Sterilization

 It is the process that destroys all microorganisms

(including bacterial microspores).
 The skin could never be sterilized without its own
destruction.
Disinfection

 A process which destroys only the vegetative

forms of organisms =basically clean.
 A disinfectant (germicide, antiseptic): any
chemical substance with either a bactericidal or
a bacteriostatic action.
 Antiseptic -- Agent applied to living tissue
 Disinfectant -- Agent applied to inanimate
surface
Surgical Disinfection

 This is an essential part of a programme for

the control of infection.
 High Risk Items: as they come in close
contact with broken skin or those that breach
mucous membranes or are introduced into a
sterile cavity.
Requirements for decontamination
practice

The basic requirements for good decontamination

practice are:
 A Management control system;
 Appropriate facilities;
 Appropriate equipment;
 Properly trained and supervised staff;
 Ensuring that single use medical devices are not
reused;
 Records of decontamination are kept.
Methods of Disinfection

 Physical: The most important as they can be relied on to

ensure the sterilization of articles used in the treatment
of patients:
– Thermal: Heat or Steam
– Radiation: infra-red radiation, - rays,  particles
– Filtration:utilizing filters capable of screening out microorganisms
 Chemical: Less effective, used for personnel
– Organic
– Inorganic
 Gaseous disinfectants: very efficient, not routine
– Formaldehyde gas
– Ethylene oxide
MANUAL CLEANING

 Cleaning is vital prior to any decontamination

procedure.
 ‘Detergent’ removes the nutritive material on
which bacterial survival and multiplication
may take place.
 This reduces the number to a level which is
not harmful for health.
MANUAL CLEANING

 Effective cleaning to remove protein from

medical devices is paramount (agents such as
CJD are not inactivated by heat).
 Dismantle or Open the instrument to be cleaned
 Friction for 2-3 minutes
 Brush, Wipe, Agitate, Irrigate, jet wash or
hand spray the item to dislodge and remove all
visible soil
 Rinse the item thoroughly with clean water
 Drying
 Physical Methods of Disinfection
HEAT

DRY HEAT
 Kills by Destructive oxidation of cell constituents
 Surest incineration
 Hot-air oven:
– inefficient, poor conductor of heat, penetrates feebly.
– 160°C for 1 hour: damages fabrics, melts rubber
– Used for: Glassware, oily fluids, powders
 Physical Methods of Disinfection
HEAT

MOIST HEAT
Effective at low temperature, in a shorter period
of time
 Boiling: 100°C for 30 minutes
 Pasteurisation: 63°C for 30 minutes
 Tyndallisation: steaming for 20 minutes for 3
successive days
 Steaming under pressure= Autoclaving
Advantages of steam

 Kills by denaturing & coagulating enzymes &

proteins
 More rapid (maximum needed time 45mn) & at
lower temperature
 Condensation of steam leads to liberation of
latent heat which raises the temperature, and
gives more penetration
 Half dense as air, so has better penetration
Steam Sterilization: Autoclave

 Principle: An autoclave is a self locking

machine that sterilizes with the high
temperature that steam under pressure
can reach.
 High-vacuum pumps remove as much as
possible air before the steam is admitted,
so the required temperature is reached
very rapidly.
Steam criteria

 Dry: no suspended droplets of water

 Close to its point of condensation: not
superheated
 Free from air: as it decreases the temperature
and the penetration
 Temperature
– 121°C: 15mn-30mn
– 134°C: 4-7mn Flashing
Steps of autoclaving

 Water in the surrounding container full and heated

 Articles in cabinet, doors bolted
 Vacuum to evacuate as much air as possible
 Steam is admitted at a high pressure of and when the
thermometre reaches the required temperature,
sterilisation begins
 Sterilisation is continued for the required time and then
the steam is turned off.
 Drying is carried-out by reapplying a vacuum to evacuate
the steam, introducing dry filtered air into the cabinet (for
15 minutes).
Efficient Autoclaving
 All instruments must be double
wrapped in linen or special paper or
placed in a special metal box
equipped with a filter before
sterilization.
 The white stripes on the tape change
to black when the appropriate
conditions (temperature) have been
met.
 Expiration dates should be printed on
all equipment packs.
 There should be a uniform
development of bars throughout the
length of the strips.
 Ready made plastic bags with strips
printed with a sensitive ink.
Control of autoclave efficiency

 Bowie-Dick test: Used for high-vacuum autoclaves, Done

every day:
– In the middle of a test pack of towel, a paper on to which a strip of
a specific tape is put, for testing.
– Uniform development of dark color indicates that the steam has
passed freely and rapidly to the center of the load.
 Biological sterilization indicators: Spores of a non-
pathogenic organism: Done weekly
– They are killed at 121°C after 15 minutes.
– Attempts to culture them is subsequently made
 RADIATION DISINFECTION

