2010 Annual ASR Meeting

1. 2010 Annual ASR Meeting Round Table Presentation – Asepsis & Instruments

2. 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

3. 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

4. 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

5. 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

6. 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

7. Surgeon Prep - Scrubbing • After donning scrubs, mask & cap • Wash hands for 30-60sec • 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Sterilization types/methods • Autoclave • Moist heat • Effectiveness dependent upon temperature, pressure, and time (normal is 121◦C / 15psi / 15min) • 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

14. 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

15. Sterilization types/methods • Flashing and Bead sterilizers • “flashing” in the autoclave = normal is 131◦C / 30psi / 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

16. InstrumentsHandling /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

17. 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

18. 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

19. 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

20. 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

21. Instrument Selection • Why different tips? • Smooth, Teeth or grooves? • Tissue retention holes, catheter holding grooves, vessel dilation?

22. Instrument Selection

23. Instrument Selection • Straight vs. curved vs. angled?

24. 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

25. Types / categories / uses: • Forceps / Clamps / Hemostats • Needle Holders (Drivers) • Retractors • Scissors / Scalpels • Electrocautery • “Other”

26. Forceps • Adson tissue forceps • Adson- Brown tissue forceps • Rat toothed forceps • Dressing forceps • Dumonts

27. Needle Drivers • Olsen-Hegar • Mayo-Hegar Castroviejo

28. Clamps • Satinsky clamp • DeBakey clamp • Cooley clamp • Bulldog clamps

29. Bone • Rongeurs • Osteotome • Bone curette • Trochar • Periosteal Elevator

30. Allis tissue forceps • Duval forceps • Vulsellum forceps • Alligator forceps • Babcock forceps

31. Retractors • Army-Navy retractor • Gelpi retractor • Wilson rib spreader • Weitlaner

32. Retractors • Finochietto retractor • Balfour retractor • Senn retractor

33. Scissors • Lister bandage scissor • Metzenbaum scissors • Iris scissors • Mayo scissors

34. Scissors • Strabismus • Micro-Vannas • Ragnell • Doyen

35. Scalpels & Blades • Handles come in #3 or #4 sizes • Blades 11,12, 15 & 10 fit #3 handle • Blades 22 and 23 fit #4 handle

36. Forceps Kelly forceps Mosquito hemostats Crile forceps

37. Hemostats • Rochester-Carmalt hemostat • Rochester- Peans hemostat

38. “Other” • Stereotaxic gear • Bovie • Human hands!

39. “Batch” Rodent Surgery / ‘tricks’ • Start with a sterile pack • Sterilize between uses = “resetting the stage”