Surgical Preparation

Lobna El Fiky
Assistant Professor of
ORL, H&N surgery
Ain Shams University

Historical perspectives
Antiseptic

= Greek for against putrefaction

Accidental observation of certain substances
stopped putrefaction of meat
Mercuric Chloride: Arabian physicians in
Middle Ages
Tincture of iodine: 1839
Pasteurs publication: 1863: microbial origin
of putrefaction

Historical perspectives
As

often in history of medicine: Change of

practice depended on the persistence of
John Lister 1870,
He introduced vigorous application of phenol
in surgery, for dressing wounds, for
sterilization of instruments

Sterilization
It

is the process that destroys all microorganisms

(including bacterial microspores).
The skin could never be sterilized without its own
destruction.

Disinfection
A process

which destroys only the vegetative

forms of organisms =basically clean.
A disinfectant (germicide, antiseptic): any
chemical substance with either a bactericidal or
a bacteriostatic action.
Antiseptic -- Agent applied to living tissue
Disinfectant -- Agent applied to inanimate
surface

Surgical Disinfection
This

is an essential part of a programme for

the control of infection.
High Risk Items: as they come in close
contact with broken skin or those that breach
mucous membranes or are introduced into a
sterile cavity.

Requirements for decontamination

practice
The basic requirements for good decontamination
practice are:
A Management control system;
Appropriate facilities;
Appropriate equipment;
Properly trained and supervised staff;
Ensuring that single use medical devices are not
reused;
Records of decontamination are kept.

Methods of Disinfection

Physical: The most important as they can be relied on to

ensure the sterilization of articles used in the treatment
of patients:

Chemical: Less effective, used for personnel

Thermal: Heat or Steam

Radiation: infra-red radiation, - rays, particles
Filtration:utilizing filters capable of screening out microorganisms
Organic
Inorganic

Gaseous disinfectants: very efficient, not routine

Formaldehyde gas
Ethylene oxide

MANUAL CLEANING
Cleaning

is vital prior to any decontamination

procedure.
Detergent removes the nutritive material on
which bacterial survival and multiplication
may take place.
This reduces the number to a level which is
not harmful for health.

MANUAL CLEANING
Effective

cleaning to remove protein from

medical devices is paramount (agents such as
CJD are not inactivated by heat).
Dismantle or Open the instrument to be cleaned
Friction for 2-3 minutes
Brush, Wipe, Agitate, Irrigate, jet wash or hand
spray the item to dislodge and remove all visible
soil
Rinse the item thoroughly with clean water
Drying

Physical Methods of Disinfection

HEAT
DRY HEAT
Kills by Destructive oxidation of cell constituents
Surest incineration
Hot-air oven:

inefficient, poor conductor of heat, penetrates feebly.

160C for 1 hour: damages fabrics, melts rubber
Used for: Glassware, oily fluids, powders

Physical Methods of Disinfection

HEAT
MOIST HEAT
Effective at low temperature, in a shorter period of
time
Boiling: 100C for 30 minutes
Pasteurisation: 63C for 30 minutes
Tyndallisation: steaming for 20 minutes for 3
successive days
Steaming under pressure= Autoclaving

Advantages of steam
Kills

by denaturing & coagulating enzymes &

proteins
More rapid (maximum needed time 45mn) & at
lower temperature
Condensation of steam leads to liberation of
latent heat which raises the temperature, and
gives more penetration
Half dense as air, so has better penetration

Steam Sterilization: Autoclave

Principle: An autoclave is a self locking

machine that sterilizes with the high
temperature that steam under pressure
can reach.
High-vacuum pumps remove as much as
possible air before the steam is admitted,
so the required temperature is reached
very rapidly.

Steam criteria
Dry:

no suspended droplets of water

Close to its point of condensation: not
superheated
Free from air: as it decreases the temperature
and the penetration
Temperature

121C: 15mn-30mn
134C: 4-7mn Flashing

Steps of autoclaving

Water in the surrounding container full and heated

Articles in cabinet, doors bolted
Vacuum to evacuate as much air as possible
Steam is admitted at a high pressure of and when the
thermometre reaches the required temperature,
sterilisation begins
Sterilisation is continued for the required time and then
the steam is turned off.
Drying is carried-out by reapplying a vacuum to evacuate
the steam, introducing dry filtered air into the cabinet (for
15 minutes).

Efficient Autoclaving

All instruments must be double

wrapped in linen or special paper or
placed in a special metal box
equipped with a filter before
sterilization.
The white stripes on the tape change
to black when the appropriate
conditions (temperature) have been
met.
Expiration dates should be printed on
all equipment packs.
There should be a uniform
development of bars throughout the
length of the strips.
Ready made plastic bags with strips
printed with a sensitive ink.

