Note: The outer 1-inch edge of the sterile margin is not sterile.
A sterile package may also be opened as follows:
1. Hold the package in one hand with the top flap opening away from the person opening the package.
2. Pull the top flap well back and hold it away from both the contents of the package and the sterile field. Using the free hand to hold the flap against the wrist of the hand holding the package is an effective technique.
3. Drop the contents gently onto the sterile field from approximately 6 inches above the field and at a slight angle.
These techniques help ensure that the package wrapping does not touch the sterile field at any time.
Commercial packages usually have specific directions written on the package for opening. In general, available packages include those with partially sealed corners, in which the container is held in one hand and the flap is pulled back with the other, and those with partially sealed edges, in which both sides of the edge are grasped, one with each hand, and gently pulled apart (Fig. 18-2).
For a sterile field to be established, the drape is plucked with one hand by the corner and opened. This corner is used to fold back the top. Then the drape is lifted out of the cover and allowed to open freely without touching anything. Another corner of the drape then is picked up carefully and laid on a clean, dry surface with the bottom farthest from the person establishing the field (Fig. 18-3).
Adding Sterile Supplies to an Established Sterile Field
Necessary sterile supplies can be added to the field using the proper package-opening techniques. Remember the following:
1. Do not reach across a sterile field.
2. Do not flip or toss objects on the sterile field.
3. A 1-inch border around the sterile field is not considered sterile.
4. Discard the outer wrapper from each sterile item.
5. Repeat this process for adding additional items to the sterile field.
Pouring a Sterile Solution
Sterile solutions are frequently poured into a metal or other container within the sterile field. Bottles containing sterile solutions usually are considered sterile on the inside but contaminated on the outside; thus special care is needed in pouring these solutions.
Begin with verifying the contents and expiration date on the solution. When possible, show the name to another health care person for verification.
Always try to use the exact amount of solution. Once opened, the solution can be considered sterile only if it is used immediately. Once the container has been set down, it is no longer considered sterile and a new container must be opened. The procedure for pouring sterile solutions is as follows:
1. Remove the lid or cap from the bottle; place it on an unsterile surface with the topside down immediately to ensure the sterility of the inner surface.
2. Hold the bottle with the label uppermost so that poured solution cannot stain and obscure the label.
3. Sterile basins into which sterile liquids will be poured are generally placed at the end of the table to avoid splashing over the entire sterile field.
4. With as little of the bottle as possible over the field, hold it at a height of approximately 1 to 2 inches over the bowl (Fig. 18-4). Pour the solution gently so that no splashing occurs. Splashing of liquids can destroy a sterile field by allowing microorganisms to move from the unsterile tabletop through the wet drape that forms the bottom of the sterile field.
5. Close the bottle with the cap if appropriate. Some institutions require marking on the label of the bottle with the date and time that the bottle was opened along with the initials of the person that opened the bottle.
Commonly used sterile packs include myelography, minor procedure, and various special procedure packs used for exams such as venograms and angiograms. Items in the typical myelography pack are shown in Fig. 18-5 and often include the following:
• Injectable local anesthetic
• Syringes and needles of various sizes
• Sterile drape
• Collection tubes (for spinal fluid)
A minor procedure pack, used for arthrography and biopsies (tissue and/or fluid samples), usually contains all of the preceding items, as well as a sterile gown. Although commercially prepared angiography packs are available, many hospitals prefer to make up their own trays. Typical supplies might include the following:
• Needles, including three 18-gauge, one 20-gauge, one 22-gauge, and one 25-gauge (the larger-gauge needles are used to inject local anesthetic)
• Sterile containers for biopsy specimens
• Plastic connector for test injections of contrast material
• One manifold (three stopcocks) for the contrast test, heparin drip, or saline flush
• Scalpel handle and no. 10 scalpel blade, used for arterial cutdown techniques
• Large number of gauze pads or topper sponges
• Up to five 10-, 20-, or 30-mL Luer-Lok syringes for saline flush
• Three 10-mL Luer-Lok syringes: Two for contrast tests, one for local anesthetic
• Forceps for sponges
• Six sponges for preparation of the puncture site with anesthetic
• Three stainless steel basins—one for saline solution, one for antiseptic, and one used as a waste basin—and one emesis basin
• Straight and curved clamps for arterial cutdown techniques
• Clamp to keep guidewire wrapped
Although persons performing aseptic procedures wear gloves, the skin of their hands and forearms should be cleaned routinely to reduce the number of microorganisms in case a glove tears. A surgical scrub is required before participation in many interventional studies. The purpose of the surgical hand scrub is (1) to remove debris and transient microorganisms from the hands, nails, and forearms; (2) to reduce the resident microbial count to a minimum; and (3) to inhibit rapid rebound growth of microorganisms.
