ASEPTICS

Aseptics is the system of

measures, which prevents the
operative wounds from the bacterial
contamination. It includes
organization measures, essentially
physical and partially chemical
methods.
 ASEPTICS
The method of aseptics was worked
out and introduced in surgical practice in
1890, by German surgeon Ernst
Bergmann (1836 -1907) and his disciple
[Link].
The main rule of aseptics is:
everything that comes into contact with
the operative wound, must be free from
bacterias (sterile).
 Sources of Infection

All sources of infection are divided on 2

types:
1. Exogenic infection:
–  From the air (less common route – 10%) -
airborne (dustborne) infection;
–  From the drops (droplet);
–  Contactive (most common route- 90%);
–  Implantative (from stitches, drain tubes).
 Sources of Infection
2. Endogenic infection from the:
–  skin;
–  respiratory tract;
–  gastrointestinal tract;
–  urinary tract.
–  During the surgical operation, lasting 1-1,5 hours, the
bacterial contamination of the air of operative room
rises on 100%. Normal amount of bacterial bodies
(corpuscles) in the operative room is 500/m3 before the
beginning of the operation and 1000/m3 during the
operation.

Operation block must be separated from the

other departments of the hospital.
 Prophylaxis of airborne
(droplet) infection
In the operative room it is prohibited to
speak, cough and sneeze. Medical personal
have to cover nostrils and mouth with special
masks or 4 or more layers of gauze, head
must be covered with special caps, feet- by
special slip-covers (top boots, boot covers).

Operative rooms for “clean” operations,

are separated from operative rooms for
purulent operation.
 PROPHYLAXIS OF AIRBORNE
(DROPLET) INFECTION
The following functional zones must be in the operative block:
1. Zone of sterile regime: operative room, preparation room and
sterilization room;
2. Zone of strict regime: sanitary room (clock-room, shower room, and
cabins for dressing of sterile surgical coats). This zone must be for keeping
of the surgical instruments and apparatus, anesthesiologic and blood
transfusion facilities and for chief nurse of operative suite;
3. Zone of limited regime (technical zone): rooms for air conditioners,
vacuum-mount, oxygen and narcotic air supply equipments, emergency
light supply apparatus, laboratory for developing of X-ray films;
4. Zone of general regime: offices for the head of the surgical block, chief
nurse and other surgical staff and room for separation of dirty linen.
 Types of surgical suit
1. Preliminary - before surgical operation;
2. Current - during the surgical operation;
3. Postoperative - after the surgical operation;
4. Final - after the finishing of working hours. It
includes the moist (humid) doing of the room
with antiseptic solutions, 1-3% sol. of
hydrogen peroxide and synthetic washing
solutions, rokkal with subsequent switching on
of bactericidal lamps (with ultraviolet
irradiation/fig. 25/), which reduces bacterial
contamination on 75-90% during 1h;
 Fig 25. Lamps for
ultraviolet irradiation
 Types of surgical suit
General (basic) doing the of room - after the working
week includes cleansing and desinfection of ceiling,
floor by the help of pulverization of antiseptic solutions
(Desinfal- contains 3% sol. of hydrogen peroxide and
0.5% sol. of lactic acid).
Prophylaxis of airborne infection includes also air filtrat
ion with air cleansing pumps (it reduces bacterial
contamination in the operative room 7-10 times during
15 minutes) and introduction in the surgical practice
the special surgery rooms with vertical (from the
ceiling to the floor) laminar stream of sterile
conditioned air which provides exchange of the air 500
times per hour.
 Prophylaxis of contactive infection
n  Instruments sterilization:

