Asepsis and Infection Control

Chapter 3
Asepsis and Infection Control

Surgical suite preparation

There are many factors that influence the outcome of any surgical procedure. The patient is an obvious contributor to the outcome. The patient’s health status at the time of surgery, the ability of the patient to heal, and the invasiveness of the procedure will affect success. The personnel involved in the surgical procedure will also influence the outcome. Anesthesia personnel have the responsibility of keeping the animal alive while under anesthesia and guiding the patient through recovery with as little incident as possible. The surgeon and any member of the sterile surgical team have the potential for introducing pathogens that may compromise the success of the case. Finally, the environment of the operating room can contribute to potential contamination if not properly cared for.

Maintaining and controlling the operating room environment is a critical step in protecting the patient and personnel from contamination. Areas to be considered include: air handling; attire; traffic; air particles; cleaning products contaminants, and a standardization of operation room cleaning procedures.

Air exchanges

Currently the Center for Disease Control (CDC) recommends 15 air exchanges per hour for operating rooms (CDC 2008). In addition operating rooms should have a laminar air flow system. Studies have shown that laminar air flow significantly reduces the number of particles in the air. If a laminar air system is not possible, a positive air flow (air flows out when the door is opened) will aid in keeping irritants out of the operating suite. Incoming air should be at the ceiling level while outgoing air should be at the floor level. Whatever type of system is used, proper care and maintenance is critical in achieving optimal efficiency. Cleaning of the system (ducts, grates, filters, and drain pans) will increase the efficiency of the system. Annual assessment of air quality in the operating room should also occur.

Surgical attire

Proper surgical attire is critical in reducing the potential for the introduction of contaminants to the surgical suite. Facility-approved, freshly laundered scrub suits are most commonly used. According to AORN (Association of Operating Room Nurses) clothing to be worn in restricted areas of the hospital (operating rooms) should not be worn to the facility from outside areas (i.e., home). Tops must be tucked into pants to avoid skin cell shedding at surgical table height. Scrubs should not be laundered at home due to increased risk of cross contamination. Once soiled or at the end of the day, the scrubs should be put in a designated hamper for laundering by the facility. Street clothes must never be worn underneath scrubs. Undershirts or tank tops can be worn for added warmth, but no article of clothing should extend beyond the sleeves or pant legs of the scrubs. Other “attire” to be worn is some type of hair-coverage device. Most commonly used is a bouffant hat. It must be large enough to cover all hair for both men and women (Figure 3.1). There are surgeon’s caps available for those individuals that can have very short hair that will be covered by this smaller type of cap (Figure 3.2).


Figure 3.1 Bouffant hat.


Figure 3.2 Surgeon’s cap.

Beard covers are also available for those with facial hair that needs to be covered. Beard covers have elastic loops on either end and those loops fit over the ears. A head covering must be worn in addition to the beard cover. There is the option of wearing a surgical hood if facial hair is present and a beard cover is not available. The surgical hood is designed to cover head hair as well as facial hair (Figure 3.3).


Figure 3.3 Surgical hood.

The use of shoe covers is still debated among facilities. Some require dedicated shoes for the operating rooms and that shoe covers be worn when leaving the restricted area of the operating rooms. Other facilities required shoe covers to be worn in order to enter the restricted area of the operating rooms. At any rate, the policy that is established by the facility must be adhered to and enforced by the veterinary technician in the operating room area. Surgical masks are the final piece of attire to be addressed. Masks should be worn whenever sterile packs are open or when there is a surgery in progress. Masks are designed to filter exhaled air, so it is imperative that they be worn correctly. Some manufacturers even print the work “inside” on the side that should be toward the face. Two styles of surgical face masks are available. First of all, the most common style is the double tie face mask. The ties are secured at the crown of the head and also at the back of the neck. Ties should not be crossed behind the head (lower ties tied at the crown of the head and upper ties secured behind the neck) and then secured as this leaves too large a gap on the side of the face for particles to escape. Masks frequently have a malleable metal band that runs across the bridge of the nose if the mask is put on correctly. This band is intended to be molded to the bridge of the nose for a conforming fit – again in an effort to reduce the number of expired particles from escaping. Another style of face mask is a pre-formed cup style that doesn’t cover as much of the face as the tie style. With the elastic strap instead of ties, it offers a speedier application and removal, but does not cover as much surface area of the face, therefore increasing the risk of aerosolized particles.


Traffic in the operating room is an often overlooked situation. People just “sticking their head in” to ask a quick question, anesthesia personnel entering and exiting the room frequently, circulating technicians being unprepared for a case and having to leave and re-enter the room numerous times with equipment, are all examples of traffic that can be avoided. Minimal movement in and out of the operating room is obviously the ideal. Once the patient has been moved into the room, positioned on the table, and has received the final sterile prep, people moving around should be minimized. Especially true with joint arthroplasty, no opening of the operating room door should occur unless there is an emergency. Since joint replacement cases are extra sensitive to surgical site infections (SSI), every effort to reduce the introduction of potential pathogens needs to be observed.

Surgical suite cleaning

Before the first case of the day

Before the first case of the day, the furniture in the operating room needs to be arranged so a good traffic flow is possible. Back tables should be pushed up against the walls; cautery units and suction units should be plugged in and be ready for use, but pushed back away from the surgery table. The anesthesia machine should be placed from where it will be used. For most cases, it will be at the head of the table. For some cases however (i.e., ophthalmic procedures or other head/facial procedures), that may mean placing the anesthesia machine at the back of the table. The surgery table should be at the height of the transport table for ease of transferring the patient. The height of the surgery table for the surgeon can be adjusted after the patient is positioned. All flat surfaces including overhead lights should be damp dusted with a lint free rag and 70% isopropyl alcohol or commercially available disinfectant wipes.

In between cases

Gross debris (blood, fluids) should be cleaned up with paper towels or mopped up as soon as the case is finished. All flat surfaces should be disinfected. It is best to avoid applying disinfectants with a spray bottle as they aerosolize particles in the operating room. Either spray the cleaning rag outside of the operating room or use commercially available disinfectant wipes. The broadest spectrum disinfectant available would be a wise choice to reduce the exposure of potentially harmful bacteria to already compromised patients. If the surgery table has a split top, cleaning the drain tray under the split must be done. Elevate one side of the table to allow access to the drainage tray to remove any contaminants that may have fallen into the tray (i.e., blood, urine, hair, sutures, etc.) (Figure 3.4). When necessary, mopping the floor with a clean mop head may be done between cases, otherwise spot cleaning would be sufficient.


