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1. Aseptic
&
Antiseptic
Techniques
Mohammed A.(MD)

2. Outline
• Introduction
• SSI
• Asepsis
– Classification
– Techniques
• Antiseptics

3. Introduction
• Surgical procedures
• interfere with the normal protective skin barrier
• expose the patient to microorganisms from both
endogenous and exogenous sources
• Prevention of surgical site infections (SSIs)
• primary concern to surgeons
• must be addressed in the planning of any
operation

4. …Cont’d
• Most disease transmissions occur due to actions of
health care personnel that ignore basic concepts of
aseptic techniques
• Reuse of syringes/ needles
• Touching of a sterile device on to a non-sterile surface
• Entering of a sterile solution without adequate
decontamination of the portal of entry…

5. Surgical site infections(SSI)
Def: (CDC)
– an incisional SSI is an infection that occurs at the
incision site within 30 days after surgery or within 1
year if a prosthetic implant is in place
– Surgical site infection (SSI) is a major cause of patient
morbidity, mortality, and health care costs

6. Surgical site infection

7. • Factors that contribute to the development of SSI
(1) those arising from the patient's health status
(2) those related to the physical environment where
surgical care is provided, and
(3) those resulting from clinical interventions that
increase the patient's inherent risk

8. Probability of sepsis in normal state

9. Asepsis
• Def:
–Reducing the number of microbes to an
irreducible number
• The purposeful prevention of the transfer of microbes
from one person to another
• Sum total of the effort to keep the pt’s env’t free from
contamination and the pt free from colonization

10. …Cont’d
• Aseptic techniques
– is a general term involving practices that minimize the
introduction of microorganisms to pts during pt care
– used to reduce the risk of post-procedure infections and
to minimize the exposure of health care providers to
potentially infectious microorganisms
– include practices performed just before, during or
after any invasive procedures

11. • Poor adherence to aseptic techniques results in considerable
morbidity and mortality*
• Health care personnel should be trained in aseptic
technique and demonstrate competency
• Impt to all health care facilities to establish policies
regarding procedures that require aseptic techniques
• Supervision and monitoring of infection control
activities is a critical element of infection control

12. Antiseptics
• Antisepsis
– prevention of sepsis by inhibition or destruction of
causative agents
• Antiseptic agents
• Chemicals applied to the skin or other living tissue
to inhibit or kill microorganisms ( both transient &
resident) thereby reducing the total bacterial counts

13. Characteristics of Antiseptics
• Rapid reduction of flora
• Wide-range of killing power
• Absence of absorption across skin/ mucous membranes
• bactericides or bacteriostatics
** Know the appropriate dilution

14. Antiseptics Vs Disinfectants
• Antiseptics
– Are cleaning solutions that inhibit and destroy
microorganisms on the living tissue (skin ,…
• Eg. Isopropyl alcohol, betadine
• Disinfectants
– Are cleaning solutions that inhibit and destroy
microorganisms on environmental surfaces
• Eg. Bleach solutions

15. Classification
• Two categories of asepsis
 General asepsis
• w/h applies to pt care procedures outside the OR*
Surgical asepsis
• Relating to procedures /processes designed to prevent
surgical site infection

16. Principles of medical asepsis
• When the body is penetrated ,and natural barriers such
as the skin is bypassed ,the pt is susceptible to any
microbes that might enter
• Even though intact skin is a good barrier against
microbial contamination, a pt can become colonized
with microbes if appropriate precautions are not taken

17. …Cont’d
• All body fluids from any pt is considered contaminated
• The healthcare team and the env’t can be a source of
contamination for the pt
• Hands of health workers are the most common
source of cross-infection

18. Key processes for medical (non-surgical)
procedures with aseptic techniques
• Hand antisepsis & appropriate use of gloves
• Skin antisepsis of the site of insertion of invasive devices (eg.
Ivs, IM
• Using and maintaining sterile pt care equipment*
• introduction of sterile item into a pt should always be
performed with “no-touch” technique**
(eg. catheterization

20. Hand washing
- is the single most important procedure for preventing
nosocomial infection
• When and how*
• Soap or antiseptics
• the use of gloves

27. Cornerstones Of Medical Asepsis
• Know what is dirty
• Know what is clean
• Know what is sterile
• Keep this conditions separate
• Remedy contamination immediately

28. 28
Surgical Asepsis
Keep the surgical
environment completely free
of all microorganisms
Sterile technique used for
even minor operation or
injections
Object is either sterile or not
sterile; if unsure then it is not
sterile.

