Transcript 2010 Annual ASR Meeting - Academy of Surgical Research

Round Table Presentation – Asepsis &
Instruments
Asepsis
Definitions
 Pathogenic = the ability to cause disease in a living
organism
 Asepsis = the maintenance of a pathogen-free
environment; the reduction of micro-organisms
to a level that will not cause infection
 Sterilization = the destruction or elimination of all
living micro-organisms and their spores
 Disinfection = the destruction of pathogenic
microorganisms on an object to a harmless level
 Some disinfectants are not effective against spores
Definitions
 Antiseptic = destroys pathogenic organisms on living
tissue
 Sanitation = the reduction of the number of organisms
on an object to an acceptable health standard; also
refers to rendering an object aesthetically pleasing and
clean
 Suffixes
 “—cidal” has a killing action
 “—static” inhibits growth
Animal prep
 Prep/scrub of surgical site(s)  Surgical site(s) must be prepared by closely clipping and
removing the hair
 This should be done in an area separate from where the
surgical procedures are to be performed
 Avoid skin abrasions and thermal injuries during
clipping and avoid clipping excess hair as this may
exacerbate hypothermia
Animal prep
 Preparation of the site should include
 Use of an appropriate skin disinfectant applied in three
cycles of scrubbing with a surgical soap (Chlorhexidine,
Iodophore)
 Rinsing with sterile water or 70% isopropyl alcohol
between each scrub with soap
 Using sterile cotton swabs or gauze, disinfection should
begin along the incision line and extend outward in a
circular pattern
Animal prep
 Draping of animal/surrounding area
 The use of a sterile drape over the animal is used to
prevent contamination of suture material and to assure a
sterile field at the surgical site
Surgeon Prep - Scrubbing
 After donning scrubs, mask & cap
 Wash hands for 30-60sec
 Scrub hands and fingers
 Wash and then scrub forearms
 Rinse and repeat
 Dry with sterile towel

beginning with fingers and moving towards the forearms, use
new towel for each hand
 Total scrub time should be around 5 minutes
Surgeon Prep - Gowning
 Grasp the exposed inside




surface and lift the gown
away from the table
Unfold the gown by
placing hands into the arm
holes
Continue placing hands
and arms through the
sleeves
An assistant fastens the
neck and the inside waist
ties
Proceed with gloving
before the fastening of the
final outside tie
Surgeon prep
 Gloving
 Closed gloving is performed after the surgeon has
donned his/her gown, but BEFORE the surgeon pushes
his/her hands through the cuffs of the gown; gloves are
pulled on as the hands are pushed through cuff
 Open gloving is also done after donning the gown, but
the hands are pushed completely through the cuffs
Surgical Area
 Traffic - access to persons not directly involved in the
activities should be limited during the surgical
procedure
 Designated support areas ideally should include
components such as animal prep, surgeon scrub,
holding and recovery areas outside of the OR
Surgical Area
 OR - the area in which surgery is conducted should be
free of clutter and disinfected prior to beginning the
surgical session.
 This area should be located away from air supply ducts
or other drafts to minimize hypothermia of the animal
and limit accumulation of dirt and dust contamination
on surfaces
Creative Draping/Sterilization
Draping accessory and support equipment (e.g. lights,
microscopes, monitoring equipment/leads, anesthesia
machine, cautery equipment, etc.) can allow the
surgeon to maintain a sterile field if adjustments to
equipment are needed during the procedure
Sterilization types/methods
 Autoclave
 Moist heat


Effectiveness dependent upon temperature, pressure, and
time (normal is 121◦C / 15psi / 15min)
Indicators range from exterior color changes on packages, to
interior and load indicators for the specific type of autoclave
 Ionizing Radiation
 Gamma Radiation

Requires special equipment and training
Sterilization types/methods
 Gas
 Ethylene oxide, Plasma Vapor




ETO requires 30% or greater relative humidity for
effectiveness against spores and requires safe aeration time
Plasma vapor can not be used on cellulose-based or
absorbable materials
Both gasses are good for heat/moisture sensitive
instruments/devices
Specialized pouches have color indicators, also need load
and interior pack indicators
 Cold
 Gluteraldehyde, Clidox
 All materials must be rinsed in sterile saline
 Most are corrosive to instruments and require prolonged
contact times
Sterilization types/methods
 Flashing and Bead sterilizers
 “flashing” in the autoclave = normal is 131◦C / 30psi / 3
min; instruments must be placed in special metal
containers with aeration holes
 “flashing” via open flame = not recommended as it is
hard to regulate the temp and time, often resulting in
warped, permanently damaged tips on fine instruments
 Bead sterilizer = ~15 seconds/instrument
Instruments
Handling /cleaning/care basics
 Lubricant – also called “instrument milk” for all
instruments with metal on metal moving parts
 Scissors, hemostats, needle drivers, self- retaining
retractors, etc.
 Do NOT use WD-40 or motor oil !!
 Ultrasonic Cleaner – best way to clean any instrument,
but especially good for hinges and any instrument with
teeth or grooves
Handling / cleaning/care basics
 Packing and wrapping
 Disposable pouches – Great for single instruments, make
sure they’re wide enough to accommodate the instrument
in an unlocked/open position
 Trays – use towels or other absorbent layer in the bottom
if autoclaving to prevent “wet packs”
 Never lock an instrument during autoclaving!


