|Year : 2013 | Volume
| Issue : 1 | Page : 38-45
Safe surgical practices and asepsis
Ravindra M Shenoy1, Archana Shenoy2
1 Department of Orthopedics, Yenepoya Medical College, Mangalore, Karnataka, India
2 M.B.B.S. Graduate, India, India
|Date of Web Publication||21-Jun-2013|
Ravindra M Shenoy
Professor, Department of Orthopedics, Yenepoya University Medical College, Nityanand Nagar, Deralakatta, Mangalore - 575 018
Source of Support: None, Conflict of Interest: None
Surgical care has become highly specialized because of scientific advances. It is now possible to handle many health problems successfully with the help of newer and innovative methods. However, to deliver care safely to patients as well as prevent harm to the personnel delivering the same, safe practices have to be followed. In developing nations especially, as modern surgical care percolates the masses, ignoring safe surgical practice may cause more harm than good and the surgeon / procedure may even earn disrepute. This article reviews different aspects of current surgical practice with respect to safe surgical care and asepsis.
Keywords: Asepsis, operating rooms, safety, surgery
|How to cite this article:|
Shenoy RM, Shenoy A. Safe surgical practices and asepsis. Arch Med Health Sci 2013;1:38-45
| Introduction|| |
Science indeed is fascinating and ever innovating. In 2002, the World Health Assembly (WHA) identified that the healthcare system worldwide had witnessed substantial public health harm due to inadequate patient safety following innovation-led changing medical practices. It adopted a resolution (WHA55.18) urging countries to strengthen the safety of health care and monitoring systems. Infection associated with health care was identified as the first challenge for 2005 - 2006 and the safety of surgical care was identified as the second challenge for 2007 - 2008.  In the wake of this, it is absolutely essential to introspect and analyze the advances in health care, to ensure their safe and judicious application in surgical practice.
Awareness of safe surgical practices begins with appropriate planning and set up of the Operation Theater (OT) and extends to well-informed personnel providing pre-, intra- and postoperative care. The place and practice may be likened to a temple and ritual; the OT complex being the temple; Operating Room, the sanctum sanctorum; maintaining asepsis, the sanctity, and perfect execution of the procedure guarding asepsis, the ritual (Anonymous).
| Basic Surgical Set Up|| |
Planning of an OT is a very serious exercise., It should be thoroughly discussed by a steering committee comprising of administrative heads, surgeons, physicians, anesthetists, nursing staff, microbiologists, biomedical engineers, maintenance personnel, engineers, and architects.
Some of the things to be considered while planning are as follows:
Only after ascertaining the above, plans for the OT complex are drawn, giving due importance to [Figure 1]:
- Procedures the room caters for that is, multidisciplinary or subspeciality practice
- Probable work load, that is, number of surgeries/day
- Approximate number of theater personnel inside and the need for a viewers' gallery with closed circuit telecast facility
- Equipment required
- Budget/funds available
- Services for maintenance and emergency repair of equipment
- Future maintenance costs
- Plan for future improvement
|Figure 1: A Model lay out plan for twin OT complex. Note the 'Zones' designed to guard sterility. Zone-1 is the maximum sterile Zone with only operating personnel inside the room. Sterility relatively decreases in the descending order of the 'Zones'|
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For handling infected and septic cases it is important to plan a separate septic OT, having no communication with the clean operating room.
- Design that facilitates maintenance of sterile environment
- Marked space for equipments
- Free space for movement
- Pre- and Postoperative care rooms
- Storage rooms
- Sterilization room
- Changing and rest rooms for personnel
- Uninterrupted power supply
| Basic Surgical Practices|| |
Creating a sterile environment in the OT and maintaining it is an art as well as a science. Even as technology helps in designing an ultra-clean ventilated OT, it is absolutely essential that the theater personnel observe aseptic practices strictly and maintain an ultra-clean environment. OT technicians should be qualified, highly skilled, and have a good knowledge of the equipment and concepts of sterility.