n  Step 1. Presterilizative preparation means the mechanical and

chemical treatment (cleaning) of needles, syringes, surgical
instruments, and transfusion sets in aim to remove pyrogenic
agents and virus of the hepatitis and AIDS. Instruments and
syringes without bacterial contamination (non infected) are
washed with water and scrubs and special solutions “A” and
“B” during 15-20 min on 50 C°.
n  Solution “A”: Perhydrol (Hydrogen peroxide) 20g,
washing (detergent) powder 5g, water 975 ml.
n  Solution “B”: 2,5% sol. of Hydrogen peroxide - 200 ml,
washing powder - 5g, water - 795 ml.
Instruments and syringes, contaminated with pus must be
washed with 0.1% sol. of diocide or 5% sol. of lisole solution
for about 30 min before their washing with solution “A” or
“B”.
 Prophylaxis of contactive
infection
Instruments and syringes after the operations for
the anaerobic infections must be preliminary stayed in
the 6% sol. Hydrogen peroxide and 0.5% washing
powder solution, boiled in the same liquid for 90
minutes and afterwards be treated as in other cases.
Needles for syringes must be washed with warm
water, then 1% sol. of sodium bicarbonate, lumen of
needle must be cleaned by stylet and 1% sol. of
ammonium hydroxide (liquor ammonii caustici), boiled
for about 30 minutes in the 2% sol. of the sodium
hydrocarbonate and repeatedly in the distilled water
after 12 h, during 40 min. Needles, contaminated with
pus, preliminary must be treated with 5% sol. of
Lysol, during 1 hour.
 Prophylaxis of contactive infection

Now single-use syringes, needles, surgical gloves and

transfusion sets are widely introduced in the medical
practice, but methods of their sterilization must not be
forgotten.
n  Rubber gloves - without undressing are washed under
the running water to remove the blood, afterwards they are
to be put into the 0.5% sol. of ammonium hydroxide (or
solution “A” or “B”) for about 30 minutes, dryed and packed
for the sterilization.
n  Test for finding the traces of blood (Benzidin test) - the
surface of the object must be covered with 3 drops of 1%
sol. of benzydine and hydrogen peroxide. Appearance of
blue-green color indicates on presence of blood and
instruments must be washed repeatedly.
 Prophylaxis of contactive
infection
Step 2. Packing and preparation for the sterilization:
n  For the dry hot sterilization instruments are
dislocated in the metallic boxes, syringes must be
taken apart and wrapped up in the dense paper.
n  For sterilization by vapor and pressure (in the
autoclave /fig. 26/) the instruments are wrapped in
the towel or sheet. Corpus and plunger of the
syringe must be separately wrapped up in the
gauze, cotton napkin and placed into the metallic
sterilization boxes (drum, bix). Surgical gloves are
wrapped up in to the gauze and placed into the
drums.
Fig 26. Autoclave
 Prophylaxis of contactive
infection

n  Step 3. Sterilization: The sterilization of

instruments, syringes (with mark-200 C°),
needles, glasses are placed in the special
cupboards for dry hot sterilization (180 C°
during 60 minutes).
n  Sterilization with vapor and pressure (in the
autoclave): surgical instruments and syringes
have to be sterilized on 132.9C° and 2 atm.
pressure during 20 minutes; rubber gloves,
drain tubes and transfusion sets must be
sterilized on 120C° and 1.1 atm. pressure
during 45 minutes.
 Prophylaxis of contactive
infection
Sterilization with boiling: it is necessary to add 2
g of sodium bicarbonate (NaHCO3) to each 1L water
(2% solution) and fill the boiler with this solution. It
increases the temperature of boiling up to 104C°,
destroys the membrane of bacteria and removes the
fat. Time of boiling for instruments - 40 min, for
syringes and needles - 45 min; for the instruments,
syringes and needles with purulent and fecal
contamination - 90 min in separated boiler, for the
equipment with anaerobic bacterial contamination -
1 h, and after 12-14 h of the storage on the room
temperature, repeatedly boiling during 1 hour.
Rubber drain tubes, catheters, gloves could be
boiled during 15 min.
 Prophylaxis of contactive
infection

Cold sterilization: for the optical instruments

(endoscopes, thoraco-laparoscopes) is used gas
sterilization with ethylen-oxyde during 16 h on 18
C° (or ethylene together with methylen bromide on
55 C° during 6 h). Endoscopes could be sterilized
with “Helipur” (Brown), or alcoholic solution of
Chlorhexidine (Hybitane) or with “Pervomur”
solution (“C-4”). Triple solution contains formalin
- 20 g, carbolic acid - 10 g, sodium bicarbonate -
30g, distilled water- 1000 ml. It has very strong
desinfective action and is useful for desinfection of
gloves, drain tubes instruments.
 Prophylaxis of contactive
infection