Control of autoclave efficiency

Bowie-Dick test: Used for high-vacuum autoclaves, Done

every day:

In the middle of a test pack of towel, a paper on to which a strip of

a specific tape is put, for testing.
Uniform development of dark color indicates that the steam has
passed freely and rapidly to the center of the load.

Biological sterilization indicators: Spores of a nonpathogenic organism: Done weekly

They are killed at 121C after 15 minutes.

Attempts to culture them is subsequently made

RADIATION DISINFECTION
High

energy ionizing radiation destroys

microorganisms and is used to sterilize
prepacked, Single-use, surgical equipment
by manufacturers
Common sources of radiation include
electron beam and Cobalt-60

CHEMICAL DISINFECTION
A SATISFACTORY AGENT SHOULD:
Be active against a wide range of organisms and
spores. Only few are truly sterilizer
Have a rapid action
Should not be toxic or irritant to the skin
Should be Persistent

There is no one disinfectant which can be

used to kill all micro-organisms in all
situations.

Types of Chemical disinfectants

Inorganic:

Iodine
Chlorine

Organic:

Alcohols
Aldehydes
Phenols
Cationic surface-active agents

Inorganic disinfectants
The halogens: Chlorine and Iodine
Have a rapid action against vegetative
organisms and spores= true sterilizers
Their action is annulled by foreign organic
material

Iodine disinfectants

The broadest spectrum of all topical anti-infectives, with action

against bacteria, fungi, viruses, spores, protozoa, and yeasts.
Tincture iodine:
2.5% iodine & 2.5% potassium iodide in 90% ethanol.
Best skin disinfectant
Irritating to raw surfaces: due to its alcoholic component
Allergic dermatitis
Iodophors: Solutions of iodine in non-ionic detergents=
Povidone iodine= Betadine
Less irritating and less staining
Less disinfectant than tincture

Chlorine disinfectants
Powerful,

Disinfect water
Particularly active against viruses
Concentrated solutions too corrosive
Usually diluted with a compatible detergent

Organic Disinfectants

Alcohols: bactericidal: 50-70% ethanol

Aldehydes:

Phenols: continued activity in organic matter as human

excreta.

Formalin: irritant, powerful=sterilizer

Glutaraldehyde: less irritant, not volatile, more rapid action.

Phenol: Toxic, expensive

Cresols: Lysol
Chloroxylenol: Dettol
Chlorhexidine: Hibitane- Alkanol
Hexachlorophane

Cationic surface-active agents:

Cetrimide: Cetavlon

Alcohol
Isopropyl Alcohol 70% (or Ethyl Alcohol 90%)
ADVANTAGES:

Causes protein denaturation, cell lysis, and metabolic

interruption.

Degreases the skin.

DISADVANTAGES:

Ineffective against bacterial spores and poorly effective

against viruses and fungi.

Glutaraldehyde (Cidex)
Cold Sterilization:
Instruments must be dry before immersion.
Glutaraldehyde is bactericidal, fungicidal,
viricidal, and sporicidal
Sterilization: a 10 hour immersion. This
prolonged chemical action can be more
detrimental to surgical instruments.
3 hours exposure time is needed to destroy
spores.
If the instruments need to be "disinfected"
only, cold sterilization is okay as
disinfection will take place in only 10
minutes.

Lysoformin

Formaldehyde & glutaral

Lysoformin: liquid concentrate with which any dilution
required can be made by simply adding water (20ml + 48L)
The timing depends on the concentration used:

flexible endoscopes
deactivation of HBV & HIV

1.5 % - 30 min
2.0 % - 15 min

Used for heat labile instruments and cleaning

Does not harm metal instruments

Chlorhexidine Gluconate
Hibitane vs Alkanol
Broadest spectrum
Better residual activity than iodophors
Occasional skin sensitivity
ADVANTAGES:
Rapid action
Residual activity is enhanced by repeated use
Less susceptible to organic inactivation than povidone iodine
DISADVANTAGES:
Occasional skin sensitivity.
Inactive against bacterial spores
Activity against viruses and fungi is variable and inconsistent
May harm metal instruments

Gaseous Disinfection
Ethylene Oxide Sterilization: EO Gas

Colorless gas, available as cartridges

Toxic and flammable, Odor similar to
ether
Has an extremely well penetration, even
through plastics
Microorganism destruction is caused by a
chemical reaction
Effective sterilization is dependent on
concentration of gas, exposure time,
temperature, and relative humidity
Powerful sterilizer: Kills all known
viruses, bacteria (including spores), and

EO Gas Sterilizer
Is

used in large hospitals, as it is expensive,

dangerous, needs more expertise.
Used for heat sensitive instruments: fabrics,
plastics, suture material, lenses, endoscopes,
electrical equipment and finely sharpened
instruments.
At 20C-25C: sterilization takes 18hours
At 50C-60C: sterilization takes 4 hours
In Demerdash: The average of the cycle is 8-14
hours

Sterility Check List

Before assuming a pack is sterile, always

evaluate the following before opening the
pack:
Expiration date
Indicator color change
General condition of wrapper and how it
had been stored
Always check for holes or moisture damage

Standards for
Surgical Scrubbing, Gowning and
Gloving
The

pre-surgical practice of scrubbing,

gowning and gloving is integral to the
minimization of risk of infection from microorganisms present in the wound at the time
of surgery.