Sterility inside the Operation Theater complex
The environment inside the OT should always remain at the best possible sterile level. Disinfection of an OT aims at keeping the operating room environment at a near sterile level, with the microorganism count reduced to a minimum (insignificant), which is considered conducive for safe surgery. Air sampling and bacterial swabs are to be sent to the microbiology laboratory once a week or as per requirement depending on the work load. ,,
Operating room personnel, patients, and materials brought into the operating room are potential carriers of contaminants and capable of introducing infectious agents to the surgical field.  Failure to restrict the number of people inside the operating room to a bare minimum, talking (loudly) unnecessarily during the procedure, and so on increases the contamination. , Blood-borne pathogens, for example, Hepatitis B and C, Human immunodeficiency virus (HIV), and secretions from the human body are potential contaminants. It is recommended that the operating room be well cleaned before and after each procedure, and at the end of the day, using the recommended disinfectants, giving due attention to all the equipment and gadgets present inside the room. After each procedure, the sterile area occupied by the sterile surgical team should be regarded as unsterile and cleaned thoroughly with mops. Clean mops are to be used each time and they are disposed after use.  The operating room air may contain microbial-laden dust, lint, skin squames or respiratory droplets. , Hence, air handling or ventilation systems of the surgical suite should be designed to minimize these contaminants. Use of High-Efficiency Particulate Air (HEPA) filters in the ventilation system makes this possible. Laminar air flow (LAF) is preferred as it is non-turbulent, uni-directional, low-velocity, and moves in parallel planes. With LAF, a contaminated particle is picked and carried safely to the exhaust point without getting deposited in between. It has to be clearly understood that surgical site infection (SSI) is multifactorial in origin. LAF alone will not prevent SSI. ,,,,, Patient preparation, preoperative antibiotics, and so on, have a major role in preventing SSI.  A bacterial colony count of less than 10 CFU/m 3 in air sampling from an empty theater and 35 CFU/m 3 in a functioning operation theater with LAF is considered acceptable. ,, Treatment with ultraviolet (UV0 light sterilizes the atmospheric air and surface of the articles inside the operating room (environment sterilization). , The method facilitates quick sterilization between two surgical procedures and plays an important role in preventing infections. Rutala WA et al., reported that a UV-C device effectively eliminated "vegetative bacteria on contaminated surfaces both in the line of sight and behind objects within approximately 15 minutes" and "C. difficile spores within 50 minutes". 
| Sterilization of Instruments|| |
All instruments should be cleaned, washed, and dried before sterilization. Meticulous sterilization procedures ensure that instruments are bacteria-free and safe for surgical procedures. Common methods employed for sterilization are:
- Gas-Ethylene Oxide (EtO)
Autoclaving is a method of heat sterilization in which steam at a temperature of 121° - 138°C, under pressure of 15 - 20 pounds is passed through instruments for about 15- 18 minutes. Proper autoclaving with the above settings eliminates all bacteria, fungi, viruses, and spores, but not prions. For denaturing prions, the recommended temperature is 132° - 138°C for a duration of 18 minutes. ,, Prior washing and cleaning considerably reduces the prion load, so does treatment with chlorine and sodium hydroxide. ,, However, the corrosive property of these chemicals restricts their universal application. Indicator tapes that change color after effective autoclaving are used to monitor the quality of sterilization.
Gas Sterilization-Ethylene oxide
The gas Ethylene oxide (EtO) kills all viruses, fungi, and bacteria, including spores, due to its alkylating potential causing denaturation of cellular proteins, nucleic acids, and enzymes of microorganisms. ,
Although very effective, its disadvantages lie in having a need for a post-sterilization aeration to remove the toxic residue, ,,, potential carcinogenicity, a labile explosive limit, which ranges from 3 - 100%, ,, and a longer sterilization time when compared to the autoclave. Its use is limited to objects that cannot withstand temperatures greater than 60° C, for example, plastics, optical, and so on. Of the two methods of EtO sterilization namely gas chamber and micro-dose method (gas diffusion method), the latter is preferred by a majority of the hospitals.
This method is employed to sterilize equipment that gets damaged by heat and steam, for example, plastics and fiber optic instruments. 
