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 vvound contamination. The basic principle of aseptic technique is that microbiological
contamination and subsequent infection cannot occur if microorganisms are totally excluded from a vvound.
The reality of aseptic technique is a vvorking set of complementary and independent technologies and operating
room protocols designed to prevent or minimise microbiological contamination of the surgical vvound. Ali items
that come into contact vvith the vvound should be sterile. If an item cannot be made sterile, it is rendered
surgically dean by vvashing vvith antiseptics or disinfectants vvhich destroy most, but not ali, microorganisms.

SOURCES OF CONTAMINATION
Bacterial contamination may ariše from the follovving:
■ the surgical team;
■ surgical equipment;
■ the operating theatre environment;
■ the patient.
The most common source of contamination is the
animal’s endogenous microbial flora. Prevention of
exposure to this population of bacteria is important at the
time of surgery, and the preoperative preparation of the
patient is concemed vvith reducing the likelihood of
contamination from this source.
In the presence of a properly prepared patient, most
particulate material and bacteria come from the surgical
team. Modem aseptic techniques are effective in reducing
contamination by exogenous bacteria. A scrubbed
surgeon, correctly attired, rarely contaminates a vvound
unless one of the barriers fails to function as expected. Ali
items of surgical equipment should be rendered sterile
prior to surgery. Air in contact vvith the surgical vvound is
the most common vehicle for delivering bacteria into the
vvound. The bacteria in the air are usually from the animal
and any non-scrubbed personnel in the operating theatre;
the concentration of bacteria in the air is directly related to
the number of people present and the degree of activity.
A number of phases are important in the prevention of
vvound contamination (see table, belovv left). Most
bacterial contamination occurs at the time of surgery.
Consequently, the perioperative and intraoperative phas- NON-STERILE BARRIERS
es are traditionally regarded as the mainstays of asepsis. Scrub suit
A scrub suit is an occlusive, but not impermeable, barrier
to microorganisms, the aim of which is to reduce partic-
PATIEMT SELECTION ulate shedding in the operating theatre. These clothes
should not be wom outside the operating theatre, or for
Evaluation of the patient for suitability for surgery should procedures vvhich carry an increased risk of contamination
be comprehensive, to assess its overall State of health, (eg, dressing changes and patient examination), if further
determine the risk of surgical wound infection and to guide surgery is scheduled.
the preoperative preparation. Important considerations are
the patient’s physical condition, the presence of Surgical head covers
intercurrent disease and any evidence of a remote site of Hair is the primary source of bacterial contamination from
infection. the surgical team and should therefore be covered. Hoods
It is a myth that animals are more resistant to infection are more effective than caps. The item chosen should cover
than humans. Operative invasion of normal tissue should the occipital and temporal regions, should be durable and
only be undertaken if postoperative infection will not comfortable to wear and should not shed lint into the
threaten the animal’s well-being or life. vvound.

Shoes and shoe covers

PREPARATION OF PERSONNEL
Non-sterile barriers such as scrub suits, masks and caps
will decrease, but not eliminate, the shedding of particu-
late matter (including microorganisms). Preparation of the
surgeon’s skin reduces the likelihood of bacterial
contamination, and sterile barriers such as gowns and Face masks
gloves further reduce contamination.
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 covers
with respect to reduction of bacterial contamination.
Of ali the traditional attire vvom to promote asepsis in the
operating room, face masks contribute the least. A single
mask does not reduce the level of environmental bacterial
contamination - droplets and microorganisms shed from
the naso- and oropharynx are directed to the sides and
bottom of the mask and ultimately reach the surgical
environment. During breathing or quiet talking there is, in
fact, little or no expulsion of bacteria-laden particles.
■ Hovvever, the evidence at present does not support the
total abandonment of face masks. Their main function is to
protect the vvound from droplets (5 to 30 pm in diam- eter)
of saliva expelled during talking. Some smaller particles
(less than 2 to 3 pm diameter) may still pass through the
mask, but particles of this siže do not fali readily on their
ovvn into the vvound during surgery. The use of surgical
hoods may improve the efficacy of mask- vvearing by
allovving the edges of the mask to be covered by the
headgear.

