Sterile Tech and Ats Tt

8/10/2019 Sterile Tech and Ats Tt

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Principle #1

Scrubbed persons function within a sterile field.2

The surgical team is made up of sterile and nonsterile members. Sterile members or "scrubbed"

personnel work directly in the surgical field while the nonsterile members work in the peripheryof the sterile surgical field. All surgical team members wear scrub attire. In addition to scrubattire, scrubbed persons must wear a sterile surgical gown, mask, and gloves within the sterilefield to establish bacterial barriers.2,4 These barriers protect the patient from the transmission ofmicroorganisms from the surgical team.

Once the scrubbed person dons the sterile surgical gown, the gown's sterility is limited to thegown portions directly viewed by the scrubbed person. These sterile areas include the gownfront, from chest to the sterile field level, and the sleeves from two inches above the elbow tothe cuff.2,4 The scrubbed personnel always perform a surgical hand scrub prior to donning theirsterile surgical gown and gloves.

Principle #2

Sterile drapes are used to create a sterile field.2,5

Sterile surgical drapes establish an aseptic barrier minimizing the passage of microorganismsfrom nonsterile to sterile areas.2 Sterile drapes should be placed on the patient, furniture, andequipment to be included in the sterile field, leaving only the incisional site exposed. 5 During thedraping process, only scrubbed personnel should handle sterile drapes. The drapes should beheld higher than the operating room bed with the patient draped from the prepped incisional siteout to the periphery.2 Once the sterile drape is positioned, it should not be moved orrearranged.5 Keep in mind that after the patient and operating room tables are draped, only the

top surface of the draped area is considered sterile.

1

Principle #3

All items used within a sterile field must be sterile.2,4

Under no circumstances should sterile and nonsterile items/areas be mixed since onecontaminates the other.4 Sterilization provides the highest level of assurance that allinstruments, sutures, fluids, supplies, and drapes are void of microorganisms. 2 The sterility of apackage is determined by events, not by time. To ensure sterility, all sterile items need to beinspected for package integrity and sterilization process indicators, such as indicator tape andinternal chemical indicators, prior to introduction onto the sterile field.2 If a package has been

compromised, it should be considered contaminated and not be used.5

Fluid or air can contaminate a sterile package. When fluid penetrates a sterile package, fluidstrikethrough occurs. The fluid creates a vehicle in which migration of microorganisms reach thesterile item. When a sterile packaged item is dropped on the floor, air penetrates the sterilepackage. The force that is created when the package contacts the floor can cause the sterilebarrier to be penetrated by forcing sterile air out and allowing contaminated air and particles intothe package.1,3



Principle #4

All items introduced onto a sterile field should be opened, dispensed, and transferred bymethods that maintain sterility and integrity.2,4

All sterile items should be dispensed to the sterile field by methods that preserve the integrity ofthe items and sterile field.1 Nonsterile personnel, usually the circulating nurse, must use good

judgement when dispensing sterile items onto the sterile field either by presenting them directlyto the scrubbed person or placing them securely on the sterile field.1,2 Sterile items that aretossed onto the sterile field may displace other sterile items, penetrate the drape, or roll off thesterile field causing contamination to occur.1,2

When opening wrapped supplies, the nonsterile person should open the top wrapper flap awayfrom them first, then open the flaps to each side. The last wrapper flap is pulled toward thenonsterile person opening the package.3 This technique of opening a wrapped package ensuresthat the nonsterile person does not reach over the sterile item inside. All wrapper edges shouldbe secured to prevent flipping the wrapper and contaminating the contents of the sterile

package or field.2,5

After a wrapper has been opened, the inside of the wrapper and its contentsare considered sterile with the exception of the 1-inch outer edge of the wrapper.1 This 1-inchouter edge of the wrapper is considered the "margin of safety" between sterile and nonsterile.When a package is double wrapped, each institution's policies and procedures determine if oneor both wrappers are opened before presentation to the sterile field.5

When opening a peel package, the nonsterile person opens the package by rolling the wrapperover his or her hands and presenting the inner contents of the package to the scrubbedperson.5 The package and its contents must be presented in such a way to preventcontamination of the sterile item or the scrubbed person. When determining package contentsterility, the inner edge of the heat seal is considered the line separating sterile from nonsterile.