Sterilization of instruments “On fire”: Metallic

instruments must be placed in the metallic basin with
15-20 ml alcohol and set on fire. This method is not
reliable, dangerous and is useful rarely in emergency
cases. After sterilization with high temperature the
cutting instruments (scalpels, scissors) become
blunt. That’s why it is preferable to use “cold”
sterilization (96° ethylic alcohol - during 30 min, or
“triple solution” - during 3 h). It is admitted to boil
the cutting instruments during 10 minin the distilled
water (without adding of sodium bicarbonate) in
gauze, turned around blades, with subsequent
placement in 96° alcohol - on 30 min.
 Prophylaxis of contactive infection
Step 4. (Keeping of the sterile materials).
It is possible to keep sterile material
in drums (boxes of Schimmelbusch /fig.
27/) for 48 h without its opening, and
for 3 days if they preliminary were
turned round in cotton, before packing
into the drums. Sterile syringes could be
kept for 25 days.
Fig 27. Drum of
Schimmelbusch
 Sterilization of the banding
materials and operative linen

Step 1. Preparation of the materials before

sterilization. Banding materials include gauzeballs,
napkins, gauze drains /tampons/ gauze straps, roller
and bandage. They are done from gauze, cotton,
viscose or lignin and must have the following
characteristics:
n  1. Biologically inert.;
n  2. High hygroscopity;
n  3. Don’t desorganizate (spill) easily;
n  4. Soft and elastic;
n  5. Easy for sterilization and tolerate high
temperature;
n  6. To be not expensive.
 Sterilization of the banding
materials and operative linen
–  Usually, expenditure of the gauze is 200m and
rollers - 225m ex per one surgical bed per year,
e.g., appendectomy needs 7m of gauze. All
dressing materials, which were in contact with
blood must be burned after the operation. The
operative linen includes: surgical coats, sheets,
towels, masks, caps, top-boots from cotton.

Step 2. Packing of the dressing materials before

sterilization. Material must be packed into the
metallic drums or into the linen sack.
 Types of the packing of the
drums
n  Universal Type: packed drum is designed for
one typical “small” operation (appendectomy,
herniotomy, phelebectomy);
n  Determined Type (purposeful): packed drum
is designed for one concrete operation
(pneumonectomy, gastric resection);
n  Special Type: The packed drum contains one
definite type of dressing materials (drum with
surgical coats, gauze napkins, gauze balls).
 Sterilization of the banding
materials and operative linen

Step 3. Sterilization: for the work with

autoclave is admitted special staff, after the
training courses. They must follow rules:
n  Autoclave must be grounded;

n  Autoclave must be in good repair;

n  Autoclave must be under the supervision

during the sterilization;
n  It is prohibited to add the water during the
sterilization;
 Sterilization of the banding
materials and operative linen
It is necessary to switch of the boiler after the
finishing the sterilization and close the valve
through which the vapor comes from the
vaporizator into the sterilization camera;
It is correct to open the door of sterilization
camera only after the reduction of the pressure
down to 0 atm.;
Time counting must be started only after the
reaching the necessary pressure. Dressing material
and operative linen could be sterilized on 2 atm.
pressure and 132.9 C° during 20 min.
Sterilization of the banding
materials and operative linen.

Step 4. Keeping of the sterile materials

After sterilization the gratings of the
drums must be closed. Drums are locked in
the special cupboards. Expire time of
keeping of the dressing material and linen
in the drums is 48 h (without opening) and
24 h in the cotton sacks.
 Methods of checking of
the quality of sterilization
Direct method: Includes making the
bacteriological cultures from the dressing
material and placement of the glasses with
non pathogenic sporogenic culture of
microbes into the drums before
sterilization, which die, if the sterilization
was performed correctly;
 Methods of checking of
the quality of sterilization
Indirect method: It means the placement of glasses with
the crystallic substances (0.5 g) with preliminary known
temperature of melting (thawing) into the drums before
sterilization.
The following substances are in use in the autoclaves:
benzoic acid (120 C°), resorcin (119 C°), antipirin (110 C°),
sulphur (120C°).
The following substances are in use for dry hot
sterilization in the cupboards: ascorbinic acid (187- 192 C°),
hydrochloride of pylocarpine (200 C°), amber acid (180-184
C°), thyourea (180°).
Most objective indirect method of checking of the
quality of sterilization is placement of maximal
thermometers into the drum.
 Methods of checking of
the quality of sterilization
Mickulicz’s method: the paper with the
inscription “sterile” on it must be covered with
starch and Lugol’s solution. It takes blue color and
inscription disappears. Afterwards the paper must
be placed into the drum and stay there during the
sterilization. Because of action of high
temperature starch will be splited and
transformed into dextrans, blue color disappears
and inscription “sterile” again becomes visible.
 Hand washing (scrubbing)
methods:

treatment (preparation) of surgeon’s

hands before surgery.
It is the most important ring for the
prophylaxis of contactive infection. All
methods include as a starting step
scrubbing of the hands and distal 2/3 of
forearm with sterile brush, soap and worm
water. Other steps are different.
 Hand washing (scrubbing) methods