PREPARATION OF THE SURGEON'S SKIN

It is not possible to sterilise the surgeon’s skin. Rather
the aims of the scrubbing protocol (described belovv) are:
■ the mechanical removal of gross dirt from the hands
and forearms;
■ a reduction in the transient microbial count to as close
to zero as possible;
■ a prolonged depressant effect on the resident
microflora of the hands and arms.
‘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-
sumed to be deposited on the skin from the mucous
membranes or the environment. ‘Resident’ flora, on the
other hand, are organisms consistently isolated from the
skin of most people; they are permanent residents of the
skin and are able to multiply vvithin the skin. The
mechanical action of vvashing removes most of the tran-
sient bacteria by friction. The resident population is killed
by antiseptic Solutions.
Scrubbing protocol
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
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.

Properties of an ideal skin preparation
agent
■ 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 vvithout skin irritation and
sensitisation
■ Economical
any contaminated case or break in the surgery schedule,
and three minutes for subsequent cases. Particular atten-
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-

CHARACTERISTICS OF SKIN PREPARATION AGENTS

Example (Trade Recommended
Agent Mechanism of action Activity Speed of action Characteristics Side effects
names) uses

Quaternary Benzalkonium chloride Broad-spectrum Slow Inactivated by soaps Pseudomonas Cleaning non- sterile
ammonium (Roccal; Sterling bactericidal (mainly and organic material infections Ulceration surfaces
compounds VVinthrop) Cationic surface agents Gram- positives) Bacteria survive under if undiluted
Change cell wall
Some viruses film
permeability Neutralise
phospholipids

Slow Neurotoxicity
Hexachlorophene Bacteriostatic
Chlorinated Inhibit electron transport Require repeated
(Ster-Zac; (Gram-positives None - other agents more
phenol and membrane bound application Must use
Hough, only) effective
derivatives enzymes alone
Hoseason) Not sporicidal
Aliphatic 70 per cent ethyl Damage lipids in cell Broad-spectrum Rapid Skin irritation Tissue Routine skin preparation,
alcohols bactericidal
alcohol membrane Protein Some residual action necrosis in open combined vvith other
precipitation Improved activity when vvounds agents
used with
chlorhexidine or
povidone-iodine

Diphenyl ethers Triclosan (Manusept, Disrupt bacterial cell wall Intermediate Routine skin preparation
Aquasept; Hough, Broad-spectrum
Hoseason) bactericidal (not some Some residual action
Pseudomonas Active in the presence
species) of organic matter
Poor fungicide

lodophors Povidone-iodine Damage cell wall Form Rapid Relatively high Routine skin preparation
(Pevidine; BK) reactive ions and protein Broad-spectrum Slovv release of active incidence of skin
(Betadine; Napp) complexes bactericidal iodine Minimal residual reactions
Fungicidal Virucidal action
Sporicidal with Inactivated by organic
prolonged contact material

