BAINES
WOUND infections have been a major problem since surgery began and, despite improved techniques to avoid
and combat them, they remain an important complication of surgery. This article discusses the stages in the
prevention of vvound contamination. The basic principle of aseptic technique is that microbiological
contamination and subsequent infection cannot occur if microorganisms are totally excluded from a vvound.
The reality of aseptic technique is a vvorking set of complementary and independent technologies and operating
room protocols designed to prevent or minimise microbiological contamination of the surgical vvound. Ali items
that come into contact vvith the vvound should be sterile. If an item cannot be made sterile, it is rendered
surgically dean by vvashing vvith antiseptics or disinfectants vvhich destroy most, but not ali, microorganisms.
SOURCES OF CONTAMINATION unless one of the barriers fails to function as expected. Ali
items of surgical equipment should be rendered sterile
Bacterial contamination may ariše from the follovving: prior to surgery. Air in contact vvith the surgical vvound is
■ the surgical team; the most common vehicle for delivering bacteria into the
■ surgical equipment; vvound. The bacteria in the air are usually from the animal
■ the operating theatre environment; and any non-scrubbed personnel in the operating theatre;
■ the patient. the concentration of bacteria in the air is directly related to
The most common source of contamination is the the number of people present and the degree of activity.
animal’s endogenous microbial flora. Prevention of A number of phases are important in the prevention of
exposure to this population of bacteria is important at the vvound contamination (see table, belovv left). Most
time of surgery, and the preoperative preparation of the bacterial contamination occurs at the time of surgery.
patient is concemed vvith reducing the likelihood of
contamination from this source.
In the presence of a properly prepared patient, most
particulate material and bacteria come from the surgical
team. Modem aseptic techniques are effective in reducing
contamination by exogenous bacteria. A scrubbed
surgeon, correctly attired, rarely contaminates a vvound
Consequently, the perioperative and intraoperative phas- NON-STERILE BARRIERS
es are traditionally regarded as the mainstays of asepsis. Scrub suit
A scrub suit is an occlusive, but not impermeable, barrier
to microorganisms, the aim of which is to reduce partic-
PATIEMT SELECTION ulate shedding in the operating theatre. These clothes
should not be wom outside the operating theatre, or for
Evaluation of the patient for suitability for surgery should procedures vvhich carry an increased risk of contamination
be comprehensive, to assess its overall State of health, (eg, dressing changes and patient examination), if further
determine the risk of surgical wound infection and to guide surgery is scheduled.
the preoperative preparation. Important considerations are
the patient’s physical condition, the presence of Surgical head covers
intercurrent disease and any evidence of a remote site of Hair is the primary source of bacterial contamination from
infection. the surgical team and should therefore be covered. Hoods
It is a myth that animals are more resistant to infection are more effective than caps. The item chosen should cover
than humans. Operative invasion of normal tissue should the occipital and temporal regions, should be durable and
only be undertaken if postoperative infection will not comfortable to wear and should not shed lint into the
threaten the animal’s well-being or life. vvound.
STERILE BARRIERS
Properties of an ideal skin preparation Gloves
agent Sterile surgical gloves should be wom to reduce further the
■ Wide spectrum of antimicrobial activity risk of bacterial contamination. Closed gloving - where the
■ Ability to decrease microbial count quickly hands are kept inside the sleeves of a sterile gown while the
■ Quick application gloves are put on - is preferred to decrease contamination.