Figure 3.4 Surgical table with split top open for cleaning.

Terminal cleaning – end of day

After the last case of the day, the surgical suite should undergo a more vigorous cleaning. All furniture should have a physical scrubbing done. All surfaces, including wheels or casters should be freed of any debris (hair, suture ends, etc.). All shelves of equipment should be scrubbed as well. All equipment such as cautery, laser, and suction machines should be wiped down with a disinfectant. Linen hampers, kick buckets, sponge basin stands, and so on should be wiped down and disinfected as well. Floors should be wet vacuumed. Mopping should be avoided unless clean mop heads and fresh solution is used on each room to prevent the spread of bacteria. Air intake grills, door handles, and window sills should be wiped down. Walls and ceilings should be checked and spot cleaned as needed.

Solutions to use for cleaning

There is no perfect disinfectant for use in the veterinary hospital, so facilities need to decide, based on their needs, what will work the best. Criteria to consider include cleaning versus disinfecting capabilities, spectrum of effect, time needed for optimum efficacy, method of application, efficacy in the presence of organic material, and of course, cost.

Sodium hypochlorite

A dilute bleach solution of 1:32 (1 oz. in 32 oz of tap water) is an effective disinfectant. Although this is inexpensive, the disadvantages may outweigh the cost effectiveness. Once mixed, it is highly unstable and light sensitive. So it needs to be made fresh every day and stored in an opaque spray bottle. The mechanism by which chlorine works is by a denaturing of proteins due to their electronegative nature. It is considered a broad spectrum disinfectant; however, it isn’t a good cleaner. So areas need to be cleaned before being disinfected. Bleach does not perform well in the presence of a detergent or an organic material and so surfaces must be free of those products. Finally, as is true with many products, it requires a 10-minute contact time to reach full effectiveness.

Potassium peroxymonosulfate

Potassium peroxymonosulfate (Trifectant®) claims bacteriocidal, virucidal, and fungicidal capabilities. Its method of action is by the denaturation of proteins and lipids of organisms. Once mixed to the 0.5, 1 or 2% solution it is stable for 7 days. It also requires a 10-minute contact time, but is an effective cleaner as well as disinfectant. Some references claim unreliable performance against dermatophytes. At the time of writing, California allowed limited use of this product.

Quaternary ammonium compounds

Quaternary ammoniums (Roccal-D® or A-33) are commonly used due to their cleaning and disinfection properties. The mode of action for the quaternary ammonium compounds QACs on microorganisms is that they irreversibly bind to the phospholipids in the cell membrane and then they denature proteins. They also require a 10-minute contact time and strict attention to dilution/mixing directions from the manufacturer (Figure 3.5). One common mistake is diluting the product with tap water when the manufacturer specifically indicates distilled water. Tap water generally contains too many minerals and contaminants that interfere with the product’s performance. Some discussion has been had regarding the ineffectiveness of these types of chemicals against non-enveloped viruses (canine parvovirus, feline panleukopenia, and feline calici virus). The addition of diluted bleach to these cleaning products produces an effective cleaning/disinfecting combination, but with the instability of bleach may prove to be an inefficient and costly alternative.


Figure 3.5 Disinfectants for cleaning the surgery suite.


Phenols (One Stroke Environ®) are broad spectrum disinfectants that are formulated in soap solutions so as to improve cleaning potential. Phenols are known to maintain activity in the presence of organic material as well as hard water. While 5% concentrations are bacteriocidal, tuberculocidal, fungicidal, and virucidal for enveloped viruses, concentrations greater than 2% are highly toxic to all animals, especially cats. This contradiction requires the discussion/decision of the use of this product in veterinary hospital situations.

Oxidizing agents

Hydrogen peroxide is one example of an oxidizing agent found in some veterinary disinfectants. Accel® Disinfectant is one product for veterinary clinics. With good effectiveness against 26 organisms including Trychophyton mentagrophytes, it also has good cleaning, sanitizing, and disinfecting properties. This agent is available in concentrate, ready-to-use spray bottles, and convenient saturated wipes.

Regardless of the type of disinfectant chosen, there are some very important things to remember. First and foremost is to read and follow the directions on the label! All too often in veterinary medicine, we inaccurately dilute chemicals based on shortage of time, no measuring device readily available, or historical visual assessment (“make it a light green color”). Improper dilution can affect the health and safety of both workers and patients as well as the overall efficacy of the products. Disinfectants will not act the way they are expected to act when improperly diluted. This inaccuracy can lead to the unintentional spread of potentially lethal organisms.

Application of the disinfectant must be done as directed by the manufacturer in order to achieve the expected action. Whether sprayed on, wiped on, mopped on, or foamed on, inappropriately applied products are ineffective.

To achieve microorganism kill/control, the chemical must also be left on the surface for the directed time. Spraying a table top and wiping it right away does practically nothing. Following the manufacturer’s instructions is imperative. Many chemicals are required to be in contact with the surface 5–10 minutes, but reading instructions for use will identify the specific time. After the proper duration of contact, completely drying the surface is critical. Often this step is “short cutted” and the surface is left damp. Moisture can actually counteract the efficacy of the products as it promotes bacterial growth, therefore making sure that the surface is dry is essential.

Patient preparation

Proper preparation of the surgical patient is a critical step in the surgical case and is related to the outcome and subsequent potential infection of the surgical site. Improper patient preparation can have catastrophic consequences for the surgical procedure and incision integrity (Tear, M. 2012).


Surgical prep of veterinary patients consists of two steps: clipping (removal) of the hair/fur and skin cleansing with an antiseptic. Clipping and prepping of the patient must be done outside of the surgery room. Loose hair, dermal flora, and splashing solutions greatly increase the risk of contamination of the area. A smock must be worn over scrubs to protect the clothing underneath whenever clipping a patient. When clipping surgical patients, the use of a size 40 clipper blade with an electric clipper is a standard approach. Various other sizes of clipper blades are available but do not provide the close removal of hair that is achieved with the 40 blade. It is also imperative that the hair be shaven against the grain of the hair to ensure the closest cut of the hair that is possible. Even with long-haired patients, it is ill advised to clip with the grain (growth) of the hair. Helpful hints that insure a symmetric, neat, nontraumatic shave include: pulling the skin tight and moving the clipper blade away from the opposite hand; keeping the clipper blade level against the skin; Figures 3.6 and 3.7 using the toothed edge of the clipper blade – at a 900 angle to the hair – to create a straight edge for the margins of the clipped area; always using a clean, sharp clipper blade to provide the cleanest, shortest cut of the hair shaft. Clipper blades with missing teeth or that feel dull should not be used and should be replaced or repaired.