29. Surgical Principles Of Asepsis
• The pt should not be a source of contamination
• The OR team should not be a source of contamination*
• Recognize potential env’tal contamination
– proper room cleaning, doors kept closed, limited traffic
• The surgical scrub must be done meticulously
• Technique of the surgeon of utmost importance

30. Key Processes Of Surgical Asepsis
• Operation theater
• Should Meet standards of asepsis at all times
• Instruments and equipments
• Disinfected , Sterilized
• Surgical team
• Use of Personal protective equipments (hat, mask, goggle
• Surgical hand scrub
• sterile gloves
• sterile guans
• Safe handling of instruments
• Post-procedure hand washing

31. …Cont’d
• Patient
• preoperative hospital stay (as short as possible)
• Preparation of operative site ( hygiene, hair removal……
• Remote infections ( treated)
• Prophylactic antibiotics, bowel preparation in colon surgery
• Skin preparation
• Drapes ,…
• Surgeon
• Technique ( dissection, hemostasis, …
• Use of drains, electrocautery,….
• Duration of operation, wound (close/ left open)….
• Wound management

33. Medical Vs Surgical Asepsis

34. Operation Theatre
• Filtered air
• frequent air change
• laminar flow of air
• limited human trafficking,…
 Even the best OR design will not compensate for
improper surgical technique or failure to pay attention
to infection prevention

35. Instruments and Equipments
• Decontamination
– process of removing or destroying micro-organisms and
organic matter. Making a re-usable item safe for patients
and staff
• Cleaning
– process that physically removes organic matter ( blood,
tissue, body fluids) but does not remove micro-organisms

36. ...cont’d
• Disinfection
• Process that reduces the number of micro-organisms
to a level that is not harmful at the site of use. Kills or
removes micro-organisms with the exception of
bacterial spores
• Sterilization
• Is the complete elimination or destruction of all
microorganisms , including spores

37. Methods Of Decontamination
• Disinfection
Physical
• Low temp steam
• Boiling water
• Washer disinfections
Chemical
• Chemical disinfectants
– (Glutareldehdye 2%, Cidex, Miltons, Clearsol, alcohol)

38. Methods Of Sterilization
• Steam (autoclaving)
• Hot air (ovens)
• Ethylene Oxide
• Low temp steam and formaldehyde
• Gas plasma
• Irradiation
• Sporicidal chemicals
* Autoclaves and sterilization systems should be continuously
monitored with routine testing for efficiency and performance

39. Patient Preparation
• Preoperative hospital stay
- should be as short as possible to reduce likelihood of being
colonized by nosocomial pathogens or acquire nosocomial
infections
• Remote infections
• Presence of untreated remote infection is associated with
an increased incidence of wound infection
• Should be appropriately treated

40. Preparation Of Skin
• The sole reason for preparing the pt's skin before an operation is
to reduce the risk of wound infection
• A preoperative antiseptic bath
• not necessary for most surgical pts ( but assess their personal
hygiene)
• Chlorhexidine gluconate is the recommended agent for such
baths(if needed)
• Obvious dirt, grime, and dried blood should be mechanically
cleansed from the operative site by using sufficient friction

41. Hair Removal
• should not be removed from the operative site unless it
physically interferes with accurate anatomic approximation of the
wound edges
• If hair must be removed, it should be clipped in the OR
• Shaving hair from the operative site, particularly on the evening
before operation or immediately before wound incision in the OR,
increases the risk of wound infection
• Depilatories are not recommended
– serious irritation & rashes (esp. when used near eyes &
genitalia)