Method of Alfeld: cleansering of the hands with

96° alcohol for 5 min;
Furbringer’s method: (a) cleansering of the hands
with 1:1000 sol. of mercurium dichloride for 1
minutes; (b) with 96° alcohol for 3 min. (c)
covering of the nails with 5% iodine tincture;
Method of Spasokukotsky-Kochergin: a) washing
of the hands in 2 basins for 3 min in each one,
filled with 0.5% sol. of ammonium hydroxide; b)
cleansing of the skin with 96O alcohol for 2.5 min;
c) covering the nails with 5% alcoholic sol. of
iodine;
 Hand washing (scrubbing)
methods
Method of Brun: a) cleansing of skin with 96O
alcohol for 10 min., or with 2% alcoholic sol. of
iodine for 3 min;
Washing with “Pervomur” (solution C-4) which
contains Hydrogen peroxide (33% - 171ml) and
formic acid (85% - 81ml) and 9.8l water. Duration
of scrubbing - 1 min;
Washing with 0.5% alcohol solution of
“Hibitan” (bigluconate of chlorhexidine) for 2-3
min;
Cleansing of the hands with synthetic anion-and
cathiogenic drugs (Sterilium, Dezogen);
Hand washing (scrubbing)
methods:
“Degmin” and “Degmicide”: 1% sol. for 2-3
min;
The “quick” method of hands preparation
with bactericide filmmaker drug ”Tserigel”:
3-4 ml of this drug is able to cover with film
both of hands for 2-3 min. It is necessary to
remove this film with alcohol, after the
finishing of operation;
Washing of the hands with 3% water
solution of “Novosept”, for 2-3 min.
 Preparation of the operative field (area)
for surgery (preoperative skin
treatment) includes
general hygienic bath (shower) at the day before surgery,
dry shaving of the operative field and subsequent
cleansering with alcohol at the day of surgery. Skin must be
widely treated with 5% alcohol sol. of iodine, operative field
must be bordered with sterile linen and skin must be
covered with 5% iodine sol. before incision, before stitching
and after the stitching, before applying the sterile bandage.
This method is known as Grossich’s and Filonchikov’s
method. Method of Bakkal means the skin cleansering with
1% sol. of Brilliantgrüne (Viride nitens);
For the skin preparation are also in use “Sterilium,
Braunol, Iodonat, β-Isodona, Rokkal and Cutasept.
 Prophylaxis of implantative
infection
(means sterilization of threads drain tubes, prosthetic
materials)

Classification of stitching materials:

diameter of thread is ranging (following to
USP) from 11/0 to 0. for eg., N3/0 thread
has size 0.20-0.29 (2mm), N8/0 - 0.04-0.049
(0.4mm). The stitching materials must have
following characteristics: biologically inert
(not allergenic), smooth surface, good
manipulative property (resistance in knot),
non-hygroscopic, elastic, don’t undergo the
biodegradation before the scar formation,
atraumatically connected with the needle.
 Prophylaxis of implantative
infection
(means sterilization of threads drain tubes, prosthetic materials)

n  Resorbable stitching materials:

n  Catgut is done from the muscular layer of the
bowels of sheeps and calf's. Time of
resorbtion is ranging between 2 weeks and 6
months. It loses 50% of its mechanical
resistance for 2-10 days. It is also very
reactogenic material. Time of resorbtion may
be increased with impregnation with the salts
of chrome;
n  Collagen and tendineous threads are not in
use because of their expensivity;
 Prophylaxis of implantative
infection

n  Polyglilcolides: Vicril (Ethicon), Dekson (Davis&Geck), Dar-

Vin (Ergon suturamed), Polisorb (USSC) are stronger, then
catgut and their resorbtion time is between 2 weeks-2
month;
n  Polydioxanon: PDS, PDS2 (Ethicon), Makson (Davis&Geck)
are monofilament threads with resorbtion time - 6 months;
n  Materials from cellulose: Okcelon and Kacelon. Resorbtion
time is ranging between few days up to few months.
n  Polyuretane is biologically inert and its resorbtion time is 1
year. All resorbable materials mustn’t be used for the vessel
grafting and heart valve prosthetics implantation.
 Prophylaxis of implantative
infection
(means sterilization of threads drain tubes, prosthetic materials)