The sterile scrub consists of scrubbing with an antimicrobial agent. Surgical scrubbing involves two basic methods: (1) the numbered stroke method, in which a certain number of brush strokes are used for each finger, the palms, the backs of the hands, and the arms; and (2) the timed scrub. Although exact procedures and times for the scrub vary among different settings and institutions, the following can serve as guidelines for the timed scrub (currently a surgical scrub with 2% chlorhexidine gluconate or 7.5% povidone-iodine is performed before each procedure):
1. Be sure that scrub brushes, antiseptic soap, and nail cleaners are available.
2. Remove all jewelry, including watches.
3. Wash hands and arms with antiseptic soap.
4. Clean subungual areas with nail file.
5. Scrub the sides of each finger, between the fingers, and the back and front of the hand for 3 minutes.
6. Scrub the arm with the hands higher than the elbows. Each side of the arm is washed to 3 inches above the elbow for 1 minute.
7. Repeat the process for the other hand and arm. The hands remain above the elbows at all times.
Gowns and gloves are put on after the surgical scrub. Gowning can be done in two ways: (1) self-gowning and (2) gowning by another person. Sterile gowning differs from gowning for isolation in that the focus is on surgical rather than medical asepsis. Gloving can also be done in two ways: (1) self-gloving and (2) gloving by another person. A sterile surface is always required for sterile gloving. Gloves have two surfaces: an inside and an outside. Before the gloves are touched, the entire glove is sterile; however, once gloving has started, the inside surface of the cuff is considered nonsterile. Gloves are packaged in a paper wrapper with the palms of the gloves facing upward and the top of the glove folded over to form a 2- to 3-inch cuff. The exposed cuff is part of the inside of the glove and is therefore part of the nonsterile side.
1. Standing approximately 12 inches from the sterile area, pick up the gown by the folded edges and lift it directly up from the package. The gown is folded so that the outside faces away.
2. Stepping back from the table, make sure no objects are near the gown. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.
3. Place the hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms.
4. An unsterile assistant can adjust the gown by standing behind and reaching inside the sleeves, grasping them, and pulling gently.
5. For the open gloving technique, pull the sleeves over the hands. For the closed gloving technique, keep the hands and fingers covered by the sterile gown.
6. An assistant fastens the back and waistband of the gown.
After the gown is on, only the sleeves and front of the gown down to the waist are considered sterile. To maintain sterile technique once in sterile gown and gloves, persons must pass each other back to back.
Self-gloving can be done using a closed or an open gloving technique. It is performed after gowning or, in the case of the open gloving technique, may be used during sterile procedures that do not require donning a sterile gown. All jewelry should have been removed. Select the appropriate size and type then check to make sure that the package is intact and dry and no tears or water stains are seen. Hands must be washed and dried before opening and putting on the gloves.
The glove package should be opened facing the person who is going to wear the gloves with the right glove on the right side.
1. The sterile person opens the package, picks up the right glove, and places the palm away from himself or herself. Slide the fingers under the glove cuff and spread them so that a wide opening is created. Keep the thumbs under the cuff.
2. The person thrusts his or her hand into the glove. Having an extremely good grasp on the cuff is important because considerable force is exerted when the hand is pushed down into the tight glove.
3. Gently release the cuff while rolling it over the wrist.
4. Proceed with the left glove using the same technique.