a. The principles of sterile technique are applied in various ways. In the following
paragraphs, the principles of sterile technique and examples of their application are
discussed. When the OR specialist understands the principles, he should be aware of other
examples of their application.
b. All materials used as a part of the sterile field for an operation must be sterile.
Certain basic items (such as the linen, the instrument set, and the basins) may be
obtained from the supply kept in the sterile supply room. Others, such as specialized
surgical instruments, may be sterilized the night before or immediately preceding the
operation and taken directly from the sterilizer to the sterile operative field. Once an
item is removed from a sterile wrapper, it must be used or discarded.
(1) Linen used in the operating room is usually dyed green. This helps to reduce the
glare from lights, thus reducing fatigue and eyestrain.
(2) Linen selected for use in the operating room should be checked to ensure that the
linen is not torn or frayed and that no holes are present in the cloth. Likewise, it
should be handled gently to prevent lint and dust from being spread about the room.
(3) Only materials known to be sterile should be used and their sterility should be
maintained throughout the operative procedure.
(4) Sterile areas are set up just prior to use.
(5) Scrub attire should not be worn outside the surgical suite.
(6) All team members should wash hands before and after the care of each patient.
c. Items should be considered unsterile if there is doubt about their sterility.
(1) If a sterile-appearing package is found in an area not designated for sterile
storage, it is considered unsterile and must be reprocessed and re-sterilized.
(2) If there is doubt about the timing of a sterilizer, its contents are considered
(3) If an "unsterile" person brushes close to a sterile table, the table is
considered contaminated. Also, if a "sterile" person brushes close to an
unsterile table, the person's sterile gown is considered contaminated.
(4) If a sterile table or sterile items are left unmonitored, the table and items are
(5) Do not drop or place clean supplies on the floor. Do not drop or place used
supplies or soiled linen on the floor.
d. Only the top surface of a draped table is considered sterile. Anything extending
over the edge or hanging over the edge is not sterile.
(1) Linen or sutures falling over the edge of the table should be discarded. The scrub
should not touch the part hanging below the table level.
(2) When the scrub drapes a table with sterile linen, he should see that the part of
the linen that drops below the table's surface is not brought up to table level again.
e. Once again, neither the circulator nor the scrub may intrude upon the other's area
at any time, although it is very important that they consult with each other and that each
is aware of what the other is doing. The duties performed by the scrub and by the
circulator are governed by specific procedural rules. Persons who are "sterile"
touch only sterile articles; "unsterile" persons touch only unsterile items. All
supplies for the "sterile" team members (scrub, surgeon, and assistants) are
provided by the circulator ("unsterile" team member) who protects the sterility
of items through the use of the wrappers on sterile packages (see Figure 1-1). These
procedures are described in paragraphs f and g below.
NOTE: In Figure 1-1, observe how the circulator handles the sterile wrapper and
the distance he stands from the sterile field.
f. The scrub is considered a "sterile" person.
(1) The "sterile" personnel gowns and gloves without touching the outside of
the gown or gloves with his bare hands.
(a) If a "sterile" team member's glove is punctured during an operation, the
glove is to be changed at once.
(b) If the glove is pricked by a needle or an instrument, the needle or instrument is
discarded from the sterile field. Notify the circulator of the needle's whereabouts.
(2) The parts of a surgical gown (see Figures 1-2 and 1-3) considered sterile are the
sleeves (except for the axillary area) and the front of the gown from table level to a few
inches below the neck opening.
(3) The scrub sets basins or glasses to be filled at the edge of the sterile table
opposite where he stands. The circulator stands near the edge of the table to fill them.
Figure 1-1. Scrub reaching for sterile
Figure 1-2. Scrub attire (front view).
Figure 1-3. Scrub attire (back view).
(4) A "sterile" team member turns away from the sterile field to have
perspiration mopped from his brow.
(5) The scrub drapes the part of an unsterile table nearest himself first.
