PRINCIPLES OF SURGICAL ASEPSIS
asepsis prevents the contamination of surgical wounds. The patient’s natural
skin flora or a previously existing infection may cause postoperative wound
infection. Rigorous adherence to the principles of surgical asepsis by OR
personnel is the founda-tion of preventing surgical site infections.
surgical supplies, any instruments, needles, sutures, dress-ings, gloves,
covers, and solutions that may come in contact with the surgical wound and
exposed tissues, must be sterilized before use (Meeker & Rothrock, 1999;
Townsend, 2002). Traditionally, the surgeon, surgical assistants, and nurses
prepared themselves by scrubbing their hands and arms with antiseptic soap and
water, but this traditional practice is being challenged by research
investigat-ing the optimal length of time to scrub and the best preparation to
use (Larsen et al., 2001). (See Nursing Research Profile 19-1.)
Surgical team members wear long-sleeved sterile gowns and gloves. Head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacte-ria from the upper respiratory tract will enter the wound. During surgery, the personnel who have scrubbed, gloved, and gowned touch only sterilized objects. Nonscrubbed personnel refrain from touching or contaminating anything sterile.
area of the patient’s skin considerably larger than that re-quiring exposure
during the surgery is meticulously cleansed, and an antimicrobial agent is
applied. If hair needs to be removed, it is done immediately prior to the
procedure to minimize the risk of wound infection (Townsend, 2002). The
remainder of the pa-tient’s body is covered with sterile drapes.
addition to the protocols described previously, surgical asepsis requires
meticulous cleaning and maintenance of the OR envi-ronment. Floors and
horizontal surfaces are cleaned frequently with detergent, soap, and water, or
a detergent germicide. Steril-izing equipment is inspected regularly to ensure
optimal opera-tion and performance.
equipment that comes into direct contact with the patient must be sterile
(Townsend, 2002). Sterilized linens, drapes, and solutions are used.
Instruments are cleaned and sterilized in a unit near the operating room.
Individually wrapped sterile items are used when additional individual items
bacteria are a concern. To decrease the amount of bacteria in the air, standard
OR ventilation provides 15 air ex-changes per hour (Meeker & Rothrock,
1999). Staff members shed skin scales, resulting in about 1,000
bacteria-carrying parti-cles (or colony-forming units [CFUs]) per cubic foot
per minute. With the standard air exchanges, air counts of bacteria are
re-duced to 50 to 150 CFUs per cubic foot per minute. The num-ber of personnel
and unnecessary physical movements may be restricted to minimize bacteria in
the air and achieve an OR in-fection rate no greater than 3% to 5% in clean,
ORs have laminar airflow units. These units provide 400 to 500 air exchanges
per hour. When used appropriately, laminar airflow units result in less than 10
CFUs per cubic foot per minute during surgery. The goal for a laminar
flow-equipped OR is an in-fection rate under 1%. An OR equipped with this unit
is frequently used for total joint replacement or organ transplant surgery.
all these precautions, wound contamination may occur during surgery but may
only become apparent days or weeks later in the form of an incisional infection
or abscess. Constant surveil-lance and conscientious technique in carrying out
aseptic practices is necessary to reduce the risk for contamination and
practitioners involved in the intraoperative phase have a re-sponsibility to
provide and maintain a safe environment. Adher-ence to aseptic practice is part
of this responsibility. The eight basic principles of aseptic technique follow:
All materials in contact with the
surgical wound and used within the sterile field must be sterile. Sterile
surfaces or ar-ticles may touch other sterile surfaces or articles and remain
sterile; contact with unsterile objects at any point renders a sterile area
Gowns of the surgical team are
considered sterile in front from the chest to the level of the sterile field.
The sleeves are also considered sterile from 2 inches above the elbow to the
Sterile drapes are used to create a
sterile field. Only the top surface of a draped table is considered sterile.
During draping of a table or patient, the sterile drape is held well above the
surface to be covered and is positioned from front to back.
Items should be dispensed to a
sterile field by methods that preserve the sterility of the items and the
integrity of the sterile field. After a sterile package is opened, the edges
are considered unsterile. Sterile supplies, including solutions, are delivered
to a sterile field or handed to a scrubbed person in such a way that the
sterility of the object or fluid remains intact.
The movements of the surgical team
are from sterile to ster-ile areas and from unsterile to unsterile areas.
Scrubbed per-sons and sterile items contact only sterile areas; circulating
nurses and unsterile items contact only unsterile areas.
Movement around a sterile field must
not cause contami-nation of the field. Sterile areas must be kept in view
during movement around the area. At least a 1-foot distance from the sterile
field must be maintained to prevent inadvertent contamination.
Whenever a sterile barrier is
breached, the area must be con-sidered contaminated. A tear or puncture of the
drape per-mitting access to an unsterile surface underneath renders the area
unsterile. Such a drape must be replaced.
Every sterile field should be
constantly monitored and maintained. Items of doubtful sterility are considered
un-sterile. Sterile fields should be prepared as close as possible to the time