Figure 3.6 Proper angle of clipper blade to skin.


Figure 3.7 Improper (too steep) angle of clipper blade to skin.

Knowing the anatomic landmarks and margins for clipping a patient for a surgical procedure is the responsibility of the technician. Having a skilled, knowledgeable person handling this task is an invaluable peace of mind for the surgeon. Good communication between the technician and the surgeon is critical for this step of the process. The technician should check with the surgeon to be sure the site of the incision is understood. Also, the technician should check with the surgeon to see if any additional areas need to be clipped for the procedure (i.e., graft site for a fracture repair or a chest tube exit site for a thoracic procedure). Technicians must have a thorough knowledge of the procedure being performed and possible intra-operative complications in order to adequately prepare the patient. The following guidelines for clipping of the surgical patient are merely guidelines. Each case must be treated individually in the event unusual circumstances are present.


In general, abdominal procedures for both male and female patients will be fairly standard. An abdominal clip will extend from the either mid sternum or the xyphoid to the pubis and laterally to the ventral edges of the ribs. Surgical procedures that are more focused on the cranial abdomen may necessitate a more cranial clipped margin to mid sternum. More caudal abdominal procedures may require the extension of the caudal margin back to the scrotum/vulva of the patient. It is recommended that when clipping an abdomen, the clipper blade always moves away from the umbilicus. That will create a cut against the grain of the hair and will provide as close a clip as possible. Short hair left on the skin, from an inadequate clip, could potentially be incised by the blade and end up as foreign body in the abdomen. Infection could result from the presence of a foreign body. Table 3.1 shows recommended guidelines for clipping margins for abdominal procedures. Whether or not the prepuce of a male is to be included in the surgical field, the hair on the prepuce should be completely removed and the prepuce flushed with a weak Povidone-Iodine solution mixture. The most common exception to this rule is when prepping a canine patient for a castration. Adding 1 ml of full strength Povidone-Iodine solution to 20 ml of tap water will be adequate. After clipping is completed and vacuuming of the hair has occurred, the prepuce can be flushed. Insert the tip of the 35 ml syringe into the prepucial opening (Figure 3.83.10). Pinch the tissue around the tip of the syringe (to trap fluid within the prepuce) and dispense approximately 10 ml of the solution. Gently massage the prepuce. Place a towel on the abdomen and pull the prepuce to either lateral side, release the pinch grip on the prepuce, and allow the fluid to escape from the prepuce onto the towel. The entire procedure should be repeated until all the dilute solution has been used. Modifications of volume of dilute solution made and administered must be considered if the patient is either a very small or a very large dog.

Table 3.1 Abdominal procedure clipping guidelines.

Procedure Cranial edge Caudal edge Lateral edge
Gastrotomy, gastropexy, splenectomy, liver biopsy/lobectomy, gall bladder, kidney Mid sternum Cranial edge of pubic bone Ventral edge of ribs
Urinary bladder, duodenum, jejunum, pancreas Xyphoid Cranial edge of pubic bone Ventral edge of ribs
Prostate, ileum, colon Xyphoid Scrotum/vulva Ventral edge of ribs

Figure 3.8 Infusing prepuce with dilute Povidone-Iodine solution.


Figure 3.9 Gently massaging prepuce.


Figure 3.10 Releasing solution from prepuce.


Thoracic procedures require either the lateral side or the ventral side of the chest to be clipped (Figure 3.11). Depending on the surgical procedure and the approach the surgeon will use, clipping margins can vary greatly. Communication with the surgeon is imperative in order to ascertain that the correct area of the patient is clipped. An additional special circumstance is true with a thoracic case, which does not occur with any other type of surgical procedure; more often than not, a chest tube will be placed in patients that have undergone thoracic surgery. The exit site of the tube must be known by the technician clipping the patient in order to guarantee enough hair has been clipped to accommodate the surgeon’s intentions for the chest tube. Again, communication with the surgeon, prior to clipping, is critically important. Table 3.2 identifies guidelines for clipping for thoracic procedures.


Figure 3.11 Lateral thoracotomy prep.

Table 3.2 Thoracic procedures clipping guidelines.

Procedure Clipping guidelines
Ventral approach via sternotomy –(lung lobectomy, heart base tumor) Cranially to the base of the ventral neck, caudally 2–3 clipper widths caudal to the xiphoid process, laterally to halfway between the dorsal and ventral midlines
Lateral approach (4–5 intercostal space usually)- (PDA ligation, lung mass, chylothorax) Cranially to the base of the neck, caudally 2–3 clipper blade widths caudal to the last rib, dorsal, and ventral midline


Prepping a patient for an orthopedic procedure is generally quite extensive (Figure 3.12). Even if the procedure is a single joint arthroscopy, the potential of an arthrotomy being performed necessitates a wide clip. The standard rule of thumb when clipping for an orthopedic procedure is to clip from the joint proximal to the incision to the joint distal to the proposed incision site. In the event of a proximal joint surgery (hip or shoulder), the clip extends a minimum to two clipper blades beyond the ventral and dorsal midline. Especially with orthopedic procedures like an arthrodesis or fracture repair, the technician must be certain to communicate with the surgeon regarding the need for clipping for an autogenous cancellous bone graft harvest. Procedures on the fore limb generally use the head of the humerus or the proximal tibia as a graft site, unless that bone is involved in the surgery. For hind limbs, the wing of the ilium is the most common bone graft harvesting site. Large margins should be clipped for the graft, and due to wide variations in animal size, exact measurements cannot be provided. A good rule of thumb is to clip 2–3 clipper blade widths in all directions from the graft site incision. Tables 3.3 and 3.4 show recommended guidelines for clipping margins for orthopedic procedures.


Figure 3.12 Clipping for an orthopedic procedure.