When opening a solution container, the nonsterile person should lift the cap straight up and pourthe contents of the bottle into a sterile container. The sterile container is either held by thescrubbed person away from the sterile field or placed near the edge of a sterile waterproof-draped table. Only the top rim of the bottle top and bottle contents are considered sterile oncethe cap has been removed from the bottle. Therefore, when sterile fluids are dispensed, theentire contents of the bottle must be poured or the fluid remaining in the bottle discarded.1 Whensolutions are poured onto the sterile field, they should be poured slowly to preventcontamination and fluid strikethrough from splashing.2

Principle #5

A sterile field should be maintained and monitored constantly.

2,5

It is the responsibility of the operating room staff to monitor and maintain the sterile field. Sterilitycan never be absolutely guaranteed, but surgical team members should make every reasonableeffort to reduce the likelihood of contamination and be vigilant to breaches in sterility. 2 When abreach of sterility occurs, team members must take immediate and appropriate action to correctthe break in technique to reduce further risk of contamination. Remember, if there is doubtregarding an item's sterility, consider it not sterile.3



The sterile field should be prepared as close as possible to the time of use.2 The sterility ofsupplies used during a surgical procedure can be affected by the events taking place within theoperating room, and the length of time the items have been exposed to the environment.4 Onceset up, the sterile field needs to be monitored constantly. When the sterile field is leftunattended, personnel, airborne contaminants, insects, and liquids can contaminate the sterilefield.2 Each facility should have policies and procedures that address these issues for the

surgical team to follow.

Principle #6

All personnel moving within or around a sterile field should do so in a manner to maintain thesterile field.2

Since the patient is the center of the sterile field, scrubbed personnel should remain close to thisarea without wandering around the room. This movement can result in contamination of thesterile field.2,4Scrubbed personnel should move only from sterile areas to sterile areas. Whenscrubbed personnel change positions, they should maintain a safe distance from each other and

always pass each other by turning back-to-back or face-to-face.2

This movement reduces therisk of contamination by ensuring the scrub persons are passing either nonsterile to nonsterileor sterile to sterile.

Scrubbed personnel should remain in the position in which they began the surgery. Forexample, if the surgery begins with the scrubbed person sitting and is completed with thescrubbed person standing, the portion of the gown that was considered sterile isuncertain.5 Scrubbed personnel should keep their arms and hands within the sterile field at alltimes to avoid any accidental contact with nonsterile items or areas. Scrubbed personnel mustmaintain a safe distance when approaching nonsterile objects and personnel. This safe distanceor "margin of safety" is important in identifying safe boundaries between sterile and nonsterileareas.

Nonsterile personnel should always remain in nonsterile areas and contact only nonsterile itemsto prevent contamination of the sterile field. It is important that the nonsterile personnel alwaysface the sterile field on approach and should never walk between two sterile fields. 2 Thisensures that the sterile area is always being observed and accidental contact is avoided. Justas the sterile scrubbed person must maintain a safe distance from nonsterile areas andpersons, nonsterile personnel must always be aware of and maintain a "margin of safety" whenapproaching sterile fields and scrubbed personnel. And finally, when delivering sterile suppliesto the sterile field, the nonsterile team member must always maintain a " margin of safety"between themselves and the sterile field, never contacting or reaching over any portion of thesterile area.5 This "margin of safety" is generally identified as a minimum of 12 inches (30 cm) ormore.

Principle #7

Policies and procedures for maintaining a sterile field should be written, reviewed annually, andreadily available within the practice setting.2

These recommended practices for aseptic technique should be used as guidelines fordeveloping policies and procedures within the practice setting.2 Introduction and review of



policies and procedures should be included in the orientation and ongoing education of allperioperative personnel.2

Training of aseptic technique and practices requires experienced and skilled surgical teammembers to demonstrate these skills to new and inexperienced personnel. New personnelshould be assigned an experienced mentor who will be a good role model and teacher providing

leadership and education in perioperative practice.

Summary

All surgical team members must practice these principles of aseptic technique to help preventthe transfer of microorganisms into the surgical wound during the perioperative period. It is theresponsibility of the surgical team members to develop a strong surgical conscience, adheringto the principles of asepsis and rectifying any improper technique witnessed in the operatingroom. In addition to the principles of asepsis, proper surgical attire plays an important role in thereduction of surgical site infections by reducing the amount of hair and skin contaminantsreaching the sterile field.

