SZTE Basic Surgical Skills: Asepsis and Antisepsis - Comprehensive Study Guide

Institute of Surgical Research Staff and Course Logistics

• Host Institution: SZTE, Institute of Surgical Research.
• Course Title: Basic Surgical Skills (Lecture 1: Asepsis and Antisepsis).
• Primary Lecturers: Mihály Boros and Andrea Szabó.
• Teaching Staff:     * Prof. Dr. Mihály Boros: Professor.     * Dr. József Kaszaki: Associate Professor.     * Dr. Andrea Szabó: Associate Professor.     * Dr. Gabriella Varga: Course organizer for lectures, Associate Professor.     * Dr. Dániel Érces: Course organizer for practices, Associate Professor.     * Dr. Tamara Horváth: Tutor.     * Dr. László Juhász: Tutor, adviser for the scientific student association.     * Dr. Szabolcs Tallósy: Tutor.     * Attila Rutai: Tutor.     * Dr. Marietta Poles: Educational advisor.
• Locations:     * Lectures/Seminars: Banga Ilona Health Sciences Education Center (BIEKK building), Auditorium Maximum, located at Szőkefalvi-Nagy B. str. 6.     * Practicals: Institute of Surgical Research, BIEKK building 3rd floor, Student’s operating theatre.
• Schedule Details:     * Lectures: Weeks $1\text{--}7$ on Mondays ($10:00\text{--}11:30$).     * Seminars/Workshops: Weeks $1, 2, 6, 7, \text{ and } 11$ at specific times for designated groups.     * Practicals: Specific time points per group (see Neptun/CooSpace).
• Facilities: Dressing room cabinets require a $100\,\text{HUF}$ coin (returned upon opening). Entrance to the simulation operating theater is allowed only after permission.

Course Requirements and Evaluation Criteria

• Practice Attendance: Minimum of $75\,\%$ attendance at practices is required for acknowledgement.
• Prerequisites: A successful practical exam is the prerequisite for taking the theoretical examination.
• Theoretical Evaluation: Written online test based on lecture PPTs, tutorial videos, and study guides including self-assessment questions.
• Practical Evaluation: Practical exam (OSATS - Organized Structured Assessment of Technical Skills) on weeks $13\text{--}14$.
• Final Grade Calculation: Based on the average of the grades (\%) of the theoretical and practical exams.

Practical Examination (OSATS) Task 1: Scrubbing, Gowning, and Gloving

• General Scoring: Students start with a grade of $5$. Each error reduces the grade by $1$. A deduction of $-4$ points requires a repeat of the exam task. Serious errors result in immediate repetition.
• Correction Rule: If a student identifies a mistake or misconduct, verbally indicates it, and corrects it (e.g., restarts the affected phase), no mark is deducted.
• Phase 1: Preparation for Scrubbing     * Required: Proper wear of cap, mask, and shoe covers (hair/nose covered); sleeves must not cover the forearm.     * Removal: All rings, watches, bracelets, and nail polish must be removed.
• Phase 2: Hygienic Hand Wash     * Process: Washing with soap to remove coarse dirt and rinsing before the mechanical phase.
• Phase 3: Mechanical Scrub     * Duration: Maximum of $2\,\text{minutes}$.     * Rules: Hands and forearms washed; during rinsing, hands must always be held above elbow level. Care taken to remove all soap foam. Water tap must be closed with elbows.     * Asepsis: No equipment or body parts (own or others) may be touched during scrubbing.
• Phase 4: Chemical Scrub (Disinfection)     * Requirement: Hands and forearms must be wiped dry after the mechanical phase before disinfection.     * Feeder Operation: Disinfectant feeder must be operated with elbows.     * Process: $5$ phases, each lasting $1\,\text{minute}$ (Total $5\,\text{minutes}$).     * Area: Distal forearm and $6$ typical parts of the hand.     * Rule: Disinfectant is not rinsed off; hands must remain above elbow level.
• Phase 5: Sterile Gowning and Gloving     * Gowning: Hands held above elbow level; outer surface of the gown must not be touched by hand or non-sterile clothes.     * Gloving: Hands touch only the inner surface of the glove. Avoid contact with non-sterile surfaces once sterile gloves are on.     * Removal: Only the inner surface of the glove is touched with bare hands after use.

Learning Outcomes and Skills Training

• Knowledge: Student must understand principles, instruments, and methods related to surgical asepsis and complications arising from misconduct.
• Skills: Ability to perform surgical scrubbing, gowning, gloving, hospital hand disinfection, and cleansing/isolation of the operative field.
• Attitude: Adherence to asepsis principles, self-discipline, and a self-reflective attitude to correct misconduct autonomously.
• Autonomy: Successful students can perform procedures autonomously and accurately under simulated and supervised clinical conditions.
• Educational Philosophy: "Edutainment" (education-entertainment) using simulation (virtual reality) and active practice in a safe environment.
• Deontology: The study of obligations, covering instruments, techniques, and the relationship between operations and functional changes in the human body.