Table 3.3 Forelimb orthopedic procedures clipping guidelines.

Procedure/location of surgery Proximal margin Distal margin
Phalange, meta carpal procedures Shoulder Toenails – including hair in interdigital space
Carpal arthrodesis, distal radius/ulna fractures, angular limb deformity, mid-shaft radius/ulnar fracture Shoulder First phalanx
Elbow surgery, distal humeral fracture, ununited anconeal process repair, fractured coronoid process repair Dorsal midline; ventral midline Carpus
Proximal humeral fracture repair, Scapular fracture repair Two clipper widths beyond dorsal midline; ventral midine Mid radius
Forelimb amputation Two clipper widths beyond dorsal midline; ventral midline; caudal to last rib; cranial to base of neck Mid radius

In addition to proximal and distal margins, all hair should be removed circumferentially on the limb.

Table 3.4 Hindlimb orthopedic procedures clipping guidelines.

Procedure/Location of surgery Proximal margin Distal margin
Phalange, digits, metatarsal Mid-femur Toenails – including hair found in interdigit space
Tibia/fibula fracture repair Hip First phalanx
Stifle surgery (cruciate ligament repair, arthroscopy, medial patellar luxation repair) Hip Tarsus
Femur (distal fracture repair) Hip Tarsus
Femoral head osteotomy, proximal femoral fracture repair Two clipper widths beyond dorsal midline Tarsus
Total hip arthroplasty Ventral midine; two clipper widths beyond dorsal midline; caudally to tuber ischii; cranial to last rib Tarsus

In addition to proximal and distal margins, all hair should be removed circumferentially on the limb.


Patients having a neurologic procedure performed have one of the easiest clipping situations. The recommended margins are to clip 3–4 vertebral spaces cranial and caudal to the suspected space. This allows ample room for the surgeon to extend the incision should other vertebral spaces need to be explored. As with other clipping guidelines, the technician must communicate with the surgeon to be sure the appropriate area is clipped. Additionally, if a cervical procedure is being performed, be sure to ask the surgeon if a dorsal or ventral approach will be utilized. Much time can be wasted if the dorsal cervical area is clipped and prepped only to find out the surgeon planned on a ventral approach! Table 3.5 displays suggested clipping guidelines for neurologic cases.

Table 3.5 Neurologic procedures clipping guidelines.

Procedure Cranial/caudal margins
Cervical ventral slot* Clip 3–4 vertebra cranial and caudal to suspected vertebral space.
Cervical dorsal laminectomy On the dorsal midline – Clip 3–4 vertebra cranial and caudal to suspected vertebral space.
Cervical dorsal laminectomy – Suspect site C1–C2 Clip mid cranium to C5
Thoracic laminectomy/hemi – laminectomy; lumbar laminectomy/hemi – laminectomy On the dorsal midline; clip
3–4 vertebra cranial and caudal to suspected space. (i.e., if suspect space is T13–L1 , clip from T10 to L4)

*Note: This clip occurs on the ventral neck.

Miscellaneous sites

Patients having a surgical procedure that involves the sensory organs – eyes, ears, tongue, or facial bones – are more challenging to prep. Special anatomic configurations as well as extra sensitive tissue require a special approach.


Ophthalmic procedures should never have a clipper involved in the surgical site prep, unless the procedure to be performed is an enucleation. This type of extra ocular procedures requires the removal of the entire eye and therefore, any accidental trauma to the eye from the clipper is a non issue because the eye is being removed anyway. Any intra-ocular procedure should have fine-bladed scissors (i.e., baby metzenbaum) used to remove eyelashes and/or any fine hair on the eyelid margins that needs to be removed. Applying a water-soluble lubricant to the blades of the scissors prior to trimming the hair will have the hair adhere to the blades rather than falling into the eye. The blades of the scissors should be wiped with clean gauze frequently and lubricant reapplied each time the blades are cleaned. Table 3.6 shows the recommended guidelines for ophthalmic procedure clipping.

Table 3.6 Ophthalmic procedures clipping guidelines.

Procedure Margins
Ophthalmic cases – intra ocular – corneal laceration repair; foreign body removal Using a fine bladed scissors with water soluble lubricant on blades – trim eyelashes and hair on eyelids near conjunctival margin
Ophthalmic cases – extra ocular – enucleation A clipper blade width from eyelid margins (dorsal and ventral direction); a clipper blade width from medial and lateral canthus.

Note: eyelids should be sutured closed prior to beginning clipping for an enucleation.


Aural surgeries vary greatly in nature and so does the clipping. Procedures of the ear canal and inner ear require a much different clip than those just involving the pinna. As a word of caution, bulla osteotomy procedures also require the clipping of the ventral neck to facilitate the approach the surgeon will make to the surgical site. Table 3.7 describes recommended clipping margins for various aural procedures.

Table 3.7 Facial/aural procedures clipping guidelines.

Procedure/location of surgery Margins
Mandibuar mass removal, mandibulectomy, fracture repair Rostral edge of mandible caudally to ramus of mandible; dorsally to commissure of lip; ventrally to ventral midline
Maxillectomy, maxillary fracture repair Rostral edge of maxilla caudally to ear; dorsally to lateral canthus of eye.
Aural procedures* – pinna hematoma lancing, mass removal, laceration repair Clip entire pinna from tip to dorsal attachment to head.
Aural procedures – lateral ear canal resection; total ear canal ablation Remove hair from medial and lateral sides of pinna; dorsally to dorsal midline; ventrally to ventral midline; rostrally to lateral canthus of the eye; caudally to base of neck
Aural procedure – ventral bulla osteotomy Laterally to the base of the affected ear; entire ventral mandible from mandibular symphosis to the mid-cervical neck.

*Check with surgeon to find out if both medial and lateral sides of pinna need to be clipped.

Head and mouth

Procedures of the mouth and head can be intra oral or extra oral. Intra-oral dental surgery is generally performed by veterinary dentists and will not be addressed in this text. Intra-oral procedures involving the removal of a mass may be performed by a soft tissue surgeon. Suffice to say, however, that intra-oral procedures generally require little to no clipping. If the mass is entirely within the mouth, there is no need to clip any hair. Procedures that are extra oral in nature do require some caution when clipping so as not to injure or traumatize either of the eyes, depending on where the incision is to be made. Table 3.7 describes the recommended clipping margins for cranio/facial procedures.


