over the field.
4. Commercially packaged supplies: Hold the package above the field and allow contents to drop on center of the field.
5. Sterile solutions: Read label to confirm solution.  Outside of container is unsterile; inside sterile.  Once it is opened, its sterility cannot be ensured for future use.  Remove cap and inert before placing it on a table.  Hold the bottle of fluid at a height of about 4-6” and to the side of the sterile field; discard a little solution before pouring; avoid spashing which will cause the field to be contaminated.
6. Use of sterile forceps: Keep the tips of wet forceps lower than the wrist at all times.  Hold sterile forceps above waist level and in sight.

Sterile Gloves

1. May be donned by open or closed method.  Closed method requires a sterile gown so in the general care area, the open method is used.
2. Gloves may be latex or vinyl and come in sizes.
3. Procedure:
   • Remove rings, especially those with stones.
   • Wash hands. 
   • Place package on clean, dry surface.
   • Open outer package, then the inner package.
   • 1^st glove (dominant hand): grasp by its cuff with thumb and 1^st finger of non-dominant hand, touching only the inside of the glove.  Insert the hand.
   • 2^nd glove: Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm.  Pull on the 2^nd glove carefully.  Adjust each glove so that it fits smoothly and pull the cuffs up.

The Surgical Team

1. Team members are categorised as sterile or non-sterile in relation to the sterile surgical field.
2. Sterile team members are those who scrub their hands and arms, don sterile attire, use sterile instruments and supplies and work in the sterile surgical field.  This includes the surgeon, physician assistant and RN first assistant and the scrub person who may be a RN, a LVN or a surgical technician.
   • The RNFA (registered nurse first assistant) replaces an assisting surgeon and has had additional training.  The duties include handling tissue and organs with instruments, providing exposure of the surgical site, suturing, etc.
   • The scrub nurse (or surgical scrub technician) sets up and maintains the sterile field, hands supplies, and instruments to the surgeon, keeps accurate count of instruments, sponges and sharps, and monitors aseptic technique.
3. Nonsterile team members team have responsibilities outside the sterile field and do not wear sterile attire.
   • The nonsterile team members include the anesthesiologist, the nurse anesthetist, and the circulating nurse.
   • The circulating nurse  must be an RN and she coordinates the care of the client and manages activities outside the sterile field.

The surgical asepsis can be effectively enforced by proper–

• Preparation of surgical pack
• Preparation of surgical patient
• Preparation of operation theatre
• Preparation of surgical team

RULES	REASONS
Surgical team members remain within the sterile area.	Movement out of the sterile area may encourage cross contamination.
Talking is kept to a minimum.	Talking release moisture droplets laden with bacteria.
Movement in the operating room (OR) by all personnel is kept to a minimum; only necessary personnel should enter the OR.	Movement in the OR may encourage turbulent airflow and result in cross contamination.
Non-scrubbed personnel do not reach over sterile fields.	Dust, lint, or other vehicles of bacterial contamination may fall on the sterile field.
Scrubbed team members face each other and the sterile field at all times.	A team member’s back is not considered sterile even if wearing a wraparound gown.
Equipment used during surgery must be sterilized.	Unsterile instrument may be a source of cross contamination.
Scrubbed personnel handle only sterile instruments; non-scrubbed personnel handle only non-sterile instruments.	Non-scrubbed personnel and non-sterile instruments may be a source of cross contamination.
If the sterility of an item is questioned, it is considered contaminated.	Non-sterile, contaminated equipment may be a source of cross contamination.
Sterile tables are only sterile at table height.	Items hanging over the table edge are considered non-sterile because they are out of the surgeon’s vision.
Gowns are sterile from midchest to waist and from gloved hand to 2 inches above the elbow.	The back of the gown is not considered sterile even if it is a wraparound gown.
Drapes covering instrument tables or the patient should be moisture proof.	Moisture carries bacteria from a non-sterile surface to a sterile surface (strike-through contamination).
If a sterile object touches the sealing edge of the pouch that holds it during opening, it is considered contaminated.	Once opened, sealed edges of pouches are not sterile.
Sterile items within a damaged or wet wrapper are considered contaminated.	Contamination can occur from perforated wrappers or from strike-through from moisture transport.
Hands may not be folded into the axillary region; rather, they are clasped in front of the body above the waist.	The axillary region of the gown is not considered sterile.
The instrument assistant during surgery should give handle side of the instruments to the surgeon.	The surgeon can use the instrument easily and the chance of any injury by the instrument is avoided.
If the surgical team begins the surgery seated, they should remain seated until the surgery has been completed.	The surgical field is sterile only from table height to the chest; movement from seating to standing during surgery may increase cross contamination.