Historical Evolution of Anesthesia and Asepsis

• Problem 1: Pain (19th Century Anesthesia)     * First Ether Narcosis: October 16, 1846, Boston. Performed by John Collins Warren (surgeon) and William Morton (anesthesiologist).     * First Chloroform Narcosis: November 4, 1846, Edinburgh. Performed by James Young Simpson (tested on himself first).     * Hungarian Milestones:         * Markusovszky Lajos (1815-1893): Tried ether on himself in Vienna, January 25, 1847.         * Balassa János (1814-1868): First surgery under ether anesthesia in Pest, February 08, 1847 ($4$ months after the Boston debut).     * 1893 Statistics (German Surgical Society): Chloroform had $46$ deaths in $133,729$ cases ($1:2,907$); Ether had $1$ death in $14,646$ cases ($1:14,646$).
• Problem 2: Infection (The New Era)     * Historical Context: Terms like "hospital gangrene" and "pus bonum et laudabile" (good and commendable pus) were used. James Simpson noted that a man on an operating table was at more risk of death than a soldier at Waterloo.     * Ignaz Semmelweis (1818-1865): Initiated the asepsis era in Vienna, 1847. Identified hands as the route of spread for "puerperal fever."     * Rule (May 15, 1847): All who enter wards must wash fingers and hands in chlorinated lime. Mortality dropped from $14.5\,\%$ (May 1847) to $1.2\,\%$ (August 1847).     * Semmelweis Reflex: The reflex-like tendency to reject new evidence because it contradicts established norms.     * Sir Joseph Lister (1827-1912): Introduced antisepsis using carbolic acid in Edinburgh, 1865.     * Louis Pasteur (1822-1895): Advanced bacteriology. Noted: "In the fields of observation, chance favors only the prepared mind."     * Robert Koch (1843-1910): Established Koch’s postulates in 1881 regarding pathogenic organisms and growth conditions.     * Ernst von Bergmann (1836-1907): Introduced Sublimatantisepsis (1877) and Dampfsterilisation (steam sterilization, 1886).     * Curt Schimmelbusch (1850-1895): Wrote the guide for aseptic wound healing.     * William S. Halsted (1852-1922): Introduced surgical gloves with Caroline Hampton and the Goodyear Rubber Company.

Core Definitions: Asepsis and Antisepsis

• Asepsis: Procedures to reduce the risk of contamination (bacterial, viral, fungal, etc.) using sterile instruments and "no touch" techniques. The goal is avoiding wound contamination.
• Antisepsis: Procedures that reduce viable microbes on skin or mucous membranes to a significant degree; destruction of disease-causing microorganisms. The goal is killing microorganisms in an infected wound.

Sources and Prevention of Surgical Infections

• Surgical Site Infection (SSI):     * Most common nosocomial infection in surgical patients.     * Incidence: $1\text{--}3\,\%$ overall; up to $10\,\%$ following colon surgery.     * Impact: Increases hospital stay by $5\text{--}15\,\text{days}$.     * Crucial Window: SSI is established within $2\,\text{hours}$ of contamination.
• Sources of Pathogens:     * Patient (endogenous flora): $75\,\%$ of infections arise from staff/patient normal flora.     * Personnel (hospital staff).     * Operating Theater Environment.
• Normal Body Flora:     * Skin: Staphylococci, Streptococci.     * Large Bowel: Gram-negative rods, Enterococci, Anaerobes.     * Urinary Tract: Normally sterile.     * Skin Flora Categories: Resident flora (deeper layers, deeper glands, cause harm if broken skin) and Transient flora (upper layers, acquired from contaminated source).
• Routes of Spread:     * Direct Inoculation: Surgeon's hands, contaminated instruments/drains.     * Airborne: Air flow in OR, staff clothing.     * Haematogenous: Sepsis from other sites or IV lines.

Hand Hygiene Protocols

• WHO Five Moments for Hand Hygiene:     1. Before touching a patient.     2. Before clean/aseptic procedures.     3. After body fluid exposure risk.     4. After touching a patient.     5. After touching patient surroundings.
• Hospital Hand Hygiene vs. Surgical Scrubbing:     * Hospital Hygiene ($30\,\text{sec}$): Aim is to prevent nosocomial infections and eliminate transient flora. Method: Hygienic hand wash with soap + alcohol rubbing ($30\,\text{seconds}$).     * Surgical Scrubbing ($5\,\text{min}$): Aim is to prevent surgical contamination, eliminate transient flora, and inhabit residual flora activity. Method: Hygienic hand wash with soap/water + alcohol rubbing ($5 \times 1\,\text{minute}$).
• Basic Steps of Hand Hygiene:     1. Palm to palm (include wrists).     2. Right palm over left back of hand (and vice versa).     3. Palm to palm with interlaced fingers.     4. Backs of fingers to opposing palms (interlocked).     5. Rotational rubbing of thumbs.     6. Rotational rubbing of fingertips on palms.