Steam will not penetrate all areas (true for gas sterilization too)
Will develop cracks in hinges because of heat expansion during
cycles
Handling / cleaning/care basics
 Staining with use  Brown/orange = phosphate deposits (from dirty autoclave water
source, high alkaline soaps) or blood

A pencil eraser will remove these, but not true rust
 Black stains = acidic detergent residue during autoclave/high heat
processing

Always rinse with DI water before sterilization
 Rainbow stains = excessive heat, may have lost metal integrity

Use heat source that has set ranges/know temps (e.g.: Germinator)
 “Out of the box” Stained  Sometimes carbon steel instruments come with an oily coating on
them from the manufacturer, this is normal and helps prevent
corrosion – it’s just mineral oil; this should be cleaned off prior to
initial sterilization
Material selection
 Carbon Steel – is the hardest of materials
 Tips may become brittle with excessive heat
 Highly magnetic and stains easily
 Stainless Steel – an alloy (mix of metals)
 many different types and grades
 Varying levels of stain resistance and magnetism
 Can still rust, corrode and pit
 Titanium – lightest of the alloys used
 Extremely corrosion, heat and stain resistant
 Completely non-magnetic
 Ceramic – offered mostly as a coating
 Very hard, scratch resistance, no reflection for work under
microscope
 Anti-corrosive, biocompatible
Instrument Selection
 Use and user preference may dictate tip shape and
angle, overall weight, and handle length and type
 Surgeon preference


Hand size
Height
 Tissue to be manipulated

Bone, brain, muscle, skin, etc
 Position / location of tissue

Depth, surrounding structures
Instrument Selection
 Why different tips?
 Smooth, Teeth or
grooves?
 Tissue retention holes,
catheter holding
grooves, vessel
dilation?
Instrument Selection
Instrument Selection
 Straight vs. curved vs.
angled?
Instrument Selection
 Colors or Plating on handles
 Can color code by type of pack, by PI, etc.
 Black plated rings typically mean a razor edge on one
blade and serrated blade on the other

Easier to cut soft tissues without crushing, making for clean
smooth-edged cuts
 Gold plated rings indicate tungsten carbide inserts
 In scissors this is preferred for use when cutting thick skin or
cartilage
Types / categories / uses:
 Forceps / Clamps / Hemostats
 Needle Holders (Drivers)
 Retractors
 Scissors / Scalpels
 Electrocautery
 “Other”
Forceps
 Adson tissue forceps
 Adson- Brown tissue
forceps
 Rat toothed forceps
 Dressing forceps
 Dumonts
Needle Drivers
 Olsen-Hegar
 Mayo-Hegar
Castroviejo
Clamps
 Satinsky clamp
 Cooley clamp
 DeBakey clamp
 Bulldog clamps
Bone
 Bone curette
 Rongeurs
 Trochar
 Osteotome
 Periosteal Elevator
 Allis tissue forceps
 Alligator forceps
 Duval forceps
 Babcock forceps
 Vulsellum forceps
Retractors
 Army-Navy retractor
 Gelpi retractor
 Wilson rib spreader
 Weitlaner
Retractors
 Finochietto retractor
 Balfour retractor
 Senn retractor
Scissors
 Iris scissors
 Lister bandage scissor
 Metzenbaum scissors
 Mayo scissors
Scissors
 Strabismus
 Ragnell
 Doyen
 Micro-Vannas
Scalpels & Blades
 Handles come in #3 or #4 sizes
 Blades 11,12, 15 & 10 fit #3 handle
 Blades 22 and 23 fit #4 handle
Forceps
Kelly forceps
Mosquito hemostats
Crile forceps
Hemostats
 Rochester-Carmalt
hemostat
 Rochester- Peans
hemostat
“Other”
 Stereotaxic
gear
 Bovie
 Human hands!
“Batch” Rodent Surgery / ‘tricks’
 Start with a sterile pack
 Sterilize between uses =
“resetting the stage”