(6) A "sterile" person should keep his hands in sight and at waist level or
(7) A "sterile" person should keep his hands away from his face and his
elbows close to his sides. He should never fold his arms because his gown may be moist
with perspiration in the axillary (under arms) region; thus, his gloves would become
contaminated. When a "sterile" person stands on a footstool, the lower part of
his gown should not brush the sterile table. (Common sense determines sterile parts of a
gown worn by tall and short members in relation to their waists and the tops of sterile
(8) "Sterile" team members should keep their contact with sterile areas to a
(a) "Sterile" team members should not lean on the sterile tables or on the
(b) The scrub should keep the large instrument table (back table) and the Mayo stand
far enough away that the gowns of other "sterile" team members do not brush
(9) "Sterile" team members keep well within the sterile area. The scrub
should allow a wide margin of safety when passing unsterile areas. He and all other
"sterile" team members should observe the following practices.
(a) "Sterile" team members should stand back at a safe distance from the
operating table while draping the patient.
(b) "Sterile" team members should pass each other back to back.
(c) A "sterile" team member should turn his back to an "unsterile"
person or area when passing.
(d) A "sterile" team member should face a sterile area when passing.
(e) "Sterile" team members should stay near the sterile table. They should
not wander about the room nor go out into the corridor.
(f) When used items or soiled sponges are placed into a basin and maintained on the
sterile field, the inside of the basin is contaminated. Handle such a basin by the outside
g. The circulator is considered the "unsterile" member of the surgical team.
(1) An "unsterile" team member should never crowd past a "sterile"
team member or field. Allow sufficient space between you and the sterile field or between
you and gowned individuals when passing them.
(a) "Unsterile" team members should keep away from sterile areas.
"Unsterile" persons should allow a wide margin of safety when passing sterile
(b) "Unsterile" persons should face a sterile area when passing it to be sure
you have not touched it.
(c) In addition, "unsterile" persons should not go within the sterile
"circle" or between two sterile fields.
(d) When passing behind a gowned team member, always notify him to avoid possible
contamination of his sterile attire if he should turn or move back and brush you.
(2) The circulator stands at a safe distance from the sterile field when adjusting the
light over it.
(a) Never reach across a sterile field. Stand outside the sterile field and hold the
extra supplies needed; allow the scrub to reach for them. Do not enter the sterile field
to perform any duties.
(b) When moving a sterile table, grasp the table legs well below the tabletop and
underneath the sterile drapes.
(c) The circulator "flips" the sterile suture material onto back table (see
h. The edge of a cover that encloses sterile contents is not considered sterile. Such
covers include the edges of wrappers on sterile packages, the caps on solution bottles,
and test tube covers. No definite line separates the sterile from the unsterile area at
the edge of the cover; therefore, the edge is considered unsterile.
(1) The scrub should lift contents from packages by reaching for them with the arm
straight out and lifting the items straight up -- with the elbow held high throughout the
(2) The circulator lifts the cap from a solution bottle so that the edge of the cap
never touches the lip. Caps are not replaced. The entire contents are dispensed and any
excess solution is discarded.
Figure 1-4. Circulating nurse
"flipping" sterile suture material from a suture packet onto the back table.
i. Sterile areas should be protected from moisture because a moist item may become
contaminated. When moisture soaks through a sterile area to an unsterile one, or vice
versa, a means of transporting infectious organisms to the sterile area is provided.
Therefore, the OR specialist should observe the following rules of practice.
(1) Sterile packages should be laid on dry areas.
(2) If any portion of a sterile package becomes damp or wet, the entire package should
(3) If a sterile package falls on the floor, it is considered unsterile.
(4) Linen packages from the sterilizer should be permitted to cool before being stored
on shelves. This procedure prevents their becoming damp from steam condensation when
placed on a cool shelf.
(5) Sterile drapes should be placed on a dry surface. (Thus, time should be allowed for
the prep solution used to paint the patient's skin to dry before draping is begun.)
(6) During surgery, if a solution soaks through a sterile area from an unsterile one or
through an unsterile area from a sterile one, the wet area should be covered with another
j. Whenever microorganisms cannot be eliminated from a field, they should be kept to an
absolute minimum. Although absolute asepsis in an operative field cannot be reached, every
effort is made to control sources of possible contamination.
(1) Skin cannot be sterilized. Skin normally harbors staphylococcus and other
organisms; however, any agent capable of sterilizing skin will also destroy it. The skin
of the patient, as well as that of members of the "sterile" team, is therefore a
potential source of contamination in every operation. However, this does not remove the
need for strict aseptic technique. Defenses within the patient's body will usually
overcome the relatively few organisms left on the skin when the following protective
measures are carried out.