The goal of asepsis and aseptic technique is to prevent the transfer of microorganisms into thesurgical wound. Preventing surgical site contamination requires the efforts of all trained surgicalteam members to use their knowledge and experience in aseptic practices to provide theirpatients with optimal care resulting in positive surgical outcomes.

Definition of terms

Clean versus ster i le techniq ue. Various definitions and descriptions of dressingtechnique for wound care exist. Terms have been used interchangeably and all aresubject to individual interpretation. The following definitions provide a point of referencefor the terms used in this document.

Steri le techn ique. Sterile is generally defined as meaning free frommicroorganisms.3 Sterile technique involves strategies used in patient care to reduceexposure to microorganisms and maintain objects and areas as free frommicroorganisms as possible. Sterile technique involves meticulous hand washing, useof a sterile field, use of sterile gloves for application of a sterile dressing, and use ofsterile instruments. “Sterile to sterile” rules involve the use of only sterile instrumentsand materials in dressing change procedures; and avoiding contact between sterileinstruments or materials and any non-sterile surface or products. Sterile technique isconsidered most appropriate in acute care hospital settings, for patients at high risk forinfection, and for certain procedures such as sharp instrumental wound debridement.3 –5

Clean techn ique. Clean means free of dirt, marks, or stains.3

Clean technique involvesstrategies used in patient care to reduce the overall number of microorganisms or toprevent or reduce the risk of transmission of microorganisms from one person toanother or from one place to another. Clean technique involves meticuloushandwashing, maintaining a clean environment by preparing a clean field, using cleangloves and sterile instruments, and preventing direct contamination of materials andsupplies. No “sterile to sterile” rules apply. This technique may also be referred to asnon-sterile. Clean technique is considered most appropriate for long-term care, home

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care, and some clinic settings; for patients who are not at high risk for infection; and forpatients receiving routine dressings for chronic wounds such as venous ulcers, orwounds healing by secondary intention with granulation tissue.1 –7

Asept ic technique. Asepsis or aseptic means free from pathogenicmicroorganisms.3 Aseptic technique is the purposeful prevention of the transfer of

organisms from one person to another by keeping the microbe count to an irreducibleminimum. Some authors have made a distinction between surgical asepsis or “steriletechnique” used in surgery and medical asepsis or “clean technique” that involves

procedures to reduce the number and transmission of pathogens.4

No touch technique. No touch is a method of changing surface dressings withoutdirectly touching the wound or any surface that might come in contact with the wound.Clean gloves are used along with sterile solution/supplies/dressings that are maintainedas clean.8

Definition of infection. Infection has been defined as a continuum from contamination,colonization, critical colonization, biofilm, and infection.9

Contaminat ion. Contamination is the presence of non-replicating microorganisms onthe surface of the wound. All open wounds have some level of bacterial burden that isordinarily cleared by the host.9 –11

Colonizat ion. In colonization, microorganisms attach to the wound surface andreplicate but do not impair healing or cause signs and/or symptoms of infection. Thebacteria are not pathogenic and do not require treatment. All chronic wounds arecolonized to varying degrees.9

Cri t ical colon izat ion. With critical colonization, the organisms attach to the woundsurface, replicate and multiply to a level that affects skin cell proliferation and tissuerepair without provoking systemic signs of infection. There is no invasion of the healthytissue at this point.9

Biof i lm. Approximately 70% of chronic wounds have biofilm.9 When organisms adhereto the wound surface, they begin to develop biofilm, which is a complex system ofmicroorganisms embedded in an extracellular, polysaccharide matrix that protects fromthe invasion of other organisms, phagocytosis, and many commonly used antibioticsand antiseptics. Biofilms are difficult to treat and eradicate.9 Recently it has beenproposed that biofilm might be present in all chronic wounds.12,13

Infect ion. Infection occurs when organisms on the wound surface invade the healthytissue, reproduce, overwhelm the host resistance, and create cellular injury leading tolocal or systemic symptoms.9,14Infection is often described quantitatively as a bacterialcount of greater than 105 colony-forming units (CFU) per gram of tissue.9However,

some organisms such as beta-hemolytic streptococci impair wound healing at less than105 CFU per gram of tissue.15 According to Kravitz,16 infection should be defined as thepresence of bacteria in any quantity that impairs wound healing.

