Lab 5 . Part 2 - Surgical team preparation - VSAC - WCVM

Surgical attire

worn to limit dirt, debris and bacteria carried into the operating area
made of loose weave fabric
V-necked shirt
pants have drawstring or elastic waist
shirts are tucked into pants
cover with clean lab coat outside OR to minimize environmental contamination
should not be worn to examine patients or change bandages if additional surgery is planned
should be changed at least daily and whenever soiled

made of glass fiber mesh sandwiched between 2 layers of cellulose fabric
thin metal strip in the top of mask improves fit along the bridge of nose
ties secured behind top of head and neck so is minimal venting
- ties should NOT be crossed at the back as this increases the size of side openings reducing filtering
goals:
- protect surgical wound from saliva droplets and microorganisms from surgical team
- redirect airflow out sides of the mask away from incision
less effective when excessive talking, sneezing and prolonged procedures
should not be worn around base of neck between procedures (contaminates scrubs)
new mask is worn for each procedure
no strong evidence masks decrease infection rates, but currently is recommended

Hands have high bacterial counts especially if visibly dirty

highest under and around nails
Surgeons’ hands have higher numbers and more pathogenic organisms than average person This is because they are frequently exposed to scrub solutions (that kill off sensitive bacteria) and contaminated wounds
jewellery is removed (can’t be effectively cleaned)
nails are short and clean (easier to effectively clean)
- no false nails or nail polish (higher resident bacterial levels and can’t be effectively cleaned)

Ideal scrub time is NOT known
- 5 minutes is safe and effective
- Currently recommended: first scrub of day is 5 minutes, subsequent scrubs are 3-5 minutes (if minimal contamination of hands in between)
Two commonly used scrub procedures:
1. timed anatomic scrub
  - all surfaces of each hand and forearm are scrubbed for a specified time
  - time varies with desired total scrub time (3-5 minutes)
2. counted brush strokes method
  - all surfaces of each hand and forearms are given a specific number of brush strokes
  - number varies from 10 - 25 depending on desired total scrub time
- Both result in similar total times
use moisturizing lotions between scrubs to reduce skin drying and bacterial shedding
ensure lotion is formulated so it does NOT neutralize chlorhexidine’s residual action

Scrub

adjust cap to ensure all hair is covered
tie clean mask securely ensuring it comfortably covers nose and mouth (ties are not crossed)
tuck scrub tops into pants
remove jewellery
hold hands above elbows so water drains from fingertips towards the elbow
open disposable brush and place on shelf above scrub sink
perform preliminary wash: wet and wash hands and forearms to 5 cm above elbow using soap from dispenser
clean nails and subungual areas using nail cleaner in package
rinse hands and arms thoroughly

Detailed Example

Begin timed scrub:

Minute 1: scrub one hand (nails, nail beds, each side of each finger and hand)
Minute 2: scrub second hand in similar fashion
Minute 3: scrub top half of each arm in a circular fashion beginning at wrist (1/2 minute each)
Minute 4: scrub bottom half of each arm in circular fashion (1/2 minute each)
Rinse hands and arms thoroughly
Minute 5: apply fresh scrub from dispenser or brush, discard brush and scrub hands only
Rinse hands and arms a final time and allow excess water allowed to drip off

Hands and forearms are now considered surgically clean ie. NOT sterile

A sterile gown are put on to place a sterile barrier between the surgeon and the patient

should be
- water resistant
- resist friction, pressure and stretch especially at forearms, elbows and abdomen (ie. not be tight)
- produce minimal lint
- comfortable and economical

goals:

protect patient from contamination by microorganisms on surgeon’s skin.
protect surgeon from patient’s microorganisms
commonly made of latex
not an absolute barrier as some gloves have holes
- accepted industry standard for new surgical gloves: < 1.5% have punctures before use
- by end of surgery, almost 1/3 have holes
- most on non-dominant thumb and index finger
- perforations NOT associated with more post-op infections likely because surgical hand scrubs reduce bacterial counts and suppress bacterial multiplication
BUT gloves should be changed when punctures are noted
Powders are placed inside gloves to make easier to put on
- talc (magnesium silicate)
  - induces acute inflammation followed by a chronic persistent granulomatous reaction when put into surgical wound (eg. glove punctures)
- cornstarch
  - causes more intense acute inflammatory reaction (especially in joints) but resolves after 4 weeks

Removing gloves

Changing gloves with closed gloving technique

Open gloving