42. Prophylactic Antibiotics
• Depending on the class of wound, use of implants, pt status
• Immediately before incision

43. Surgical wound classification
• Clean / Class I
– Uninfected operative wound in which no inflammation is
encountered.Respiratory, alimentary and genito-urinary
tracks are not involved
– 1.5%
• Clean-contaminated/ Class II
– Any operative wound in which the respiratory, alimentary or
genito-urinary tracks are opened in a controlled manner
without contamination
– 8%

44. ...cont’d
• Contaminated/ Class III
– Open fresh accidental wounds. Operations with major break in
sterile techniques. Gross contamination or major spillage. Non
purulent inflammation
– 10-15%
• Dirty-infected/ Class IV
– Old traumatic wounds with devitalised tissue and those that
involve existing clinical infection or perforated viscera. Organisms
involved were present in the operative field before the operation
– 25%

45. Prepping (skin preparation)
• Necessary reduction in microorganisms can be achieved
by using
- 70% povidone-iodine (10% available povidone-iodine &
1%
available iodine) or
- 0.5% chlorhexidine gluconate
- 70% isopropyl alcohol
both for mechanical cleansing of the intertriginous folds & the
umbilicus and for painting the operative site
 For iodine-sensitive pts, one can use isopropyl or 70% ethyl
alcohol. Apply to the skin with a gauze swab for 3 minutes and
allow to dry before draping

46. Draping
• Sterile drapes helps to create sterile surgical
field(s) by delineating the field around the pt
• Sterile drape packs should be opened aseptically
• Contents do not touch non-sterile items
• Drapes should be sterile, dry
– impermeable(if possible)

47. Surgical Team
• The surgical scrub
• Definition
– is the process of removing as many microorganisms as
possible from the hands and forearms by mechanical
washing and chemical antisepsis before participating in a
surgical procedure
• Despite the mechanical action and the chemical
antimicrobial component of the scrub process, skin is never
sterile
• Duration
• Not universally defined
• 5 min scrub before the 1st
case
• 2 - 3 min scrub in between cases

48. ..cont’d
• Technique
– surgical scrub brush and an antimicrobial soap
solution
– Chlorhexidine containing
– Alcohol based solutions / lotions

49. There Is No Compromise with Sterility
It’s Considered Sterile or Unsterile

50. Surgical Hand Scrub-Technique
1. Wet the hands and forearms
2. Apply antiseptic agent from
the dispenser to the hands
3. Wash the hands and arm
thoroughly to 2 inches above
the elbows, several times
4.Rinse thoroughly under running
water with the hand upward,
allowing water to drip from
the flexed elbows

51. 5. Take a sterile brush or
sponge (from a package or
dispenser) and apply an
antiseptic agent ( if it is
not impregnated in the
brush)
6. Scrub each individual
finger, including the nails,
and the hands, a half
minute for each hand.

52. 7. Hold the brush in one hand and
both hands under running
water, and clean under the
fingernails with a disposable
plastic nail cleaner. Discard the
cleaner after use
8. Again scrub each individual
finger, including the nails and
the hands with the brush, half a
minute for each hand

53. The Final Rinse
1. Be sure to keep both arms
in the upright position
(careful not to touch the
faucet!) so that all water
flows off the elbows and
not back down to the
freshly scrubbed hands.
2. Bring arm through the
water once, starting with
the fingers, then pull the
arm straight out. Do not
let water run down to
hands, must drip off
elbows

54. 9. Rinse the hands and brush, and discard the brush
10. Reapply the antimicrobial agent and wash the hands
and arms, applying friction to the elbows, for 3
minutes. Interlace the fingers to clean between
them
11. Rinse the hands and arms as described in the
previous slide.