Clinical signs of infection include lack of healing after 2 weeks of proper topical therapy,erythema, increase in amount or change in character of exudate, odor, increased localwarmth, friable granulation tissue, edema or induration, pain or tenderness, fever, chills,elevated white blood cell count, and elevated glucose in patients with diabetes.9Inpatients who are immunosuppressed or have ischemic wounds, signs of infection can



















































































be subtle. Signs of inflammation such as a faint halo of erythema and moderateamounts of drainage might be the only signs of an infected arterial wound.17 Studieshave shown that in chronic wounds, increasing pain, friable granulation tissue, woundbreakdown, and foul odor have high validity for infection.17,18

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Definition of Wounds

Wound. A wound is any break in the skin that can vary from a superficial to a fullthickness wound. A partial thickness wound is confined to loss of the epidermis andpartial loss of the dermis; whereas a full thickness wound has a total loss of theepidermis and dermis and can involve the deeper subcutaneous and muscle tissuesand/or bone.19,20

Acute wound . Acute wounds occur suddenly and are commonly due to trauma orsurgery, which triggers blood clotting and a wound repair process that leads to woundclosure within 2-4 weeks.14,19

Chronic wound . A chronic wound is a one that does not does not proceed through anorderly and timely repair process requiring more than 4 weeks to heal such as vascularwounds and pressure wounds.14,19

Surgical wou nd. A surgical wound that heals in an orderly and expected fashion maybe considered an acute wound. Surgical wounds heal by primary closure or are leftopen for delayed primary closure or healing by secondary closure. Primary closurefacilitates

he anti-serum works to provide immediate passive immunity while the

toxoid nudges the body's immune system to produce its own antibodies and

provides active immunity. So, while the anti-serum provides immediate

antibodies that start to neutralize the tetanus toxin, the toxiod stimulatesthe body to produce its own immunity.

The immunity from the anti-serum peaks in about 2 days, so it very quickly

fights the tetanus, and it lasts for 25 days or so. During this time, if the

patient was given the toxiod, their own immune system has kicked in and

created antibodies that continue to fight the tetanus if needed.

There is no reason that I know of why one has to be given immediately

before the other. The anti-serum is only given if there is active tetanusinfection or there is significant risk for tetanus AND the patient has received

fewer than 3 toxiod boosters.









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You give the antitetanus serum because it contains passive antibodies that can

immediately start attacking any antigens if present. While that is going on, the body

reacts to the toxoids injected into it by producing its own antibodies, this process is

slow thus we need the antitetanus serum for immediate protection

The primary difference between tetanus toxoid and anti-tetanus serum is the

application. Both substances are designed to combat tetanus. The tetanus toxoid is

given to prevent infection while the anti-tetanus serum is prescribed to combat an active

tetanus infection. The latter is a substance that is resorted to when infection has already

occurred and prospects for recovery are already grim. Patients who have dirty wounds

may be given both substances to avoid infection or to combat infection as an added

precaution.

Tetanus toxoid is what a tetanus vaccine contains. You're body will make anti-bodies

to tetanus once given the tetanus vaccine, offering you protection for "up to" 10

years from the bacterial disease in case you cut or burn yourself. But if you didn't

complete the series of 3 shots yet, see next paragraph. At 9-10 years from last shot,

get a booster shot. Called Td/dT if you're an adult, or instead get Tdap/dTap if you're

an adult and haven't had the Tdap/dTap yet. DTaP and DT are for children under 7.

Tdap/dTap came out around 2005. It's adds a booster dose of acellular pertussis for

adults, so you'll be protected from the nasty pertussis cough for "up to" 10 years. It

boosts the DTaP series you might have had a child.3000-5000 units of anti-tetanus serum is injected into and around the site of a

wound for people that haven't completed a series of 3 tetanus vaccine shots, or,

even if so, it's been more than 5 years since the last tetanus vaccine shot.

Sometimes if anti-tetanus serum is not available, intravenous immune globulin will

be given. The serum provides people who don't have enough anti-bodies to tetanus

yet for the reasons listed above in this paragraph. The serum is made from what

they collect out of human volunteers who have extra immunity to tetanus.

If the risk of contracting tetanus is high, after an injury spoiled with infected matter, it is

common to inject antitetanus serum containing gammaglobulins. The advantage is that

immediate immunity against the toxin is offered.

TT given for people with bad immunization (and booster) history -- Antibody levels do

not rise until 4 days after vaccination, so vaccination at the time of injury is of no use.

Sterile Tech and Ats Tt

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