Perineal procedures are also a unique clipping situation. Whether a perineal hernia repair, an anal sacectomy, or a perianal tumor removal, the margins for clipping are fairly standard. One additional step in the patient prep that is unique to any perineal procedure is the placement of a purse string suture in the anus. The method of a purse string suture placement will be described in the patient prep section of this chapter. In most states, this should be considered a task that can be delegated to technicians as it is not a primary closure of a wound but rather a step in a nursing procedure. It is advisable to check with the Practice Act in the state to determine the eligibility to perform this task. Table 3.8 outlines the recommended hair removal margins for various perineal procedures.

Table 3.8 Perineal procedures clipping guidelines.

Procedure Cranial edge Caudal edge Lateral edge
Anal sacectomy Base of the tail Ventral side of tail To level of tuber ischii on both sides
Perineal urethrostomy Base of tail Ventral side of tail and ventrally on limbs to stifle. Only medial aspect of limbs need be clipped To the level of the tuber ischii
Perineal hernia Base of tail or cranially to lower sacral vertebrea Ventral side of tail and ventrally to level of abdomen To level of tuber ischii

Amount of hair to be clipped is dependent on the size of hernia.

Open wound clipping

Open wounds are considered contaminated but still require special attention when clipping. The main focus when prepping an open wound is to prevent any more contamination (hair) from entering the wound. A couple of options are available to achieve this goal. First of all, a saline soaked sponge can be placed over the wound. Be sure to leave all wound edges visible; so removal of hair can be accomplished on the edges. Any hair that may fly or fall into the wound will land on the sponge and will be much easier to remove than if it had landed on the tissue. Once clipping has been completed, simply fold the corners of the sponge(s) to the middle and lift it out of the wound.

Another option is to cover the open wound with a thick layer of water soluble lubricant. Once the wound is covered with a lubricant, clipping may begin. It is always best to clip away from the wound, but clipping against the grain of the hair must also be observed. Care should be taken to avoid, as much as possible, depositing any clipped hair in the wound. Once clipping is completed, the wound must be flushed well with sterile saline, before the prepping begins, to remove the lubricant and any hair that may have fallen into the wound.

After clipping for any surgical procedure, a complete vacuuming of all the removed hair must occur (Figure 3.13). Ensure stray clumps of hair under the patient or on the towel the patient is lying on are removed. If the technician’s smock has large amounts of hair on it, don’t forget to vacuum the smock as well. Holding the vacuum hose with one hand permits the other hand to be free to manipulate the animal’s skin or the towel to avoid having those items sucked into the hose. Placing one finger (of the hand holding the vacuum hose) over the end of the hose will cut the suction to aid in avoiding traumatizing tissue with excessive suction power.


Figure 3.13 Central vacuuming system.

Clipper care

After each patient has been clipped, the blade should be evaluated. If any teeth are missing from the blade, the blade should be removed and thrown away. If the blade appears to be intact, it needs to be cleaned and lubricated. After each use, clipper blades must be disengaged from the clipper head, removed, and cleaned. Using a stiff plastic (not metal) bristle brush, remove the hair from the blade, the teeth and the clipper head. Re-attach the blade, but do not snap the blade into place until the clipper is running. Once the clipper has been turned on, snap the blade into position being certain to properly engage the blade. If the teeth are not moving or there is a knocking or rattling sound, the blade is not properly positioned. Once the blade is running smoothly, spray a commercially available clipper blade lubricant on the teeth and allow it to run for at least 1 minute. After a minute of running, take a paper towel or gauze and blot away any excess lubricant. Blades should also be greased according to manufacturer’s recommendations. If a new clipper blade is placed on the clipper head, before it is used on a patient, it must be cleaned with a commercial blade wash. With the clipper running, submerge just the teeth in the blade wash for a minute or so. Remove the blade from the solution, turn off the clipper and blot away any excess solution on the blade. This step will remove oils from the factory and will improve the longevity of the blade.

Patient skin preparation

Preparation of the skin of the surgical patient has been a long debated issue. Information used as a guideline for human surgical patients doesn’t translate exactly for veterinary patients. Efficacy of products on animal skin differs from human skin due to the different thickness (i.e., bovine skin vs. human skin), fat content (i.e., porcine skin vs., human skin) and that fact that animal skin, for the most part, is covered by fur. Nonetheless, often references with a human surgical patient base are utilized as standards of care with veterinary patients. Smocks worn while clipping should be removed for the prep. A surgical head cover, mask, and exam gloves should be worn to decrease the risk of cross contamination of the surgical site.

Surgical scrub products

There are two basic options of surgical scrub products available for use for surgical patient preparation. Each has redeeming qualities of its own, but overall one is superior when all categories are considered (Figure 3.14).


Figure 3.14 Scrub products available for patient prep.


Chlorhexidine scrub is a 2% or 4% detergent-based product that can be used to cleanse the surgical site of veterinary surgical patients. It has a rapid onset of action, persistent effectiveness in the presence of bodily fluids and has excellent residual effect. Chlorhexidine requires a 3-minute contact time to maximize the benefits of the product. It can be rinsed with sterile water or 70% isopropyl alcohol. Generally, the 2% product is rinsed with 70% isopropyl alcohol and the 4% product is rinsed with sterile water. Care should be taken to supplement body heat with an external device as much as possible because rinsing agents can cause hypothermia.


The other option for patient prep is povidone-iodine. Although less expensive than chlorhexidine, it is inactivated in the presence of organic material, has significantly lower residual activity, and when rinsed with isopropyl alcohol, has lower effectiveness. Because it is an iodine-based product, the orangish/brown color is appreciated by some as an indicator of what area has been covered.

Although there have been a few studies comparing Chlorhexidine and Povidone-Iodine as patient prep materials, there is a recent study with human surgical patients, comparing the rate of SSI (surgical site infections) and the skin preparation product used, that proves helpful. The patients were either prepped with 2% Chlorhexidine gluconate and rinsed with 70% isopropyl alcohol or 10% Povidone-Iodine scrub and painted with 10% aqueous Povidone-Iodine solution. The study showed that those patients prepped with 2% Chlorhexidine had a significantly lower rate of SSI 30 days post operatively. The findings concluded that due to Chlorhexidine’s many redeeming qualities, the skin flora of the patient was reduced, thus lowering SSI ( It would seem reasonable to translate this same application to veterinary medicine and veterinary surgical patients.