Bisdiguanide Chlorhexidine Alter cell wall Rapid Good residual action Occasional skin Routine skin preparation
compounds
(Hibitane, Hibiscrub; permeability Protein Active in the presence reactions and
Broad-spectrum
ICI) precipitation of organic matter photosensitivity
bactericidal (not some
Pseudomonas
species) Minimal
action against spores
and viruses
 ate antibacterial effect and a prolonged residual activity. If Steam sterilisation of instruments
such a practice is adopted, minor punctures in gloves are Cleaning
not associated with a significant increase in wound Gross contamination must be removed as a first step,
infection rates. regardless of the sterilisation technique used. Dried
blood conceals microbes, particularly in the less
Govvns
accessible parts of the instruments, and renders
Sterile surgical gowns are used as a further barrier
sterilisation more difficult. Instruments should be
between the surgical team and the patient. Govvns should
cleaned as soon as possible after use. Immediately after
be made of a material that establishes such a barrier (thus
surgery they should be rinsed in cold water to remove
eliminating the passage of microbes), that is resis- tant to
blood and debris. If there is a delay before final cleaning,
blood and aqueous fluids and that is free from linting,
they should be immersed in warm water containing an
eliminating the number of airbome particles.
effective detergent.
Disposable, single-use govvns have superior barrier
Manual cleaning is best achieved using a hand
properties, particularly vvith respect to fluid absorption.
brush vvith soft bristles. Abrasive cleaners should be
Studies have shown that non-woven disposable govvns
avoided, as should ordinary soap vvhich leaves behind
greatly reduce the number of airbome particles and
an insoluble film. A vvasher-steriliser cleans instruments
vvound infection compared vvith cloth govvns, although
in an agitated detergent bath before automatic steam
this difference is much less marked for clean procedures.
sterilisation. Hovvever, this results in unvvrapped
Reusable govvns result in less vvaste and are cheaper
instruments, and is not suitable for routine sterilisation of
to use. Hovvever, the priče differential is somevvhat
surgical supplies. Ultrasonic cleaners clean via the
smaller vvhen the time, effort and cost of laundering and
process of cavitation. Minute gas bubbles are formed by
sterilising the govvns is taken into account. Cloth govvns
ultrasound vvaves vvhich expand until they are
lose ali their barrier properties vvhen vvet. In addition,
unstable, then collapse. Implosion of these bubbles
each time the govvn is laundered the pores in the fabric
creates a minute vacu- um vvhich is responsible for
vviden, further decreasing the barrier properties. These
removing tightly bound soil. Instruments should be
govvns must be regularly inspected for holes. It should be
loaded vvith ali box locks open.
noted that mending of govvns by sevving results in many
needle holes much bigger than the natural pores in the Preparation of packs
material. Instruments and supplies are segregated according to
Govvns vvith integral or added impervious sleeves their intended use. Materials are positioned vvithin
should be used if the govvn above the glove is subjected to packs to allovv complete steam penetration.
moisture. Gloves should cover the elasticated cuff of the Instruments should be sterilised vvith their box locks
govvn. open and complex instruments, such as Balfour
retractors, should be disassembled. Containers such as
kidney dishes are positioned such that the open end is
STERILISATION OF SURGICAL EQUIPMENT
facing dovvn or horizontally. Instrument packs should be
packed on edge vertically, in longi- tudinal rovvs vvithin
Ali instruments, implants and equipment vvhich are to be
the steriliser so that they are oriented in the direction of
used during surgery must be sterilised before use. There
the steam flow. A small amount of space should be left
are several different methods of sterilising available (see
betvveen each pack. Linen packs should be positioned
belovv). The choice of method vvill depend on:
such that their layers are oriented vertically, so that air
Fibreoptic equipment Plastic catheters and syringes Anaesthetic tubing and steam travel dovvnvvards to escape betvveen the
Optical instruments High speed drills and burrs
layers. Care should be taken to prevent overloading and
blocking of the inlet and exhaust valves.
METHODS OF STERILISATION

Physical Chemical
Autodave operation
A number of minimum time-temperature standards have
Heat Gaseous
Steam Ethylene oxide been established for the routine sterilisation of packs
Moist heat (boiling) Formaldehyde (see table, page 27). It is generally agreed that 13
Dry heat Beta-propiolactone
minutes at 120°C is a safe minimum standard; five to 10
Irradiation Liquid minutes at this temperature vvill destroy most resistant
Gamma irradiation Alcohols (ethyl alcohol, isopropyl alcohol)
microbes, vvhile the addition- al time provides a margin
Ultraviolet light Aldehydes (formaldehyde, glutaraldehyde)
High energy electrons Chlorhexidine of safety. Emergency sterilisation is carried out at 131°C
lodophors for three minutes. The sterilising time begins vvhen the
Phenols
Quaternary ammonium compounds temperature of the exhaust gases reaches the desired
level. Therefore, the cycle time includes this heat up
time, as well as the sterilising time, and generally lies in
CHOICE OF STERILISATION METHOD FOR VARIOUS ARTICLES
Steam Dry heat Ethylene oxide the range of 15 to 45 minutes. The time taken to heat up
the steriliser is much reduced in pre- vacuum and
Glassvvare
pulsing type units.
Instruments