 High energy ionizing radiation destroys

microorganisms and is used to sterilize
prepacked, Single-use, surgical equipment
by manufacturers
 Common sources of radiation include
electron beam and Cobalt-60
CHEMICAL DISINFECTION

A SATISFACTORY AGENT SHOULD:

 Be active against a wide range of organisms and
spores. Only few are truly sterilizer
 Have a rapid action
 Should not be toxic or irritant to the skin
 Should be Persistent

There is no one disinfectant which can be

used to kill all micro-organisms in all
situations.
Types of Chemical disinfectants

 Inorganic:
– Iodine
– Chlorine
 Organic:
– Alcohols
– Aldehydes
– Phenols
– Cationic surface-active agents
Inorganic disinfectants

The halogens: Chlorine and Iodine

 Have a rapid action against vegetative
organisms and spores= true sterilizers
 Their action is annulled by foreign organic
material
Iodine disinfectants

The broadest spectrum of all topical anti-infectives, with action

against bacteria, fungi, viruses, spores, protozoa, and yeasts.
 Tincture iodine:
– 2.5% iodine & 2.5% potassium iodide in 90% ethanol.
– Best skin disinfectant
– Irritating to raw surfaces: due to its alcoholic component
– Allergic dermatitis
 Iodophors: Solutions of iodine in non-ionic detergents= Povidone
iodine= Betadine
– Less irritating and less staining
– Less disinfectant than tincture
Chlorine disinfectants

 Powerful, Disinfect water

 Particularly active against viruses
 Concentrated solutions too corrosive
 Usually diluted with a compatible detergent
Organic Disinfectants

 Alcohols: bactericidal: 50-70% ethanol

 Aldehydes:
– Formalin: irritant, powerful=sterilizer
– Glutaraldehyde: less irritant, not volatile, more rapid action.
 Phenols: continued activity in organic matter as human
excreta.
– Phenol: Toxic, expensive
– Cresols: Lysol
– Chloroxylenol: Dettol
– Chlorhexidine: Hibitane- Alkanol
– Hexachlorophane
 Cationic surface-active agents:
– Cetrimide: Cetavlon
Alcohol

 Isopropyl Alcohol 70% (or Ethyl Alcohol 90%)

ADVANTAGES:
 Causes protein denaturation, cell lysis, and metabolic
interruption.
 Degreases the skin.
DISADVANTAGES:
 Ineffective against bacterial spores and poorly effective
against viruses and fungi.
Glutaraldehyde (Cidex)

Cold Sterilization:
 Instruments must be dry before immersion.
 Glutaraldehyde is bactericidal, fungicidal,
viricidal, and sporicidal
 Sterilization: a 10 hour immersion. This
prolonged chemical action can be more
detrimental to surgical instruments.
 3 hours exposure time is needed to destroy
spores.
 If the instruments need to be "disinfected"
only, cold sterilization is okay as
disinfection will take place in only 10
minutes.
Lysoformin

 Formaldehyde & glutaral

 Lysoformin: liquid concentrate with which any dilution
required can be made by simply adding water (20ml + 4-
8L)
 The timing depends on the concentration used:
– flexible endoscopes 1.5 % - 30 min
– deactivation of HBV & HIV 2.0 % - 15 min
 Used for heat labile instruments and cleaning
 Does not harm metal instruments
 Chlorhexidine Gluconate
Hibitane vs Alkanol

Broadest spectrum
Better residual activity than iodophors
Occasional skin sensitivity
ADVANTAGES:
Rapid action
Residual activity is enhanced by repeated use
Less susceptible to organic inactivation than povidone iodine
DISADVANTAGES:
Occasional skin sensitivity.
Inactive against bacterial spores
Activity against viruses and fungi is variable and inconsistent
May harm metal instruments
Gaseous Disinfection
Ethylene Oxide Sterilization: EO Gas

 Colorless gas, available as cartridges

 Toxic and flammable, Odor similar to
ether
 Has an extremely well penetration, even
through plastics
 Microorganism destruction is caused by a
chemical reaction
 Effective sterilization is dependent on
concentration of gas, exposure time,
temperature, and relative humidity
 Powerful sterilizer: Kills all known
viruses, bacteria (including spores), and
fungi
EO Gas Sterilizer

 Is used in large hospitals, as it is expensive,

dangerous, needs more expertise.
 Used for heat sensitive instruments: fabrics,
plastics, suture material, lenses, endoscopes,
electrical equipment and finely sharpened
instruments.
 At 20°C-25°C: sterilization takes 18hours
 At 50°C-60°C: sterilization takes 4 hours
 In Demerdash: The average of the cycle is 8-14
hours
Sterility Check List

