2010 Annual ASR Meeting Round Table Presentation Asepsis

2010 Annual ASR Meeting 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 -60 sec 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 / 15 psi / 15 min) 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 / 30 psi / 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 De. Bakey clamp Bulldog clamps

Bone Rongeurs Bone curette 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 Micro-Vannas Ragnell Doyen

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”