Formaldehyde and gluteraldehyde are the common aldehydes used for chemical sterilization by the immersion technique. These chemical sterilizing agents are harmful to human beings and adequate precaution must be taken when used. As formaldehyde takes a longer time for sterilization, gluteraldehyde is most commonly used. Gluteraldehyde is highly caustic and may be injurious to the skin and mucous membrane. Also, it is considered to be mutagenic, and hence, should be disposed carefully. Based on FDA-cleared product label claims and literature, ,, immersion time required to achieve high-level disinfection varies from 5 - 12 minutes. Ortho-pthalaldehyde is another aldehyde that is known to sterilize gluteraldehyde-resistant spores.  It is more expensive and is known to stain skin proteins gray.
| Aseptic Practices|| |
"A surgeon should guard asepsis like a sage guarding celibacy" (Anonymous)
Aseptic practices aim at isolating the surgical wound from the surrounding environment. Breach in these practices may allow microorganisms to contaminate the operation site and cause infection.
Every single person entering the operating room should have or have had a bath and changed into a clean scrub suit, preferably sterilized. The hair is to be covered with a cap and face with a mask. A hood cap and bigger size face mask are used to cover long hair and a beard, respectively. All unnecessary articles are to be left behind in the changing room locker, for example, wristwatch, wallet, jewelry, and the like, and in recent times cell phones. Personnel having bacterial infections of the respiratory tract, skin, and the like, should not be in the vicinity of the OT nor come in contact with patients prior to surgery.
Steps to be taken prior to opening the room for surgery:
Shifting of the Patient
- Confirm the status of disinfection
- Confirm that the culture swab reports are negative for pathogens
- Ensure that the effectively autoclaved instruments are organized in sets of trays or boxes
- Ensure that the patient is well prepared before he is received into the room
- Each member of the team is designated his duties
Proper identification of the adequately prepared patient as well as the site to be operated on, and verification of the medical records, including the patient's informed consent is a must, prior to shifting. Two different trolleys are to be used while shifting. One, for shifting the patient to the sterile bay, and the other, from the sterile bay to the operating room. The trolleys should never be interchanged under any circumstances.
Sterile surgical barrier
Scrubbing, donning, and painting are important preliminary steps to be practiced by the surgeon in order to establish a bacterial barrier and prevent transmission of bacteria from the surgeon to the patient and vice versa.  Any shortcomings could be an invitation for a disaster.
Food and Drug Administration (FDA) standards state that antimicrobial solutions used for surgical scrub should be non-irritating, possess a broad-spectrum of antimicrobial properties, substantially reduce microbes that reside on the skin to an irreducible minimum, be fast-acting, and have persistent, cumulative activity. Solutions of 7.5 and 10% povidone iodine (PI) and 4% chlorhexidine gluconate (CHG) fulfill these criteria.  PI acts via oxidation after penetrating the bacterial cell wall. CHG alters the bacterial osmotic equilibrium by binding to the negatively charged bacterial cell wall and at high concentrations results in cell death. Addition of low concentrations (0.5 - 1%) of CHG or PI to alcohol-based preparations results in significantly greater residual activity.  Alcohol denatures cell wall proteins, leading to rapid lysis of the cell, but it has no persistent antimicrobial effect acting alone, as it rapidly evaporates. Hence, it should not be used alone.
Procedure: With jewelry removed, nails clipped, and hands washed preliminarily with disinfectant soap, the procedure of scrubbing begins. Care must be taken to ensure that no clothing comes in contact with the scrubbing sink. Foot pedal/sensor controlled faucets are preferred with avoidance of hands brushing the faucet. Scrubbing always begins at the finger tips and nail beds and methodically proceeds proximally stopping approximately an inch short of the elbow crease.
[Figure 2] depicts a standard method of scrubbing. To ensure effective and uniform scrubbing, counting the strokes while scrubbing is a good practice (about 20- 30 for each part).
|Figure 2: A methodical way of scrubbing the hand and forearm up to the elbow|
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A thorough wash with clean / sterile water follows a good scrub. As fluid, which is considered to be a pathogen transmitter, flows in the direction of gravitational force, it should always drain from the finger tip toward the elbow during the wash. This procedure is repeated twice lasting for three to five minutes, thereby, giving adequate time for the disinfectant to act. Care is taken to see that each scrub stops a little short of the previous level below the elbow. Next, the hand is wiped dry with a sterile towel. Moist and wet surfaces are to be considered as potential sites of contamination.  The fact that 18.6% of the sterile surgical gloves perforate during surgical procedures,  justifies the need for a good scrub reducing infectious agents on the hands before donning gloves.  Even after a thorough scrub and wiping the hand dry with a sterile towel methodically, the hand is to be considered as a potential source of contamination.