Before assuming a pack is sterile, always

evaluate the following before opening the
pack:
 Expiration date
 Indicator color change
 General condition of wrapper and how it
had been stored
 Always check for holes or moisture damage
 Standards for
Surgical Scrubbing, Gowning and
Gloving

 The pre-surgical practice of scrubbing,

gowning and gloving is integral to the
minimization of risk of infection from micro-
organisms present in the wound at the time
of surgery.
Accessing to the operating theatre

 Wear prescribed
operating suite attire
 Remove jewellery
 Keep fingernails short,
clean, healthy
 Wear appropriate
protective attire: masks,
head, overshoes..
 REMEMBER

 What went inside the machines is

the STERILISED material
 Personnel are only DISINFECTED
Surgical Hand scrub

 No touch: infrared robinets, with your elbow, leg…

 Use brush??
 The ideal duration of the scrub is not agreed.
 Accepted time is 5 minutes: appears safe
 Some surgeons do not rinse off the chlorhexidine or
Betadine in order to enhance residual activity.
 Alternative: Two-stage surgical scrub:
– an initial 1- or 2-minutes scrub with 4% chlorhexidine
gluconate or povidone-iodine followed by application
of an alcohol-based product
Surgical Hand scrub

 Trim fingernails and Wash for 30-60 seconds

with surgical scrub.
 Scrub fingers with a sterile scrub brush
 Make sure to scrub all sides of each finger,
including the area between fingers.
Surgical Hand scrub

 Scrub hands and arms with a sterile scrub brush. Make

sure to scrub each surface of each hand and arm
 An accepted contact time is 10 brush strokes per surface
 During scrubbing, rinsing and drying, hands are held
above elbows. This is done so that water will not be
dripping from upper arms onto lower arms and hands
Drying Hands

 A sterile towel is included within the sterile gown pack.

 One hand and forearm are dried by one side of the towel.
 Always dry in the direction of hand to elbow so that
contamination of the upper arm is not spread by the towel
to the surgeon's hand.
Gowning

 All gowns are folded and packaged for sterilization, with

the inside exposed so that the surgeon may handle the
gown without contaminating the outside of the gown.
 Grasp the exposed inside of the gown and lift the gown
away from the table.
 Your hands are disinfected and the gown is sterilized
Gowning

 Unfold the gown by placing hands into the white arm

holes. Continue placing hands and arms through the
sleeves..
Gowning

 An assistant fastens the neck tie and the

inside waist tie.
PLEASE: DO NOT DRY YOUR HANDS IN
THE FRONT OF THE GOWN
Types of Gowns

 Disposable Paper Gown: resistant to wetting so they

are less permeable to bacteria, expensive. It is usually a
wrap around gown. The ties "wrap around" the surgeon.
 Linen (cloth): comfortable and reusable. When it
becomes wet, bacteria can permeate. The cloth gown is
also known as a front sterile gown. The gown is just tied
in the back.
 Gloving

Sterile surgical gloves can be worn by:

Open method:
– The gloves are presented to enable the introduction of the
hands on the inside surface directly
– The nurse with her sterile glove opens the glove for the
surgeon who introduces directly his hands on the inside surface
of the glove

DO NOT ADJUST THE FIRST

GLOVE BEFORE PUTTING
THE SECOND ONE !!!
Gloving

Closed gloving:
 This is the introduction of hands covered with the
cuff of a sterile gown.
 So, If you are planning on closed gloving, do not
thrust hands through the cuffs.
 This is usually performed by the first person to
be sterilized= the nurse
Gloving: Closed method

 An assistant opens the sterile pack of gloves and drops

them into the sterile field.
 The inside of the cuff of the glove is grasped by the
opposite hand (still within the gown) until introduction
Patient Preparation

 Sterilization is best done with a detergent

followed by a disinfectant on a larger area of the
surgical field. H&N??
 Use Ample Detergent
 Scrub roughly the skin in any direction for 2-3mn
??Remove the excess of the detergent
 Apply the disinfectant first on the most clean area
 Scrub in one direction only
Draping

 Standard head drape: two towels, one under

the shoulders and the other wrapped around
the head
 Better to suture the drapes to the skin to
prevent shifting
 Towels are used for lateral draping
 Drapes should lie flat
Practical Sterilization
Instruments sterilization

 Metal Instruments: Avoid chemical sterilization

– Autoclave
– EO chamber
– Formaldehyde beads or powder
 Sharp-edged: avoid heating & wetting:
– EO chamber
– Formaldehyde beads or powder
Practical Sterilization
Instruments sterilization

 Catheters, gloves,…: depend on pre-sterilized,

disposable equipment
– Radiation
– EO chamber
 Endoscopes: avoid heat
– Cidex
– Lysoformin
– Autoclaving
 Handles of drills:
– Autoclave after washing and oiling
– EO chamber
THANK YOU