55. Drying the Hands and forearms
1. Reach down to the
opened sterile package
containing the gown, and
pick up the towel. Be
careful not to drip water
onto the pack. Be sure no
one is within arm’s reach
2. Open the towel full-length,
holding one end away
from the nonsterile scrub
attire. Bend slightly
forward

56. 3. Dry both hands thoroughly
but independently. To dry
one forearm, hold the towel
in the opposite hand and,
using the oscillating motion
of the forearm, draw the
towel up to the elbow
4. Carefully reverse the towel,
still holding it away from the
body. Dry the opposite
forearm on the unused end
of the towel

57. Gowning and Gloving Techniques
1. Reach down to the sterile
package and lift the folded
gown directly upward
2. Step back away from the
table into an unobstructed
area to provide a wide
margin of safety while
gowning
3. Holding the folded gown,
carefully locate the
neckline

58. 4. Holding the inside front of the
gown just below the neckline
with both hands, let the gown
unfold, keeping the inside of
the gown toward the body.
Do
not touch the outside of the
gown with bare hands
5. Holding the hands at shoulder
level, slip both forearms into
the armholes simultaneously

59. 6. The circulator nurse brings
the gown over the shoulders
by reaching inside to the
shoulder and arm seams.
The gown is pulled on,
leaving the cuffs of the
sleeves extended over the
hands.
The back of
the gown is securely tied or
fastened at the neck and
waist, touch the outside of
the gown at the line of ties or
fasteners in the back only.

60. Gloving --- Closed Gloving Technique
1. Using the right hand and keeping it within
the cuff of the sleeve, pick up the left glove
from the inner wrap of the glove package by
grasping the folded cuff

61. 2. Extend the left forearm
with the palm upward.
Place the palm of the
glove against the palm of
the left hand, grasping in
the left hand the top edge
of the cuff, above the palm.
* In correct position, glove
fingers are pointing
toward you and the
thumb of the glove is
down

62. 3. Grasp the back of the cuff in
the left hand and turn it
over the end of the left
sleeve and hand
The cuff of the glove is now
over the stockinet cuff of
the gown, with the hand still
inside the sleeve

63. 4. Grasp the top of the
left glove and
underlying gown
sleeve with the
covered right hand.
Pull the glove on
over the extended
right fingers until it
completely covers
the stockinette cuff.

64. 5. Glove the right hand
in the same manner,
reversing hands.
Use the gloved left
hand to pull on the
right glove.

65. Gloving the Right Hand

66. Scrubbing, Gowning, and Gloving Complete

67. Gloves, Gowns, Drapes
• Wearing two pairs of surgical gloves
– to provide an additional barrier and to further reduce the risk
of contamination
• The current CDC recommendation is to use surgical
gowns and drapes that resist liquid penetration and
remain effective barriers when wet

69. Sterile Technique
• Sterile object remains sterile only when touched by another
sterile object
• Only sterile objects may be placed on a sterile field
• A sterile object (field) out of range of vision or an object held
below a person’s waist is contaminated
• When a sterile surface comes in contact with a wet, contaminated
surface, the sterile object or field becomes contaminated by
capillary action
• The edges of a sterile field or container are considered to be
contaminated (1 inch)

70. Surgical Principles Of Asepsis
• Know what is sterile
• Know what is not sterile
• Keep the two apart
• Remedy contamination immediately

71. Define Sterility
• Gowns are considered sterile in front from chest high to
the operative level
• Sterile persons should keep hands in sight and keep
them at or above waist level
• Contamination occurs when sterile gown and drapes are
permeated*
• Tables are sterile only at the operative level

72. Maintain Sterility
• All items used within the sterile field must be sterile
• Sterile persons touch only sterile items or sterile areas
• Articles of doubtful sterility are considered unsterile
• Unsterile personnel stay beyond one foot of the sterile field
• Every case is considered dirty and the same infection control
precautions are taken for all pts

73. Remedy contamination immediately!!!
• When contamination occurs , take care of it
immediately
• Break in technique is pointed out and action is
taken to change situation …..change gloves

74. Surgeon
• Most of the local factors that make a surgical site favorable
to bacteria are under the control of the surgeon
– Careful attention to cleanliness and technique
• Hemostasis
• sharp dissection
• fine sutures
• anatomic dissection
• gentle handling of tissues
• obliterate dead space
• Expeditious surgery(Speed and poor technique are not suitable
approaches)
• Appropriate use of electrocautery…

75. • Drains
• Operative site should not be drained through
the wound
• Closed suction drain… preferable
• Simple penrose drain( can also function as an
access route for pathogens