Sterilization and Disinfection Methods

• Sterility Assurance Level (SAL): Probability of a viable microorganism remaining. Standard for scalpels/implants is $10^{-6}$ (one in a million).
• Autoclave (Steam under pressure):     * Highly effective and inexpensive.     * Parameters: $134\,^{\circ}\text{C}$ for $3\,\text{minutes}$ OR $121\,^{\circ}\text{C}$ for $15\,\text{minutes}$.     * Monitoring: Mechanical (temp/pressure printouts), Chemical (indicator tape), and Biological (Geobacillus stearothermophilus spores).
• Dry-Heat Sterilizer: For materials damaged by moisture (powders, sharp instruments). Slow penetration.     * Settings: $170\,^{\circ}\text{C}$ ($60\,\text{min}$), $160\,^{\circ}\text{C}$ ($120\,\text{min}$), $150\,^{\circ}\text{C}$ ($150\,\text{min}$).
• Ethylene Oxide (ETO): Highly penetrative, toxic/flammable, suitable for heat-sensitive items.     * Parameters: $450\text{--}1200\,\text{mg/l}$ gas concentration; $37\text{--}63\,^{\circ}\text{C}$; relative humidity $40\text{--}80\,\%$. Exposure: $1\text{--}6\,\text{hours}$.
• Sporicidal Chemicals (Cold Sterilization): Used for immersion of heat-sensitive items.     * Agents: $2\,\%$ Glutaraldehyde (Cidex), $35\,\%$ Peracetic acid, sodium perborate (Sekusept).     * Timing: Most bacteria killed in $10\,\text{min}$, but spores require >3\,\text{hours}.
• Gas Plasma Sterilization: Hydrogen peroxide gas plasma generated via vacuum and microwave/radio frequency. H2O2 decomposes into water/oxygen (no harmful residue). Duration: $45\text{--}75\,\text{minutes}$.

Surgical Attire and Operating Room Behavior

• Surgical Attire: Scrub suits (only for surgery), disposable caps/hoods, masks (cover nose/mouth), shoe covers, sterile gowns, and gloves (latex or hypoallergic).
• Sterile Field Boundaries:     * Gowns are sterile only from the axillary line to the waist in the front, and the sleeves up to $10\,\text{cm}$ above the elbow.     * Non-sterile areas: Back of the gown, axillary region, and anything below the waistline.
• Rules of the Operating Room:     * Sterile members stay within the sterile area (patient, sterile tables, draped equipment).     * Movement and talking must be minimized (droplets contain bacteria).     * Non-scrubbed personnel must not reach over sterile surfaces.     * Scrubbed members face each other and the sterile field at all times.     * Questionable sterility = contaminated.     * Sterile tables are sterile only at table height.     * Moisture leads to strikethrough contamination (transfers bacteria from non-sterile to sterile surfaces).

Patient Preparation and Wound Management

• Preoperative Prep:     * Pre-op bath reduces skin germ count.     * Shaving: Must be done immediately before surgery ($1\,\%$ infection rate). If done >12\,\text{hours} prior, the rate rises to $5\,\%$ due to colonization of abrasions.     * Skin Preparation Solutions:         * Isopropyl alcohol ($70\,\%$): Denatures proteins, fast-acting, short duration.         * Chlorhexidine ($0.5\,\%$): Disrupts cell walls, persistent ($6\,\text{hours}$), doesn't kill spores.         * Povidone-iodine (Betadine): Oxidizes free iodine, kills spores, but inactivated by blood.
• Cleansing Technique: Start at the planned incision line, moving parallel to the sides. Repeat $5\,\text{times}$ with gradually smaller areas.
• Isolation of surgical area:     1. Lateral sheets.     2. Distal transverse sheets (foot side).     3. Proximal transverse sheets (head side).     4. Mayo stand placement.     5. Self-adhesive foil.
• Postoperative Period: Ward placement, dressing changes only when justified using sterile gloves/instruments, emphasize hand disinfection.

Operating Room (OR) Setup and Personnel

• Environment: Room size $50\text{--}70\,\text{m}^2$. Humidity $30\text{--}60\,\%$. Air changes >15\text{--}20 per hour with laminar flow. Positive pressure ensures air moves from clean to less clean areas.
• OR Equipment: Adjustable table with removeable pad, overhead lights with sterile handles, anesthesia machines, Mayo stand (adjacent to site for frequent tools), Back table (other supplies), Kick bucket (discard sponges).
• Cleaning Robots: Xenex Germ-Zapping Robots™ use pulsating xenon-UV lamps ($120\,\text{flashes/min}$ for $10\text{--}20\,\text{min}$).
• Personnel Roles:     * Surgeon: Guides the flow and scope.     * First Assistant: Hemostasis, suturing, dressing.     * Second Assistant: Exposure of the field.     * Scrub Nurse: Assists gowning/gloving, maintains orderly sterile field.     * Circulating Nurse: Non-sterile member; does not scrub or don sterile attire.     * Anesthesia Team: Anesthesiologist and assistant.
• Positions:     * Operator (Surgeon): Usually on the patient's right side.     * First Assistant: Facing the surgeon.     * Second Assistant: To the right or left of the surgeon.     * Scrub Nurse: Facing the surgeon, left of the first assistant.
• Spatial Separation: Sterile (aseptic) rooms for clean surgeries (hernia, goiter); "septic" rooms for contaminated surgeries (appendectomy, abscess).