Accessing to the operating theatre

Wear prescribed
operating suite attire
Remove jewellery
Keep fingernails short,
clean, healthy
Wear appropriate
protective attire: masks,
head, overshoes..

REMEMBER
What

went inside the machines is

the STERILISED material
Personnel are only DISINFECTED

Surgical Hand scrub

No touch: infrared robinets, with your elbow, leg

Use brush??
The ideal duration of the scrub is not agreed.
Accepted time is 5 minutes: appears safe
Some surgeons do not rinse off the chlorhexidine or
Betadine in order to enhance residual activity.
Alternative: Two-stage surgical scrub:
an initial 1- or 2-minutes scrub with 4% chlorhexidine
gluconate or povidone-iodine followed by application
of an alcohol-based product

Surgical Hand scrub

Trim

fingernails and Wash for 30-60 seconds

with surgical scrub.
Scrub fingers with a sterile scrub brush
Make sure to scrub all sides of each finger,
including the area between fingers.

Surgical Hand scrub

Scrub hands and arms with a sterile scrub brush. Make

sure to scrub each surface of each hand and arm
An accepted contact time is 10 brush strokes per surface
During scrubbing, rinsing and drying, hands are held
above elbows. This is done so that water will not be
dripping from upper arms onto lower arms and hands

Drying Hands

A sterile towel is included within the sterile gown pack.

One hand and forearm are dried by one side of the towel.
Always dry in the direction of hand to elbow so that
contamination of the upper arm is not spread by the towel
to the surgeon's hand.

Gowning

All gowns are folded and packaged for sterilization, with

the inside exposed so that the surgeon may handle the
gown without contaminating the outside of the gown.
Grasp the exposed inside of the gown and lift the gown
away from the table.
Your hands are disinfected and the gown is sterilized

Gowning

Unfold the gown by placing hands into the white arm

holes. Continue placing hands and arms through the
sleeves..

Gowning

An

assistant fastens the neck tie and the

inside waist tie.
PLEASE: DO NOT DRY YOUR HANDS IN
THE FRONT OF THE GOWN

Types of Gowns

Disposable Paper Gown: resistant to wetting so they

are less permeable to bacteria, expensive. It is usually a
wrap around gown. The ties "wrap around" the surgeon.
Linen (cloth): comfortable and reusable. When it
becomes wet, bacteria can permeate. The cloth gown is
also known as a front sterile gown. The gown is just tied
in the back.

Gloving
Sterile surgical gloves can be worn by:
Open method:

The gloves are presented to enable the introduction of the

hands on the inside surface directly
The nurse with her sterile glove opens the glove for the
surgeon who introduces directly his hands on the inside
surface of the glove

DO NOT ADJUST THE FIRST

GLOVE BEFORE PUTTING
THE SECOND ONE !!!

Gloving
Closed gloving:
This

is the introduction of hands covered with the

cuff of a sterile gown.
So, If you are planning on closed gloving, do not
thrust hands through the cuffs.
This is usually performed by the first person to be
sterilized= the nurse

Gloving: Closed method

An assistant opens the sterile pack of gloves and drops

them into the sterile field.
The inside of the cuff of the glove is grasped by the
opposite hand (still within the gown) until introduction

Patient Preparation
Sterilization

is best done with a detergent

followed by a disinfectant on a larger area of the
surgical field. H&N??
Use Ample Detergent
Scrub roughly the skin in any direction for 2-3mn
??Remove the excess of the detergent
Apply the disinfectant first on the most clean
area
Scrub in one direction only

Draping
Standard

head drape: two towels, one under

the shoulders and the other wrapped around
the head
Better to suture the drapes to the skin to
prevent shifting
Towels are used for lateral draping
Drapes should lie flat

Practical Sterilization
Instruments sterilization
Metal

Instruments: Avoid chemical sterilization

Autoclave
EO chamber
Formaldehyde beads or powder

Sharp-edged:

avoid heating & wetting:

EO chamber
Formaldehyde beads or powder

Practical Sterilization
Instruments sterilization

Catheters, gloves,: depend on pre-sterilized,

disposable equipment

Endoscopes: avoid heat

Radiation
EO chamber
Cidex
Lysoformin
Autoclaving

Handles of drills:

Autoclave after washing and oiling

EO chamber

THANK YOU