n  Non-resobable stitching materials:

n  With organic origin: Silk - is very

reactogenic and can fix the microbes on
it’s surface, but has very good
manipulative characteristics (golden
standard), Cotton;
 Prophylaxis of implantative
infection
With synthetic origin:
n  a) Polyamides (capron, neilon, dacron): reactogenic and
may be destroyed between 3 months and 2 year.
n   b) Polyethers (lavsan, ethibond, mersilen, M-dec) are
more inert than silk and polyamides but not so strong in the
knot.
n  c) Polyolefins: Prolene (Ethicon), Polypropylene
(Sharpoint), Surgipro (USSC), Surgilen (Devis&Geck) are
monofilament threads, most inert and more stronger in knot
and could be used also in the infected tissues.
n  d) Fluorpolymers (Gore-Tex) is more inert and
thromboresistant than polyolefin's and that’s why they are
very useful in the cardiovascular surgery.
n  e) The stainless steel wire is in use for stitching the
sternum, hernioplastics, in gastrointestinal tract surgery.
Metallic clips stitches (Michel’s clips and Stapler apparatus of
Ethicon) from tantalum and titanium (more stronger) are
most inert between non-absorbable materials.
 Types of Needles

usual surgeon’s (suture) needle (with

needle’s eye), atraumatic swagged
(without needle’s eye), pricking, round
pricking, straight pricking, curved
cutting (surgeon’s circle needle), fine
(narrow), Dechamp’s (ligature needle),
large, intestinal suture, skin suture.
 Types of Needles
Types of Needle-Holders:
n  gynecological (Hegar’s),
n  ophthalmic,
n  deep-cavity,
n  Mathie’s and Troyanov’s.
Sterilization of the stitching material:
Stitching material may be sterilized at the factory in
packed condition by the help of γ-irradiation from the
radionuclids-isotopes 60CO and 137Cs. This type of
sterilization doesn’t reduce the mechanical strength of the
thread. Metallic stitching material (wire, clips) could be
sterilized by autoclaving or boiling, cotton, flax, capron,
lavsan - by autoclaving.
 Types of Needles
n  Kocher’s method of sterilization (for silk, capron,
lavsan, flax, cotton):
1. Washing of the stitching material with hot water
and soap for 10 min;
2. Placement in the hermetic glasses with ether (for
removal of fat) during 24h;
3. Placement in the 70˚ alcohol during 24h;
4. Boiling in 1:1000 sol. of mercurium dichloride
during 10-20 min;
5. Keeping in the 96˚ alcohol;
6. Making the bacteriological examination after 2
days;
7. Synthetic threads may be sterilized by their boiling
for 30 min.
 Types of Needles
Sterilization of the Catgut: at the factory
the catgut is sterilized by γ-irradiation.
Method of Klaudius-Kuhn: removal of fat
with placement into the ether during 24h.
Placement into the Lugol’s sol. during 10
days.
Placement in to the “new” Lugol’s solution
for 10 days.
 Types of Needles:

Storage (Keeping) in the 96˚alcohol;

bacteriological examination after 4-6 days.
Gubarev’s method of sterilization of
catgut means it’s placement into the
Lugol’s alcoholic solution during 10 days
and 10 days additionally in the “new”
solution.
 Sitkovsky’s method of catgut sterilization:
a) standard removing of the fat.
b) Cleaning of the rolls of the thread with 1:1000
solution of mercurium dichloride.
c) Putting into the 2% sol. of potassium iodide on
following time: for N0 threads - on 30 sec, N1 - 1
min, N2 - 2 min., N3 - 3 min.
d) Hanging the threads in the hermetic glasses
with the crystallic iodine (in the glass with 3L - 40g
of iodine on the bottom) on following time: NN0-1
- 3 days, NN2, 3- 4 days, NN5,6 - 5 days. After the
bacteriological checking the threads are ready for
use.
n  Fig 25. Lamps for ultraviolet irradiation
n  Fig 26. Autoclave

n  Fig 27. Drum of Schimmelbusch