■ Long residual lethal effect Various studies have shown that a large percentage of
■ Active in the presence of organic matter surgical gloves appear to have minor perforations by the
■ Safe to use vvithout skin irritation and end of an operation. For this reason, the hands should
sensitisation always be scrubbed properly, and the method chosen
■ Economical should achieve both an immedi-
any contaminated case or break in the surgery schedule,
and three minutes for subsequent cases. Particular atten-
Quaternary Benzalkonium chloride Broad-spectrum Slow Inactivated by soaps Pseudomonas Cleaning non- sterile
ammonium (Roccal; Sterling bactericidal (mainly and organic material infections Ulceration surfaces
compounds VVinthrop) Cationic surface agents Gram- positives) Bacteria survive under if undiluted
Change cell wall
Some viruses film
permeability Neutralise
phospholipids
Slow Neurotoxicity
Hexachlorophene Bacteriostatic
Chlorinated Inhibit electron transport Require repeated
(Ster-Zac; (Gram-positives None - other agents more
phenol and membrane bound application Must use
Hough, only) effective
derivatives enzymes alone
Hoseason) Not sporicidal
Aliphatic 70 per cent ethyl Damage lipids in cell Broad-spectrum Rapid Skin irritation Tissue Routine skin preparation,
alcohols bactericidal
alcohol membrane Protein Some residual action necrosis in open combined vvith other
precipitation Improved activity when vvounds agents
used with
chlorhexidine or
povidone-iodine
Diphenyl ethers Triclosan (Manusept, Disrupt bacterial cell wall Intermediate Routine skin preparation
Aquasept; Hough, Broad-spectrum
Hoseason) bactericidal (not some Some residual action
Pseudomonas Active in the presence
species) of organic matter
Poor fungicide
lodophors Povidone-iodine Damage cell wall Form Rapid Relatively high Routine skin preparation
(Pevidine; BK) reactive ions and protein Broad-spectrum Slovv release of active incidence of skin
(Betadine; Napp) complexes bactericidal iodine Minimal residual reactions
Fungicidal Virucidal action
Sporicidal with Inactivated by organic
prolonged contact material
Bisdiguanide Chlorhexidine Alter cell wall Rapid Good residual action Occasional skin Routine skin preparation
compounds
(Hibitane, Hibiscrub; permeability Protein Active in the presence reactions and
Broad-spectrum
ICI) precipitation of organic matter photosensitivity
bactericidal (not some
Pseudomonas
species) Minimal
action against spores
and viruses
ate antibacterial effect and a prolonged residual activity. If Steam sterilisation of instruments
such a practice is adopted, minor punctures in gloves are Cleaning
not associated with a significant increase in wound Gross contamination must be removed as a first step,
infection rates. regardless of the sterilisation technique used. Dried
blood conceals microbes, particularly in the less
Govvns
accessible parts of the instruments, and renders
Sterile surgical gowns are used as a further barrier
sterilisation more difficult. Instruments should be
between the surgical team and the patient. Govvns should
cleaned as soon as possible after use. Immediately after
be made of a material that establishes such a barrier (thus
surgery they should be rinsed in cold water to remove
eliminating the passage of microbes), that is resis- tant to
blood and debris. If there is a delay before final cleaning,
blood and aqueous fluids and that is free from linting,
they should be immersed in warm water containing an
eliminating the number of airbome particles.
effective detergent.
Disposable, single-use govvns have superior barrier
Manual cleaning is best achieved using a hand
properties, particularly vvith respect to fluid absorption.
brush vvith soft bristles. Abrasive cleaners should be
Studies have shown that non-woven disposable govvns
avoided, as should ordinary soap vvhich leaves behind
greatly reduce the number of airbome particles and
an insoluble film. A vvasher-steriliser cleans instruments
vvound infection compared vvith cloth govvns, although
in an agitated detergent bath before automatic steam
this difference is much less marked for clean procedures.
sterilisation. Hovvever, this results in unvvrapped
Reusable govvns result in less vvaste and are cheaper
instruments, and is not suitable for routine sterilisation of
to use. Hovvever, the priče differential is somevvhat
surgical supplies. Ultrasonic cleaners clean via the
smaller vvhen the time, effort and cost of laundering and
process of cavitation. Minute gas bubbles are formed by
sterilising the govvns is taken into account. Cloth govvns
ultrasound vvaves vvhich expand until they are
lose ali their barrier properties vvhen vvet. In addition,
unstable, then collapse. Implosion of these bubbles
each time the govvn is laundered the pores in the fabric
creates a minute vacu- um vvhich is responsible for
vviden, further decreasing the barrier properties. These
removing tightly bound soil. Instruments should be
govvns must be regularly inspected for holes. It should be
loaded vvith ali box locks open.