Drapes, govvns, svvabs Cutting instruments

Most rubber articles Ophthalmic instruments Drill

Glassvvare bits

Some plastic goods Povvders and oils

 Types of autodave
Vertical pressure cooker
The vertical pressure cooker is a simple machine which
operates by boiling vvater in a closed Container, like a
household pressure cooker. It usually has an air vent at
the top, which is closed once the air has been evacuated,
allovving the pressure (15 psi) to build up. Hovvever, since
steam is less dense than air, there is a danger that some
air will be trapped under a layer of steam vvithin the
steriliser. In addition, the manual operation of such a
machine leaves room for human error in the sterilisation
cycle.
Gravity or downward displacement autodave
The gravity or downward displacement autodave 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, vvhere it is vented to the outside.
Once the air is eliminated, the temperature rises. The
coldest steam, or steam with the highest air content,
continues to be discharged, and a thermometer placed at
this exit registers the temperature 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
AUTOCLAVE TEMPERATURE, PRESSURE, TIME COMBINATIONS
Temperature (°C) Pressure (psi) Sterilising time (minutes)
121 15 15
126 20 10
134 30 3-5
■ the amount and type of equipment to be sterilised;
■ financial constraints;
■ available space.
Each has its advantages and disadvantages, and usually
several methods will be used for ali the equip- ment
required. The table at the foot of page 26 lists the method
of choice for the sterilisation of various articles.
Physical methods of sterilisation are generally more
reliable, and steam is the most ffequently used. Chemical
sterilisation is achieved primarily with ethylene oxide;
other agents are rarely used. Failure of instrument sterili-
sation usually results from inadequate maintenance of the
equipment or attempts to modify sterilising proce- dures
vvithout careful attention to detail.
PHYSICAL METHODS OF STERILISATION
Heat
The temperature range within which microorganisms are
able to survive is determineđ largely by the thermal via-
bility of their protein and nucleic acids, and denaturation of
cell proteins appears to be the principal means by which
heat destroys microbes. There is no one temperature at
which ali microorganisms are killed. The thermal
destruction of bacteria is time- and temperature-
dependent; in addition, when moisture is present, bacter-
ial death occurs at a lower temperature and in a shorter
time (bacterial spores killed after 15 minutes exposure to
steam at 121°C will only be destroyed after one hour in a
hot air oven at 160°C, for example).
remain damp, allovving entry of microorganisms during
the storage period. This type of machine is not suitable for
a busy surgical unit needing to autodave a large number of
instruments, govvns 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 vvithin
packs. These machines allovv emergency sterilising
('flashing') of surgical instruments and materials. They are
fully automatic with fail safe mechanisms, and their
efficacy and reliability outvveigh other types. Hovvever,
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 vvithin the
chamber to a set level, vvhereupon the chamber is vented
to a minimum pressure preceding the next pulse. The
cycle time is shorter than that of gravity displacement
units.
■ STEAM. Sterilisation with saturated steam under pressure
is the most dependable and most widely used means 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 direct
contact, and therefore certain items such as oils/ greases
and items sealed in completely non-porous containers,
such as a stoppered tube, will not be sterilised.
Heat-sensitive items which may be damaged include
fibreoptic equipment, lenses and some plastic goods,
particularly those designed to be disposable.
Air present in steam sterilisers is the principal factor
which reduces the efficacy of the process by limiting the
diffusion of steam and its condensation as well as the
attainment of a high temperature. Modem steam sterilisers
(autoclaves) differ chiefly in the mechanisms by which
they evacuate air from the sterilising chamber (see box
above).
The procedure for steam sterilising instruments is
outlined in the box on page 26.
■ MOIST HEAT (BOILING). Boiling cannot be guaranteed to kili ali
microorganisms and spores because the maximum
temperature of 100°C is insufficient to kili spores. It
should, therefore, not be considered a method of
sterilisation.
■ DRY HEAT. Dry heat kills microorganisms by causing
oxidative destruction of bacterial protoplasm. The range of
equipment which may be sterilised in this way is restricted;
fabrics, rubber goods and plastic are easily damaged.
RECOMMENDED TIME AND TEMPERATURE RATIOS FOR HOT AIR OVENS during the cycle. Instruments should be clean and dry
Item Temperature (°C) Time (minutes)
before undergoing sterilisation, since grease and protein
Glassvvare will slow the process and water will react with the gas.
180 60
Non-cutting instruments Occlusive bungs and caps should be removed to allow
180 60
penetration of the gas. Individually packaged items are
Povvders, oils
160 120 placed in a polythene liner bag. Many packaging materials
Cutting instruments 150 180 may be used, with the exception of nylon autoclave tape,
which does not allow good penetration by the gas (see
The table above lists recommended time and temper-
later). A glass ampoule containing ethylene oxide is placed
ature settings for dry heat sterilisation. Hot air ovens are