(a) The patient's skin is given a shave and scrub just prior to surgery and is again
thoroughly cleansed in the operating room just prior to the incision.
(b) As much of the operative area is cleansed as is feasible and the surrounding skin
(c) Some areas cannot be scrubbed vigorously. Mucous membranes are gently prepped since
scrubbing would damage the tissue. When the site of operation is the mucous membrane of
the nose, mouth, throat, or anus, the number of microorganisms present is great. However,
these parts of the body do not usually become infected by organisms that normally inhabit
(d) When scrubbing the patient's skin, a sponge is used only once for prepping an area.
Once the sponge is removed from contact with the skin, the sponge is discarded into a kick
(e) All of the patient's skin area except the site of incision is covered with sterile
(f) Sterile towels or other sterile material may be used to cover the skin after the
incision is made. The reason for this additional precaution is to protect the surgical
wound from the waste products continually excreted by the skin. In addition, airborne
organisms continuously pose a threat of contaminating the incision.
(g) When the knife used for the skin incision is no longer needed, the scrub isolates
it from other items on the sterile field.
(h) The skin of operating room personnel is another source of contamination. They
follow rigid steps in scrubbing their hands and arms using brushes and detergents and
adhering to strict technique. This is done to remove the maximum number of organisms. When
drying their hands, sterile hand towels should not touch their scrub clothes.
(2) The cap worn on the head of team members should completely cover the hair to
prevent particles of dandruff or hair from falling on the sterile field or in the room.
(3) Infected areas are grossly contaminated. All team members should avoid scattering
(4) The air is usually contaminated by dust and droplets.
(a) Team members are required to wear a mask covering the nose and mouth during an
operative procedure. The mask must cover the mouth and nose entirely and be tied securely
to prevent venting. The strings should not be crossed when tied because the sides of the
mask will gap. A pliable metal strip is inserted in the top hem of most masks to provide a
firm contour fit over the bridge of the nose. This strip also helps prevent fogging of
eyeglasses. Air should pass only through the filtering system of the mask. Masks should be
either on or off. They should not be saved from one operation to the next by allowing them
to hang around the neck or by tucking them into a pocket. Bacteria that have been filtered
by the mask will become dry and airborne if the mask is worn necklace fashion. By touching
only the strings when removing the mask, contamination of the hands will be reduced. Masks
should be changed between procedures and sometimes during a procedure, depending on the
length of the operation and the amount of talking done by the surgical team.
(b) When possible, the respiratory tract of the patient should be isolated from the
incision. In some cases, isolation is achieved by using the anesthesia screen. This serves
as a barrier between the incision and the respiratory tract.
(c) Team members should not talk except when essential. Silence is even better than
masking to reduce the number of organisms spread from nose and throat.
(d) Team members should avoid sneezing and coughing.
(e) Persons who have colds or any active infection should be excluded from the
(f) Main corridors are considered to be contaminated areas; therefore, doors from
corridors into the operating rooms should be kept closed. Also, sterile items without
wrappers should not be carried through corridors.
(g) Walking through and around the operating room should be kept to the necessary
(h) All dusting should be damp-dusting with a germicide solution. Floors should be
wet-vacuumed between cases as well as at the end of the day. Dry-dusting and dry-mopping
should be avoided in the operating room since the dust created by these methods would
continue to settle or float in the room for hours.
(i) The bedclothes over the patient should be handled gently when he is being
transferred to the operating table in order to avoid throwing lint off into the air. Local
policy may require bedclothes to be removed/replaced prior to the entry in the operating
room; nevertheless, the patient should be covered with a cover sheet at all times.
(j) Dressings removed from a wound should be placed at once in a bag and the bag should
be closed and discarded. Drainage that is left exposed to the air may become dried, thus
enabling the infectious organisms in it to become airborne and be carried to other parts
of the surgical suite and the hospital to infect others.
Content Providers: The U. S. Army, The U.S. Navy
Ancillary Content and Online Version: David L. Heiserman
Publisher: SweetHaven Publishing Services