noted that mending of govvns by sevving results in many
needle holes much bigger than the natural pores in the Preparation of packs
material. Instruments and supplies are segregated according to
Govvns vvith integral or added impervious sleeves their intended use. Materials are positioned vvithin
should be used if the govvn above the glove is subjected to packs to allovv complete steam penetration.
moisture. Gloves should cover the elasticated cuff of the Instruments should be sterilised vvith their box locks
govvn. open and complex instruments, such as Balfour
retractors, should be disassembled. Containers such as
kidney dishes are positioned such that the open end is
STERILISATION OF SURGICAL EQUIPMENT
facing dovvn or horizontally. Instrument packs should be
packed on edge vertically, in longi- tudinal rovvs vvithin
Ali instruments, implants and equipment vvhich are to be
the steriliser so that they are oriented in the direction of
used during surgery must be sterilised before use. There
the steam flow. A small amount of space should be left
are several different methods of sterilising available (see
betvveen each pack. Linen packs should be positioned
belovv). The choice of method vvill depend on:
such that their layers are oriented vertically, so that air
Fibreoptic equipment Plastic catheters and syringes Anaesthetic tubing and steam travel dovvnvvards to escape betvveen the
Optical instruments High speed drills and burrs
layers. Care should be taken to prevent overloading and
blocking of the inlet and exhaust valves.
METHODS OF STERILISATION
Physical Chemical
Autodave operation
A number of minimum time-temperature standards have
Heat Gaseous
Steam Ethylene oxide been established for the routine sterilisation of packs
Moist heat (boiling) Formaldehyde (see table, page 27). It is generally agreed that 13
Dry heat Beta-propiolactone
minutes at 120°C is a safe minimum standard; five to 10
Irradiation Liquid minutes at this temperature vvill destroy most resistant
Gamma irradiation Alcohols (ethyl alcohol, isopropyl alcohol)
microbes, vvhile the addition- al time provides a margin
Ultraviolet light Aldehydes (formaldehyde, glutaraldehyde)
High energy electrons Chlorhexidine of safety. Emergency sterilisation is carried out at 131°C
lodophors for three minutes. The sterilising time begins vvhen the
Phenols
Quaternary ammonium compounds temperature of the exhaust gases reaches the desired
level. Therefore, the cycle time includes this heat up
time, as well as the sterilising time, and generally lies in
CHOICE OF STERILISATION METHOD FOR VARIOUS ARTICLES
Steam Dry heat Ethylene oxide the range of 15 to 45 minutes. The time taken to heat up
the steriliser is much reduced in pre- vacuum and
Glassvvare
pulsing type units.
Instruments
Glassvvare bits
Shaving
Shaving removes hair with minimal stubble, but causes
dal compound that rapidly kills accessible microorgan- shorter surgical scrub, this time using sterile swabs and
isms. These criteria are currently best fiilfilled by gloves is advocated by some authorities. Altematively, the
chlorhexidine and povidone-iodine. Although some stud- surgeon may apply antiseptic solution to the surgical site
ies comparing the efficacy of these two agents have using sterile swabs on sponge-holding forceps.
demonstrateđ that chlorhexidine is more effective, other
studies have failed to document a significant difference in DRAPING THE PATIENT
bacterial kili rates or in postoperative wound infec- tion. Draping maintains asepsis by preventing contamination of
The use of either agent is justified, although chlorhexidine the surgical site by hair and the immediate environ- ment.
has the advantages of prolonged residual activity, The drapes should cover the entire patient and table,
continued activity in the presence of organic matter and leaving only the surgical site exposed. The ideal material
reduced incidence of skin reactions. will provide a barrier to bacteria and debris from
It is important to note that Gram-negative bacteria, non-sterile areas for the duration of the surgery. It should
particularly Pseudomonas species, can live and multiply be easy to sterilise, economical and retain its barrier
in some dilute antiseptic Solutions. For this reason, such properties under the conditions in which it is used. It must
Solutions should be dispensed freshly from concentrated remain securely fastened to the patient during
stock Solutions into sterile containers. Dilute Solutions manipulation. Both reusable and disposable type drapes
should be discarded after 48 hours. are available; their relative advantages and disadvantages
are considered in the table (below left).