within the liner bag, which is then sealed. The glass vial is
small but economical in terms of purchase and running
snapped open within the bag to release the gas. The
costs, but have largely been superseded by the autoclave,
steriliser unit is closed and the ventilation tumed on. After
which has the advantages of being larger and suitable for
sterilisation, the Container is aerated and the item should be
most types of equipment. In addition, a long cooling period
left in a well-ventilated room for 24 hours to allow the
is necessary before the items may be used. High
ethylene oxide to dissipate. However, it may take up to six
vacuum-assisted ovens reduce the sterilising time to 15
days for the gas to be completely removed from certain
minutes for most articles and convector ovens incorpo- rate
plastic and rubber items.
a motor to circulate air through the unit. However, neither
Ethylene oxide is effective for the sterilisation of many
type is commonly used in veterinary medicine.
types of equipment, but its use is limited by the siže of the
Irradiation sterilising chamber, the duration of the cycle and concems
Microorganisms can be destroyed by exposure to gamma regarding its toxicity. This method is there- fore restricted
rays, ultraviolet light or by high-energy electrons. Gamma to items damaged by heat. It should not be used to sterilise
irradiation is the most effective of these meth- ods, any object previously sterilised by irradiation, particularly
enabling a measured dose to be given most easily. Many those made ffom PVC, because this may result in the
pre-packaged items such as catheters, syringes and suture formation of highly toxic ethylene chlorhydrin, which is
material are sterilised this way. Ultraviolet light has poor difficult to elute.
powers of penetration and is rarely a true sterilising agent.
Cold sterilisation
High-energy electrons, meanvvhile, are more suited to the
Cold sterilisation refers to the soaking of instruments in
sterilisation of small articles, such as adhesive dressings or
disinfectant Solutions. This method should really only be
syringes.
considered a means of disinfection, although some
Filtration manufacturers guarantee sterilisation following pro- longed
Filtration may be used to remove microbes from liquids or immersion (usually 24 hours). Occasionally, cold
gases; for example, when preparing Solutions of heat- sterilisation is used for articles that cannot be exposed to
labile substances which cannot be sterilised by any other steam, such as anaesthetic accessories, or to disinfect
method, or preparing large volumes of sterile water. Its lensed instruments such as endoscopes.
Principal use is in the removal of bacteria from the air in Disinfectants should play no part in the sterilisation of
surgical suites. critical instruments (ie, those that potentially may be
introduced beneath the surface of the body). Hovvever,
CHEMICAL METHODS OF STERILISATION should there he no alternative but to cold sterilise an arti-
Gas or liquid agents may be used for sterilisation. These cle, a 2 per cent buffered aqueous solution of glutaralđe-
methods were developed to sterilise materials damaged by hyde has been recommended as a true sterilising solution;
wet or dry heat. Ethylene oxide is the only gaseous agent in such a solution is bactericidal and virucidal in 10 minutes,
general use. and sporicidal in three hours. This agent is extremely
irritating to tissues and articles must, there- fore, be rinsed
Ethylene oxide with sterile saline before use. The Chemical solution and
Ethylene oxide is capable of destroying ali known bacteria, the article to be sterilised should be placed in a tray or bowl,
spores and fungi, and at least the larger viruses. It preferably with a lid, to prevent evaporation or
inactivates cellular DNA and prevents cell reproduction. contamination by microorganisms.
Concems have been expressed regarding its use, since it is
toxic, irritant to tissues and inflammable except when STERILISATION INDICATORS
mixed with carbon dioxide. Several factors influence the It is important to monitor the efficacy of the method of
ability of ethylene oxide to destroy microbes, including sterilisation, and to be able to teli whether an item has been
temperature, pressure, concentration, relative humidity and sterilised. The various means of doing so are out- lined
time. As the temperature increases, its ability to pen- etrate briefly below. Indicators, hovvever, should not be relied on
increases and the time required for sterilisation decreases. too heavily. Exact standards for preparing, packaging and
However, the only system available in the UK operates at loading of supplies are the best guaran- tees of the
room temperature for 12 hours. effectiveness of the procedure.
The machine used in ethylene oxide sterilisation con-
sists of a plastic Container with a ventilation system to Chemical indicators
prevent gas entering the work area. It should be kept in a Chemical indicators undergo a colour change when a
clean, well-ventilated location away from the work area; certain temperature is reached or when exposed to a certain
the temperature of this location should be at least 20°C Chemical. They provide no indication about the time of
exposure to a given sterilant and, if placed on the surface of
a package, do not indicate that the contents have been
sterilised. Hence, for this reason, they should
not be over-interpreted. Their main value is in informing
personnel that a pack has been exposed to a sterilising
