Asepsis & Antisepsis in

Surgery

Dept of Surgery
National University of Singapore

Asepsis in Surgery

Asepsis : freedom from infection or

prevention of contact with microorganisms
Aseptic technique : instruments, air,
drapes, gloves and gowns are free from
microorganisms
Antisepsis : prevention of sepsis by
inhibition or destruction of agents

Asepsis

Defined as a process or procedure performed

under conditions in which bacterial
contamination has been minimised

1847
1865

Semmelweis
Lister

Asepsis
Technique

wash hands and instruments with

carbolic acid
wear gloves
spray OT with carbolic acid

Lister - Lancet 1867

amputation mortality 46% 15%

Asepsis Today
OT

20 air changes per hour

filtered air
laminar flow if needed

Surgeon

hand scrub iodophors or

hexachlorophene solution
sterile gloves - technique
sterile gown - technique
aseptic technique in surgery

Asepsis today

Patient
shave only day of op
skin prep with iodophor or hexachlorophene
drape with impermeable membrane
protect wound
beware long surgery, drains, other illness

Instruments - autoclave or gas sterilised

Antisepsis

Bacterial flora

Resident: Coag ve Staph, Corneybacterium,

Acinetobacter, enterobacterium

Transient: Staph aureus, MRSA

Antisepsis- Destruction or removal of the

transient flora

Surgical Site Infection (SSI)

10-15% of nosocomial infections

60% at the incision site

Significant morbidity and mortality

Increased hospital stay and costs

Superficial Incisional SSI

Occurs within 30days and involves skin or

subcutaneous tissue and one of the following

Purulent discharge
Positive culture
Clinical signs of infection
Clinical diagnosis

Deep incisional SSI

Occurs within 30days if no implant left in situ

Occurs within 1yr if implant left in situ and
one of the following
Purulent discharge from deep incision
Dehisence of deep incision
Discharging abscess
Clinical diagnosis

Organ/Space SSI

Occurs within 30days if no implant left in situ

Occurs within 1yr if implant left in situ and one of the
following
Infection involves organ/ space or any related
anatomy
Purulent discharge from deep space
Positive culture
Deep abscess confirmed clinically or radiologically
Clinical diagnosis

Surgical wound classification

Clean / Class I- Uninfected operative wound in

which no inflammation is encountered. Primary
closure with closed drainage. 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%)

Surgical wound classification

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%).

Patient factors

Age
Nutrition
DM
Obesity
Smoking
Colonisation
Immunosuppression
Blood transfusion
Anaemia

Malignancy
Co-existing infection
Length of pre-operative
stay

Operative factors

Category of operation
Duration of operation
Skin asepsis
Surgical scrub
Preoperative shaving
Preoperative skin prep
Antimicrobial
prophylaxis
OT sterilisation
Sterilisation

Foreign material
Surgical drains
Surgical technique
Poor haemostasis
Dead space obliteration
Tissue trauma

Normal body flora

Anatomical site

Head and neck

Thorax

Upper GI

Lower GI

Female genital tract

Flora
Staph (aureus & coag neg), Strep,
cornybacteria, Neisseria,
haemophilus, anaerobes
Staph (aureus & coag neg),
As oropharyngeal and Gram neg rods
including enterobacter, Lactobacilli
AerobicGram neg rods including
enterobacter, enterococci.
Anaerobes- bacteroides, clostridium
yeasts
Large bowel flora, Staph , Strep,
corneybacteria and lactobacilli

Hand hygiene

Procedure
Patient

Risk of SSI=
Dose of bacterial contamination X
virulence/ resistance of patient

Hygienic hand wash: Post contamination procedure

using a bactericidal wash that is active against
transient organisms to prevent further transmission

Asepsis in Surgery

Hygienic hand rub

Bactericidal agent which is alcohol based

without the addition of water

Contains emollient

Fast acting and easy to use

Can be used repeatedly

Surgical scrub

To remove debris and transient micro organisms

from nails, fingers and forearms

Reduce the resident flora to a minimum

Inhibit rapid rebound growth on bacterial flora

The anti microbial agent should reduce micro

organisms on intact skin, be non irritant, broad
spectrum, fast acting and have a residual effect.