Rinsing agents

Rinsing agents have traditionally been either 70% Isopropyl Alcohol or sterile water/saline (Figure 3.15). While alcohol does add some antiseptic qualities, some feel the hypothermia caused by evaporating alcohol outweighs any antiseptic benefit. Using sterile water/saline to rinse the detergent product from the animal’s skin has less of a hypothermic effect and offers no additional antiseptic value. Additionally, sterile water/saline may increase the sudsing action of the scrub product, which means special attention must be paid to ensure that complete removal of the scrub agent is attained. Determining which product to use may be based on the size of the patient having surgery, the product used to cleanse the skin, the type of surgery being performed, and the estimated length of the anesthetic episode. All these factors can contribute to hypothermia and the benefits must be compared to the consequences.


Figure 3.15 Rinsing products available for patient prep.

Final paint solutions

Final painting of the clipped and scrubbed area needs to happen as a final step in the skin preparation process. Which ever chemical base (Chlorhexidine or Povidone-Iodine) is used for the scrub, the same solution should also be used for the final paint (Figure 3.16). Povidone-Iodine is used full strength as it comes from the manufacturer. Chlorhexidine however is diluted according to the manufacturer’s direction, which is generally one ounce Chlorhexidine solution in one gallon of tap water.


Figure 3.16 Final solution products available for patient prep.

Patient prep patterns

Target pattern

Depending on the proposed incision site, there are various methods or patterns for cleansing the skin that can be utilized. For abdominal, thoracic, neurologic, or lump/mass removals, a target pattern should be used. It is aptly named the target pattern because when properly executed, it resembles a target or bulls eye. Starting at the center of the clipped area (which should be the proposed incision site), the skin is cleansed with surgical scrub applied in a linear, back-and-forth movement. When using a sponge, it is advantageous to fold the corners of the sponge to the center to better control the surface area of the sponge touching the patient. There need not be excessive pressure placed on the skin. In fact, too much pressure can result in abrading the skin which can create a breeding ground for bacteria and actually compromise the incision. If redness or capillary oozing appears, the amount of pressure being exerted by the person prepping must be greatly reduced to the point of barely touching the skin. Contact time with the surgical scrub is what affects the effectiveness, not the amount of pressure used to apply the product. After constant contact with the proposed incision site (about 15 seconds), the sponge continues to be moved in a small back-and-forth motion while moving outward from the center to the periphery of the clipped area. If the sponge becomes contaminated (by hair or other organic material), it should be discarded and a new sponge obtained. The new sponge should begin where the old one ended and continue moving in an outward motion toward the hairline. Once the sponge touches the hair, it may continue to be used if only touching hair (Fossum, T. 2007). The entire area that is clipped should be scrubbed. After the initial scrub is completed, a decision needs to be made. Some surgeons prefer to have the site scrubbed two more times with the surgical scrub before rinsing with a rinsing agent. This approach provides a constant contact time. Other surgeons prefer to have the site scrubbed once, rinse with either 70% Isopropyl alcohol or sterile water/saline, then scrub again, then rinse, then repeat the cycle one more time. This approach has interrupted contact time, but it is easier to remove all the scrub detergent from the skin. There has been no proof that one method is more beneficial than the other as long as the recommended contact time is achieved.

The rinsing agent should be applied to the shaven area using the same target pattern. If using sterile water/saline to rinse, a good squeeze of the sponge, to remove excess fluid, will be helpful. This will help decrease excessive sudsing as mentioned previously, which can hinder complete removal of the scrub agent. It is important that all detergent be removed from the skin as it can cause tissue irritation if transferred to internal tissues. The clipped area needs to be cleansed at least three times to meet the essential contact time without excessive drying or abrading of the skin. If however, after checking the rinse sponge of the third cycle of cleansing, there is still dirt being removed, cleansing should continue until the rinse sponge is clean. Most small animals will be clean after the three cycles, but animals that live in an area where they are exposed to more dirt (outside kennel, farm) or those involved in a trauma (hit by car, penetrating wound) may need the additional cleansing. In an ideal situation, at this point the patient would be transported to the surgery room, positioned on the surgery table, and then have a sterile prep performed. However, quite frequently this doesn’t occur. If no sterile prep is performed, a final application of paint solution is applied, using the same target pattern. Paint solution may be applied with a spray bottle instead of with a sponge, although the disadvantages outweigh the advantages. Application with a spray bottle results in the solution falling on surfaces not intended to be sprayed (patient’s fur, table top, and floor) and causes a mess. Also, application with a spray bottle may mean the solution is sprayed in uneven amounts on the animal’s skin, which may mean not all solution is dry before surgery begins. Although spray application is accomplished quickly, this is the only advantage. Application of the final solution with a sponge allows for a controlled, even application of solution. However applied, the solution must be allowed to fully dry prior to draping and the incision is made to allow the product to perform to its full potential. The patient can then be moved into the surgery room, taking special care not to contaminate the prepped area. At a minimum, another final paint solution application should occur after final positioning on the surgery table.

Orthopedic prep

Patients having surgery on any limb will most likely need an orthopedic prep. This method of skin preparation offers the surgeon the ability to have full circumferential access to the limb as well as having the ability to handle and maneuver the limb as needed during the procedure.

First of all, the distal end of the surgical limb, if available, must be covered to the carpus/tarsus with an exam glove or a nonadhesive elastic type bandage material (Figure 3.17). Once the distal limb is covered, a stirrup (for suspending the limb) must be made. Using 1″ or 2″ tape, rip a piece approximately 30″ long to be used to create the stirrup, which will elevate the limb (Figure 3.18). Large breed dogs or dogs with long legs may need a slightly shorter piece, while small dogs or shorter legs will need a longer piece of tape. Regardless of the length, leave the last 1–2″ on either end as a regular-width tape. The tape in between needs to be folded on itself lengthwise, with the sticky sides facing each other, to form a nonsticky surface. The ends are then adhered to the covered paw, on either the medial and lateral surfaces or the dorsal/palmar or plantar surfaces, leaving the loop visible. The tape is then used to cover the tape ends on the paw to secure the stirrup so it doesn’t slip (Figure 3.19). If the distal portion of the limb is the surgical site, a Backhaus penetrating towel clamp can be clamped onto a toenail for limb suspension. The tape stirrup is then passed through the ring handles of the towel clamp, the free ends of the stirrup are secured to one another and the limb is ready for suspension. Providing support to the limb, lift the leg and place the loop over an IV pole hook. Elevate the pole so the leg is straight, but not lifting the animal off the table. In the case of a fracture, providing support to the limb is imperative to avoid bone fragment ends from causing more trauma to the tissues. Once elevated, the traction on the limb tissues will stretch and fatigue the muscles. This action may help the surgeon with reduction of the fracture, due to the muscles being more relaxed.