process, not that sterilisation has been achieved.
Chemical indicators include Chemical indicator strips,
tubes full of a liquid which changes colour on exposure to
heat (Browne’s tubes), indicator tape which is impreg-
nated with Chemical stripes which change colour on
exposure to heat or ethylene oxide (Bowie-Dick indicator
tape), and inks impregnated on the surface of a pack which
change colour on exposure to heat or ethylene oxide.
Biological indicators
Biological indicators consist of bacterial spores which are
more resistant to the sterilant than those agents likely to be
present as contaminants. Tubes or strips containing the
spores are included within the sterilising vessel and are
then incubated for a number of days. Biological indicators
have the advantage that they provide absolute proof that
sterilising conditions have been met. 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 applied Chemical methods in
conjunction with regular maintenance of the equipment
should obviate the need for biological indicators.
Temperature/pressure recordings
Larger autoclaves have visible temperature and pressure
gauges, and these variables may be plotted on a record- ing
chart during the operation of the machine. Thermocouples
can be used to record the temperature within the sterilising
chamber for the duration of the cycle to ensure that the time
and temperature require- ments are met.
PACKING SUPPLIES FOR STERILISATION Various
materials are available for packaging supplies for
sterilisation, and several factors influence which material is
chosen. The material must be resistant to damage when
handled. The sterilant must be able to pen- etrate the
material chosen during sterilisation, and be easily
exhausted from the pack once sterilisation is com- plete.
Microorganisms must not be able to penetrate the outer
surface of the wrapper. The siže of the sterilising chamber
and the items to be sterilised may also have a bearing, as
may cost and personal preference.
■ NYLON FILM designed for use in an autoclave is avail-
able in a range of sizes, is reusable and is transparent,
allowing the contents of the pack to be seen without
breaking the seal. However, it becomes brittle after
repeated use, resulting in the development of tiny holes and
therefore contamination of the pack. It may be diffi- cult to
remove sterile items without contaminating them on the
edges of the bag.
■ SEAL-AND-PEEL POUCHES are disposable bags consist-
ing of a paper back and a clear plasticised ffont with a
foldover seal. They are available in a wide variety of sizes
and are suitable for steam or ethylene oxide sterilisation.
The risk of contamination during opening is small. Double
wrapping decreases the risk of contamination during
storage.
■ PAPER may be used as an outer layer for packs. The
most suitable type is crepe-like (ie, slightly elastic and
conforming). Although it is frequently reused, it is intended
to be disposable.
■ LINEN SHEETS are strong, conforming and reusable, but
are permeable to moisture. Therefore, a double wrap of
linen is covered by a waterproof, paper-based wrap for
surgical packs.
■ METAL DRUMS with steam vents in the side, which are
closed after sterilisation, are often used with small, portable
autoclaves (for instruments, gowns, drapes, etc). However,
they are often multi-use, so there is a degree of
environmental contamination each time the drum is
opened. There is also a risk of contamination through items
touching the edge or outside of the drum. They are
relatively expensive, but long-lasting.
■ BOXES AND CARTONS made from cardboard may be
used for gowns, drapes or packs. They are relatively cheap
and may be reused.
Sterile packs should be stored in closed cabinets, rather
than on open shelves; safe storage times are sig- nificantly
longer in cabinets and there is less risk of items getting wet.
Ali packs should be dated, preferably with an expiration
date.
MAINTENANCE AND DESIGN OF THE
OPERATING THEATRE
Despite improvements in operating theatres, sterility
remains difficult to achieve. The design, construction and
layout of an operating theatre, as well as operating room
protocols, will affect how readily the principles of aseptic
technique may be applied.
DESIGN
The operating room should be situated in a convenient
location for work, but out of the general ‘traffic flow’. The
use of an end room with a single door will minimise traffic,
as will only having necessary personnel enter the room. To
decrease contamination fiirther, only correctly attired
personnel should be allowed in the room at any time, and
the room should not be used for other purposes, such as
examination or treatment of animals.
The room should be large enough to accommodate the
surgical team, patient and ancillary equipment, but small
enough to facilitate cleaning and reduce bacterial
contamination, and to discourage the storage of redun- dant
items. The airflow should move from the area of least to the
area of greatest contamination. The air within the operating
room should be at a mild positive pressure, so that air flows
out when the door is opened. The windows should be
prevented from opening to prevent contamination from
outside. A minimum of 25 air changes per hour is required
if the air is recir- culated, or 15 if it is vented to the outside.
Fan heaters should be avoided since they cause air and dust
movement.
The operating room should be constructed so that it is
easily cleaned and the potential for harbouring micro-
organisms is reduced. The walls and floors should be