Use of a brush: By using 4% CHG and 7.5% PI Furukawa K et al., and Loeb et al., reported that it is possible to make hands bacteria-free without using a brush for scrubbing. , Kobayashi H. used a brush along with antiseptics and found that among the two, CHG is found to be less damaging to the skin when compared to PI and also as effective as PI.  No consensus has been arrived at as of today, with respect to use of a brush, and its use remains to be a protocol-based traditional practice. However, a brush can clean the undermined area of the finger tips and nail beds. A single-use brush is known to cause less damage to the skin. ,
After following the principles of a thorough hand scrub, a gown is donned and the ties are fastened without compromising sterility. Gowns with high water and oil repellence and smaller pore size provide the most protection.  Body exhaust suits can provide additional protection from droplet transmission. However, this manner of additional respiratory protection is necessary only when there is a risk of airborne transmission.  Before donning the gown, it is a good practice to use a 80% ethanol-based or 45% propanol-based hand-rub solution for 1.5 - 3 minutes (EN12791 protocol). , Immediately after donning, the gloves are worn. The gloves are worn in such a manner that the outer aspect of a glove is not touched by the hand [Figure 3].
|Figure 3: (a-e) The method of donning gloves after scrubbing. Note that the outer surface of the gloves is never touched by the hand. Only the inner surface comes in contact with the scrubbed hand|
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Studies have demonstrated that two layers of latex gloves significantly decrease the rate of exposure in comparison to a single layer of latex gloves. Wearing cut-resistant gloves and changing the outer gloves at a predetermined interval further reduces the exposure rate. ,,, Thus, if there is a break in the glove or the glove touches a non-sterile surface accidentally, it is immediately changed with a new pair. During such an event, even the instrument in the hand is to be considered unsterile and discarded immediately to be replaced later with another sterile instrument.
Awareness is absolutely necessary that even though a person has donned all sterile accessories, he / she is still unsterile from within. He / she should always remember that only the front portion of the gown, which is viewed by him, is considered sterile, that is, from the chest to the surgical field and from approximately two inches below the elbow to the cuff. Other portions, especially the back, are considered unsterile. 
When performing surgery, it is important to prevent these so called unsterile areas from coming in contact with the operating field, instruments or other sterile personnel of the team.
He / she must practice to stand with hands clasped in front of the chest at a small distance when idle or while waiting, being aware not to touch unsterile articles in the operating room. Dropping the hand below chest level or standing with folded arms is unacceptable.
The patient is always considered to be a major source of infection. Hence, gently scrubbing the area to be operated and around with solutions such as CHG, alcohol, PI, and so on, prior to painting is desirable. The area is minimally draped with sterile drapes. This practice keeps the area clean and sterile just prior to the actual painting and draping.
Ten percent PI (stock solution) is bactericidal and has been used as a standard agent for painting.  Berkelmen RL et al., used several brands of PI solution and demonstrated more rapid killing of Staphylococcus aureus and Mycobacterium chelonae at dilutions of 1:2, 1:4, 1:10, 1:50, and 1:100 than the stock solutions. Staphylococcus aureus survived a two-minute exposure to the stock solution but did not survive a 15-second exposure to a 1:100 dilution of the iodophor. Both stock and dilute preparations of 10% PI solution demonstrated rapid bactericidal action against Klebsiella pneumoniae, Pseudomonas cepacia, and Streptococcus mitis.  Kobayashi and Darouiche RO et al., reported CHG had the same bactericidal effect as PI, but it is less damaging to the skin. ,
Procedure: Painting always begins at the site of the proposed incision and is carried out from proximal to distal and center to periphery. It is carried out thrice, each cycle lasting two to three minutes, thus giving adequate time for the antimicrobial solution to exercise its bactericidal effect. To-and-fro movement and rubbing are considered as unacceptable practices.