Figure 3.17 Covering the distal end of the limb.


Figure 3.18 Applying a hanging stirrup.


Figure 3.19 Securing the stirrup with tape.

The orthopedic prep begins at the center of the clipped hanging limb, at the proposed incision site. Fold the corners of the prep sponge into the middle and hold all four corners to better control the sponge. Holding the limb by the taped, suspended foot, begin scrubbing the skin, moving the hand in short vertical strokes, circumferentially (all the way around) on the limb. Once one complete circling of the limb has been completed, the sponge is moved just proximally on the limb and the pattern is continued. Due to the larger surface that needs to be covered with this prep, subsequent sponges may be needed as the pattern moves proximally on the limb. When starting with another sponge, the prep should begin where the previous sponge ended. As with the target pattern, once the sponge touches hair, it can only continue to touch hair and may never return to the clipped skin. With a new scrub sponge, the prep is again started at the center of the suspended limb. Begin scrubbing the skin, moving the hand in the same short vertical motion, circumferentially on the limb. Once one complete circling of the limb has occurred, the prep continues moving the sponge distally toward the foot. Once the taped foot is reached, the sponge is discarded. Care should be taken to avoid over saturation of the tape as that may loosen the adhesive and the limb may fall down. After scrubbing the entire clipped area, the pattern can be repeated either with another scrub sponge or with a rinse sponge, as previously discussed. After the limb is sufficiently cleansed (at least three scrubs/rinses or until the rinse sponge is free of dirt and minimal contact time has occurred) a clean (not sterile) towel needs to be laid over the down limb. The surgical limb is then carefully lowered and laid on the towel. The patient is transported to the surgical suite and positioned on the surgery table. The leg is then carefully re-suspended and the towel removed in preparation for the final prep. ALL orthopedic procedures should always have a sterile prep performed following final positioning of the patient on the surgery table.


Perianal/perineal procedures are generally prepped utilizing a modified target pattern. Once the clipping and vacuuming is complete, the next step is the placement of a purse string suture in the anus. This is done to help eliminate the leakage of fecal material onto the surgical field. Unless the surgeon requests that this need not be done, it is a standard inclusion in the patient preparation. Depending on the type of surgery being performed, the anal sac openings may or may not be contained within the purse string suture. Anal sacectomy surgery generally requires the anal gland openings be left outside of the suture, or within the surgical field. However, some perineal surgery (i.e., perineal herniorraphy) will require anal sac opening inclusion within the suture pattern. Most urinary related procedures such as episioplasty or perineal urethrostomy surgeries will also encourage anal gland openings within the purse string. In the case of anal sac carcinoma, no purse string pattern may be placed at all in order to provide the surgeon with full access to the entire gland. It is best to check with the surgeon prior to placement of the purse string if there is any doubt. Some people find it easier to place this suture with a straight needle, although a curved needle certainly can be used, as long as the suture is 2–0 or 3–0 in size. Since it is a limited term suture, whether the suture is absorbable or non-absorbable is not an issue, but a monofilament is preferred. In this situation, placement of this stitch is not a primary wound closure, nor a curative measure, so it should be allowed by most jurisdiction’s Practice Acts. If any doubt arises regarding the legality of a credentialed veterinary technician performing this procedure, the Practice Act should be consulted. To place the suture pattern, start first by looking at the anus and imagining it as a clock face. With the needle at the 11 o’clock position take a superficial bite and have the needle exit at the 1 o’clock position. Starting the next bite where the previous one exited the skin, drive the needle superficially and exit at the 5 o’clock position. For the ventral placement, enter the skin at 5 o’clock, drive the needle superficially and exit at the 7 o’clock point. The final bite begins at 7 o’clock and moves in a dorsal direction, superficially and exits at the 11 o’clock point. Superficial placement is imperative for all the bites, but especially for the lateral stitches to avoid inadvertently penetrating the anal glands. In essence a “box” has been placed around the anus. Pull the suture tight to cinch down the anal opening and tie the suture. A simple square knot is sufficient. Cut the suture tails long enough to be able to find them, but not so long they interfere with the procedure. A bold note should be made on the anesthesia sheet or the surgical report indicating the placement of the purse string. This note will act as a reminder to remove the suture post procedure, but before recovery.

After the purse string stitch has been completed, the prep can begin. Working from clean to dirty areas, the clipped area lateral to the anus should be scrubbed with the target pattern. Using a new sponge for each side, perform the target pattern until hair is touched. Use a new sponge and scrub just the anus, then discard that sponge. This modified pattern is repeated until the rinse sponge is free of dirt, with a minimum of three repetitions. The appropriate contact time must also be met. The final solution is applied using the same pattern.

Patient positioning

Once the patient has received the initial prep, they are ready to be transported to the operating room. There are many devices available for assisting with positioning the patient on the surgery table. Proper positioning of the patient is a critical step in the patient prep process. Surgeons require the patient be positioned in a straight and anatomically correct fashion. Once patients are positioned to the surgeon’s liking, they must not shift or move from that position until the end of the surgery. Some surgery tables have a split top, which allows either one or both sides of the table top to be adjusted. Options from a flat surface to a full “V” position are available. For patients in dorsal recumbency this may be all that is required to maintain the patient in the surgical position required. For deep chested dogs, long sandbags will be an effective method for maintaining dorsal recumbency in addition to the table “V”. Foam wedges may also be used but may slip and if contaminated by blood or other fluids may be difficult to clean. Also available for use, if the table top is solid and cannot be adapted to the animal’s shape, is a thoracic positioner (Figure 3.20).


Figure 3.20 Thoracic positioner for maintaining dorsal recumbency.