constructed of impervious, non-staining materials with- out
seams, and the walls and ceiling painted with a light-
coloured waterproof paint. The comers and edges of walls
should be coved to allow easy cleaning. The room should
contain as little fumiture as possible. What fumi- ture there
is should ideally be constructed from stainless Steel and
glass, as this is easier to clean and disinfect. Cabinets
should have tight-fitting doors; recessed cabi- 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 multiple small lacerations and skin erosions that are rapidly
Clean operations should be perfonned first - particularly colonised by bacteria. Shaving is no longer rec- ommended
when implants are used and contaminated surgery last. because it has been associated with up to a 10-fold increase
There should be a separate room for dirty procedures. An in post surgical wound infection rates.
operation list should be kept so that if any sepsis problems
ariše, the cause may be identified. Depilatories
Depilatories, although an atraumatic method of hair
MAINTENANCE AND CLEANING removal, have not gained popularity in veterinary prac- tice
A routine cleaning programme in the operating theatre is because they are less effective on the coarse hair of animals
essential if a high standard of asepsis is to be achieved. At and are expensive. They may also produce skin reactions.
the start of each day, ali the furniture and surfaces should be
damp-dusted with a dilute disinfectant solution (dry dusting Clipping
would simply move dust around the room). In between Clipping is the recommended technique for hair removal.
cases, the operating table, equipment and surfaces. Sharp blades (without missing teeth) and liberally applied
including the floor, should be cleaned if soiled. At the end lubricants and coolants minimise the propensity for skin
of the day, ali floors should be vacuumed to remove debris trauma. Nicks in the skin may harbour bacteria and cause
and loose hair, and then cleaned with disinfectant. Ali irritation, leading to post- operative self-trauma. The
waste material should be removed. Surface equipment, Clipper blades should be cleaned in between cases and may
lights and scrub sinks should be disinfected. need to be sterilised after clipping contaminated sites.
Once weekly, there should be a more thorough cleaning Clipping should be perfonned away from the operating
session in which ali equipment is removed from the room, theatre to minimise contamination.
and the floors and walls are scrubbed. A disinfectant with A minimum of 15 cm each side of the proposed inci-
detergent properties which will remove organic matter, and sion site should be clipped. If multiple procedures are to be
which is active against a wide range of bac- teria, including perfonned, ali sites should be clipped at the same time. For
Pseudomonas species, should be used. After removing procedures on the limbs, hair on the entire limb is clipped
excess solution, the disinfectant should be allowed to dry to as far as the dorsal midline. Paws are difficult areas to clip
provide a longer residual activity. Ali equipment should be without causing trauma and have a higher resident bacterial
meticulously cleaned. population. If access to the paw is not required, it can be
Ali cleaning utensils should be designated specifical- ly covered by an impermeable material to obviate clipping.
for use in the operating room, kept clean and stored away Contamination of open wounds by loose hair and dander
from the sterile area. can be minimised by covering the area with
saline-moistened gauze swabs or applying sterile
water-soluble gel and clipping away from the wound. A
PREPARATION OF THE PATIENT vacuum should be used to remove hair and debris from the
clipped area and adjacent table surfaces imme- điately after
The skin and hair of the patient harbour a significant clipping.
reservoir of bacteria. Endogenous bacteria originate from
vvithin the body; exogenous bacteria are found on the PREPARATION OF THE PATIENT'S SKIN
surface of the animal and include environmental The patienf s skin cannot be completely sterilised. The aim
contaminants. Bacteria normally residing on canine skin of preoperative preparation is to reduce the numbers of
include Staphvlococcus, Mitrococcus, Streptococcus, bacteria without damaging the skin. The transient bacteria
Acinetobacter, Clostridium and Bacillus species as well as on the skin surface can be killed with antiseptic Solutions,
some Gram-negative bacilli and diphtheroids. but the resident bacteria in the hair follicles and sebaceous
Preoperative preparation of the patient entails remov- glands cannot be destroyed. The level of resident bacteria
ing hair from the proposed surgical site and adjacent areas, may be reduced with adequate preparation but, during the
cleansing and the use of antiseptic agents and aseptic operation, they come to the surface of the skin and are a
draping of the surgical site. Some patients may require source of contamination. Surgical scrub Solutions are
preoperative bathing if gross contamination is present. formulated with antiseptic and detergent properties, and are
applied first. An antiseptic solution (water- or
HAIR REMOVAL alcohol-based) is then applied to give residual bactericidal
Hair removal is required for most surgical procedures. This activity.
may be carried out before anaesthesia or while the patient is
anaesthetised. Removal of hair before anaesthesia results in Skin preparation agents
a shorter anaesthetic time, and most of the loose hairs are Various skin preparation agents are available (see table,