Fingernails

Sub ungal regions harbour bacteria

Trimmed nails

No varnish or artificial nails

Use a scrub

Patient preparation

Length of stay proportional to SSI rate

MRSA colonisation

Shower with antiseptic agent

Shaving before procedure

1% Iodine or 0.5% Chlorhexidine in 70% alcohol

Care with diathermy

Drapes

Aseptic barrier

Careful placement around surgical field

Cotton vs. disposable

Wet drapes provide ideal culture medium

Antiseptic agents

Rapid action
Broad spectrum
Persistent effect
Safety
Acceptability
Alcohol, chlorhexidine, Triclosan, Iodine,
Iodophores
Binds to stratum corneum

Antiseptic agents

Alcohol

Denaturation of protein

Chlorhexidine

Disruption of cell wall

Triclosan

Disruption of cell wall

Iodine / Iodophores

Oxidation/substitution
of free iodine

Skin care

Avoid damaged / cracked skin

Latex allergy

Gloving

Emollients

A good scrub..
a)

b)

Thoroughly moisten hands

and forearms
Sub ungal areas cleaned
with nail cleaner

c)

Apply antimicrobial agent

with friction

d)

Fingers and arms scrubbed

on 4 sides

a)

Hands higher than elbows

b)

Avoid splashing

c)

Discard brush

d)

Repeat as necessary!

Decontamination

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.

Decontamination

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.

Sterilisation- process which frees an object of

all living organisms.

Methods of decontamination

Disinfection

Physical Low temp steam

Boiling water
Washer disinfections
Chemical
Chemical disinfectants
(Glutareldehdye 2%, Cidex, Miltons, Clearsol, alcohol)

Methods of Sterilisation

Steam (autoclaving)
Hot air (ovens)
Ethylene Oxide
Low temp steam and formaldehyde
Gas plasma
Irradiation
Sporicidal chemicals

Drains

Drains

Apparatus used to remove debris after

surgery

Early drains were gauze or rubber

Modern drains - plastic, siliconised,

soft rubber

Drains
Types of drains

Open drains

Closed drains
suction or free
sump drains

Drains

Open drains
External end left free
Collection into bag or gauze
Closed drains
External end into collection
device
Suction may be applied

Drains
Open drains

soft and atraumatic

open system - bacteria

skin in contact

difficult to measure

demanding nursing care

cant handle large amounts

no suction

Drains
Closed drains

closed system - bacteria can be minimised

skin - effluent diverted away

easy to measure

easier to nurse

can handle large amounts

suction available

stiffer - more traumatic

Using Drains

Decide on indication
Decide on drain type
Positioning
Care - complications
Removal

Drains - Indications

Prophylactic
anticipated collection
leak after anastomosis
abscess wall continues to secrete

Therapeutic
collection present
pneumothorax, haemothorax
liver abscess
peritoneal haematoma

Drains - Type

Body area
head/ neck /joints
small caliber
abdomen/thorax
any caliber

Type of fluid
viscous
large caliber
irritating
closed system

Amount of fluid
large amounts
suction sump

Drains - Position

Dependent

Not in contact with bowel if possible

Away from anastomosis

Never through main wound

Drains - Complications

Blockage
Dislodge in or
out
Viscera damage
Skin infection
Cavity infection

Drains - Care

Check for blockage

ensure suction working

empty containers

Ensure secure anchor

Protect skin

Cavity infection

keep dry
dressing change
remove early
antiseptic in collection container

Monitor amounts and type of fluid

Drains - Removal
Therapeutic indication

Amounts

abdomen/chest < 100mls

head/neck <20 mls

Imaging ensures cavity recovered

May remove in stages to allow collapse of cavity

Prophylactic

Time of event has passed

Case discussion

This is 20 year old male

patient who had surgery a
week ago

What has happened?

Signs & symptoms

Investigations?

Treatment?

Case 2