Skin preparation protocol Four drapes may be used to isolate a rectangle con-
The initial surgical site preparation is performed outside taining the proposed surgical site or, altematively, a sin-
the operating theatre. The vvearing of surgical gloves gle fenestrated drape. Each comer of the draped square is
during preparation decreases the risk of contamination by secured to the patient’s skin by towel clamps, Michel clips
the operator’s hands; the gloves do not need to be sterile or sutures. Penetration of the drape by a clamp will destroy
during these initial stages of the procedure. Antibacterial the barrier at that point. In addition, clamps are considered
detergents are usually applied to the skin with wet, contaminated after making contact with the patient’s skin
lint-free gauze swabs. It has been reported that a gloved and so a new clamp should be used if the drape is
hand may be as effective in decreasing total bacterial repositioned. If four single drapes are used, a second
numbers. Scrub brushes should be avoided as they can draping layer, consisting of a large, single sheet with a
cause excessive skin trauma. Central opening, may be used on top of the first layer. A
Both the detergent’s lather and the scrubbing action waterproof disposable drape between the two layers will
are important for the mechanical removal of debris and improve the effectiveness of the barrier if cloth drapes are
bacteria. Excessive vigour should be avoided because it used. Additional drapes or towels may be used during
brings bacteria within the follicles to the surface and surgery to protect the tissues when there is an increased
causes irritations or abrasions that are rapidly colonised risk of contamination, for instance during enterotomy.
by bacteria. There should be just sufficient water to Another method, useful for orthopaedic pro- cedures on
produce a good lather. Too much water will result in limbs, is to cover the limb with a double lay- ered
dilution of the agent, and hence reduced efficacy, and orthopaedic stockinette and suture it to the wound edges.
wetting of the patient, potentiating both heat loss during This technique allovvs the entire limb to be draped, while
the surgery and moist contamination (‘strike through’) of still permitting manipulation. The inclu- sion of a plastic
surgical drapes. layer underneath the stockinette improves its barrier
Once the scrub is completed, an antiseptic such as 70 properties.
per cent ethyl alcohol, or a mixture of ethyl alcohol and Adhesive barrier drapes have been recommended as a
chlorhexidine or povidone-iodine, is applied or sprayed solution to the problems inherent in current draping tech-
on to the proposed surgical site. A sterile drape may be niques. They are waterproof and their adhesive nature
placed over the prepared area and the animal is trans- allovvs rapid application, vvithout the need for additional
ported to the operating theatre. skin attachment. The incision is made directly through the
Once within the operating theatre, a similar, but drape, and their transparency aids orientation and
identification of landmarks. Significant reductions in the
Advantages Disadvantages
Excellent vvater repellent properties
numbers of bacteria in surgical vvounds at closure have
ADVANTAGES AND DISADVANTAGES OF DISPOSABLE AND REUSABLE DRAPES AND GOVVNS been documented using these drapes, although this has not
Always in good condition Labour saving Less laundry been reflected in a significant decrease in vvound infection
Can be obtained pre-sterilised rates for clean and clean-contaminated proce- dures in
Disposable
Cheaper Less waste
Expensive man. Acceptance of these drapes in veterinary surgery is
May be less conforming low due primarily to their cost, the unreliable adherence of
Large stock reguired the drapes to the area adjacent to the surgical site and
studies questioning their effectiveness in human surgery.