shed before surgery reducing the potential for page 25). The ideal agent is a broad-spectrum bacterici-
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, ali methods of hair removal
cause some degree of trauma to 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 causes
 dal compound that rapidly kills accessible microorgan-
isms. These criteria are currently best fiilfilled by
chlorhexidine and povidone-iodine. Although some stud-
ies comparing the efficacy of these two agents have
demonstrateđ that chlorhexidine is more effective, other
studies have failed to document a significant difference in
bacterial kili 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 vvearing 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
Advantages Disadvantages
Excellent vvater repellent properties
ADVANTAGES AND DISADVANTAGES OF DISPOSABLE AND REUSABLE DRAPES AND GOVVNS
Always in good condition Labour saving Less laundry
Can be obtained pre-sterilised
Disposable
Cheaper Less waste
Expensive
May be less conforming
Large stock reguired
Reusable Poor barrier properties
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
vvashing
shorter surgical scrub, this time using sterile swabs and
gloves is advocated by some authorities. Altematively, 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 debris from
non-sterile areas for the duration of the surgery. It should
be easy to sterilise, economical and retain its barrier
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 disadvantages
are considered in the table (below left).
Four drapes may be used to isolate a rectangle con-
taining the proposed surgical site or, altematively, a sin-
gle fenestrated drape. Each comer 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 allovvs 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
allovvs rapid application, vvithout 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 vvounds at closure have
been documented using these drapes, although this has not
been reflected in a significant decrease in vvound 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 surgical site and
studies questioning their effectiveness in human surgery.
ASEPTIC OPERATIVE TECHWIIQUE
Good technical surgery is concemed 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.
CREATING THE STERILE FIELD
The sterile field, an area of asepsis creating by unwrap-
ping a large sterile pack onto an instrument trolley, is set up
as near to the time of surgery as possible and moni- tored to
avoid contamination. The instruments should be laid out by
an individual wearing a sterile gown and gloves. It is bad
practice for an unscrubbed person to complete this
arrangement using Cheatle forceps, because of the greater
risk of contamination occurring when ungloved hands are
moved to and fro across a sterile table. Ali items within this
field are sterile and a new set of sterile instruments should
be used for each procedure. Sterile items added to the
sterile field must not touch non-sterile areas, such as the
hands of the person opening the package or the edges of
wrappers and pack- ages. The patient becomes the centre of
the sterile field through placement of sterile drapes that
protect the sur- gical site from contamination and establish
a work area for the surgical team.
Ali packages of sterile items should be inspected for
perforation, permeation by liquid or outdated sterilisa- tion
dates, indicating that the item is no longer sterile.
MAINTAINING THE STERILE FIELD The sterile field
encompasses the sterile table containing the items
necessary for the procedure, the draped patient and the
surgical team members vvearing sterile gowns. The front
of the gown from chest to table level and the sleeves from
above the elbow to the cuff are considered sterile. The back
of the gown, neckline, under the arms and the gown below
table level are considered non-ster- ile. Gowns and gloves
that become punctured or tear, or that become permeated
by liquid must immediately be replaced or reinforced. Any
other break in asepsis should immediately be noted and
rectified.
Surgical team members should approach the sterile
field face first to maintain asepsis and prevent con-
tamination. Movement around the sterile field should be
limited to avoid compromising sterility. Sterile team
members remain near the sterile field, and non- sterile
personnel remain away from it, to avoid accidental
contamination. No non-sterile personnel should reach
across the sterile field. During the procedure, contam-
inated instruments should not be retumed to the sterile
table.
POSTOPERATIVE CARE
Aseptic technique does not finish at the end of the surgical
procedure. In the postoperative period, sterile dress- ings
need to be maintained and changed using aseptic
technique. Indvvelling catheters and surgical drains need to
be attended to similarly. Incorrect patient management in
the postoperative period can reduce the benefits of
minimising or preventing bacterial contamination in the
pre- and intraoperative phases.
SUMMARV
The various protocols for achieving surgical asepsis dis-
cussed in this article may be adapted according to the
facilities available at the individual practice or hospital,
economic necessity and personal preference. Under ali
circumstances, however, the highest standards of asepsis
should always be sought and maintained. An inability to
achieve these is soliciting failure.
The most common reasons for breaks in aseptic tech-
nique are summarised in the box on the left.