Sterile drapes play an important role in establishing a bacterial barrier. Ideally these should be disposable and made of water proof / repellent material.  When sterile disposable gowns and drapes were used in place of cotton reusable drapes, the incidence of bacterial contamination dropped from 6.5 to 2.83%.  Only sterile personnel should hold the drapes and proceed with draping. Draping always proceeds from the part prepared for surgery to the periphery. Only the outer surface of the drape is considered to be sterile. Once the drapes are positioned, they should not be moved or re-organized. After draping is complete, a sterile boundary has to be established for movement of sterile personnel only.
Movement During the Procedure
Members of the operating team should be grouped as sterile members, that is, personnel scrubbed for the procedure, and non-sterile members, that is, personnel who have not scrubbed for the procedure. The sterile members function within a sterile field and the non-sterile members function outside the field. Both have responsibilities of maintaining the sterility of the operating room. It is important for a sterile member to move cautiously during the procedure in order to maintain sterility and prevent contamination.
General guidelines on movement within the OT:
- There should be a safe distance, approximately 12 inches or more, between a sterile and non-sterile member
- Wandering in the OT ignoring the sterile field is unacceptable
- Scrubbed personnel should change positions either following a back-to-back or face-to-face turn. This will ensure non-sterile to non-sterile or sterile-to-sterile contact, and not otherwise.
- Prevent personnel from entering or leaving the room once the procedure begins, as any surface, living or inanimate, can serve as a vector or carrier of an agent that could interfere with asepsis. 
| Maintenance and Monitoring of the Sterile Field|| |
It is the duty of both the sterile and non-sterile members of a surgical team to be vigilant during the surgical procedure in order to maintain sterility. Any breach should be addressed immediately with remedial measures, for example, (i) torn gloves - gloves to be changed immediately. (ii) Non-sterile member of the team touching the drape - the drape is to be covered with a fresh drape.
Delivery of items during the procedure
The non-sterile person should be well versed with the steps to be followed during delivery of sterile items to the operation table. The removal of wraps should be done in such a way that sterility is not compromised during the process.
Sharps, Accidents, and Waste disposal
Sharps should always be handled with utmost caution. Accidental sharp injuries and contact with potentially infectious material are best prevented by having a thorough knowledge about handling of sharps and universal precautions. Accidents that unfortunately occur must be dealt with according to the hospital protocol and reported to the hospital's Occupational Health Department for monitoring and follow-up. OT waste must be handled appropriately according to the hospital waste segregation guidelines that have been formulated by the institution.
Surgical team and team work
"The surgical procedure is viewed as a team work which is done rightly, at the right time, every time" (Anonymous)
Adequate preoperative planning of both an emergency as well as an elective procedure is a must.
The surgeon is considered as the leader of the team who is responsible for the smooth conduct of the procedure. , Therefore, it is imperative that he/she has appropriate physical and mental attitude along with the necessary proficiency and skill. Performing dissections on a cadaver is regarded as a superior method of acquiring basic surgical skills. He/she must ensure the safety of the personnel inside the OT, for example, while using electrocautery, the 'C' arm image intensifier, pneumatic tools, and so on. Untoward events occurring during the procedure should not turn him/her off balance. He/she should be bold enough to act decisively, with proper steps, to overcome such situations without panicking. It is nice to work and complete the procedure without flinching, however stressful the situation may be. If pushed to a stalemate-like situation, it is better to hold the procedure for a while, discuss with the assistants and other colleagues before continuing the procedure.
The first assistant should be as good as the surgeon with similar skills as the surgeon. He / she should be proficient to complete the surgery unimpeded, if for some unavoidable reason the surgeon retires.
The staff nurse should be capable of taking overall charge of the theater personnel, including medical men, when necessary. He/she should be specially trained to guard asepsis. He/she must be able to follow the surgical steps and it is desirable that he/she give the right instrument every time during the procedure. He/she should possess the required skill for handling surgical instruments as well as their maintenance.
| Conclusion|| |
If the aspects discussed here are practiced, it will be possible to deliver surgical care safely without any harm to patients as well as personnel. Faulty techniques once learnt are difficult to correct. Therefore, it is important that the surgical personnel in training, learn the right methods before they step into practice and go on to teach. Surgical practice will then become safe and successful, truly benefiting millions of people undergoing operative procedures.
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[Figure 1], [Figure 2], [Figure 3]