Additionally patients in dorsal recumbency will need to have their limbs restrained away from the surgical field. Soft ropes or “leg ties” are available and work well. Roll gauze, IV tubing or elastic bands are not recommended as they may apply too much pressure to the soft tissue and impede distal limb circulation. Leg ties should be placed just proximal to the carpus and tarsus, with a half hitch placed just distal to those joints (Figure 3.21). Double placement aids in better distribution of pressure to reduce circulation issues. Most surgery tables have either brackets or rubber rollers on the sides of the table near each corner. Brackets require a figure 8 method of securing of the leg tie with a half hitch on the last loop to hold the rope (Figure 3.22). Rubber rollers are easier to use and simply require the leg tie be passed between the two rubber rollers to securely hold the rope (Figure 3.23). Care should be taken to avoid excessively extending the limbs. The forelimbs should have the leg ties brought over the head of the table, not the sides, to help maintain normal joint anatomy. Hind limbs should be extended to full range of motion, although not excessively stretched, and the ropes should be brought over the end of the table, not the sides. Normal anatomy of the hind leg joints can be maintained with this approach. Rear limb leg ties brought over the side of the table force the hips into a frog leg position and for lengthy procedures, this is not recommended. Additionally, the limbs will be closer to the animal’s body and not impede the surgeons work. There is a special type of positioning aid for dogs having arthroscopic surgery on the stifle. The brace holds the limb in a flexed position to assist the surgeon. The brace must be covered by a sterile drape before the limb can be placed on it.


Figure 3.21 Leg tie with half hitch on limb.


Figure 3.22 Table bracket with figure 8 leg tie.


Figure 3.23 Table roller for securing leg tie.

Patients in lateral recumbency may be maintained in the desired position by the use of sand bags or vacuum positioning aids. Hug-U-Vac® and Vac-Pac® are both positioning devices that conform to the patient to maintain the position; then a vacuum process is used to evacuate the air from the device. As the positioning aid hardens as the air is removed, the patient is held in the desired position. These devices help with thermostasis as well as they are insulated and protect the patient from the cold surface of the surgery table. Vacuum aids are especially helpful when positioning patients for ophthalmic procedures or thoracic cases that necessitate the patient be positioned in an oblique state rather than a level lateral position. Patients in lateral recumbency will also require the limbs to be restrained by leg ties. Larger breed dogs may have sandbags, foam, or some other type of “spacer” placed between the upper and lower limb to help alleviate stress on the upper limb joints.

Patients undergoing spinal surgery are generally placed in ventral recumbency. The use of sand bags and/or vacuum aids is required in order to achieve and maintain proper positioning of the patient. Patients in this position must be monitored for adequate respiratory capability. The vacuum positions aids are quite stiff and hard following evacuation of the air and are therefore not very good at allowing expansion of the chest wall if conformed too tightly to the patient. Positioning aids should not be “wrapped around” the chest of the patient, but rather gathered or formed along the sides of the chest.

Patient warming

Normal body thermoregulatory systems are compromised by anesthesia, so maintaining an appropriate body temperature for the patient is very challenging. Surgical complications can often be linked to patient surgical/post-surgical hypothermia, so external supplementary means must be used. In addition to peripheral vasoconstriction, hypothermia can compromise the immune system and elevate both blood pressure and heart rate, thus affecting wound healing.

Heated surgery tables

One method of supplemental heat is the use of a heated surgery table top. Some surgery tables are constructed with heating elements enclosed with in the table top and a control box to adjust the temperature setting (Figure 3.24). As there is a constant source of heat, there is the potential for a thermal burn; so placing a towel between the table and the patient is advised. Care should be taken not to use a towel that is too thick as then the benefit from the heated top may be compromised by the density of the towel.


Figure 3.24 Control box for heated surgery table.

Circulating water blankets

Other types of supplemental heating generally revolve around the use of a pad of some sort and a control unit or box (Figure 3.25). Circulating water blankets have been employed for a long time and are now available with hard plexiglass pads as well as the traditional softer vinyl pads. A claw or tooth that punctures a vinyl pad will result in a soaking wet patient due to the water escaping form the pad. A plexiglass pad eliminates the possibility of this occurring due to the durability of the plexiglass. Returning to the recovery area to check on a patient only to find a flood and a soaking wet patient is very frustrating. As with any constant heat source, a towel should be placed between the pad and the patient.


Figure 3.25 Supplemental heating devices.

Convection warming systems

The use of forced warm air enveloping the patient has increased in recent years. A light weight disposable paper pad with many small holes is positioned to cover as much of the patient as possible. Once the patient is positioned on the surgical table, but before the drapes are placed, the pad is placed over the patient (Figure 3.26). After the surgical drapes have been placed, the unit is turned on. While the drapes do assist in keeping the warm air close to the patient, there is some concern with increased air particles and potentially compromising aseptic technique with the addition of the warm forced air. This type of warming device is effective at quickly warming hypothermic patients in recovery.


Figure 3.26 Hot air warming system.

Solid warming pads

Multiple styles of solid warming pads that can be used are also available. Many of the pads deliver a low voltage current to the solid pad. Internal sensors regulate the temperature of the pad and greatly reduce the risk of hot spots or uneven heating. The highest setting on these pads should not be used unless there is a towel between the patient and the pad. Some models have an automatic shut off which inhibits thermal burns as well. Some of the styles of solid pads can be wrapped around (envelope) the patient, which in turn results in less hypothermia.

Alternative methods

Alternative methods of supplementary heat include warmed bags of fluids, rice socks, warming discs, and hot water gloves (Figure 3.27). These devices, while warm, can certainly provide external heat for the patient. They are readily available, relatively inexpensive, and reusable, but the disadvantages must be considered. First of all, smaller warming devices will provide supplemental heat to only an isolated area of the body. Other methods previously discussed have a much greater body surface contact area, therefore increasing heat absorption. Secondly, the warmed devices only provided warmth for a limited period of time and then they start to cool. As the rice socks or any other such device cools, it will also cool the patient, therefore making these choices contraindicated for procedures longer than 30 minutes.


Figure 3.27 Alternative warming devices.

Patient sterile prep

Following positioning of the patient, the sterile prep may begin. A sterile patient prep is done in exactly the same way as the initial prep, with the major difference being the use of sterile products. Prep sets can be made a couple of ways, depending on clinic choice. A small instrument pan (3″ × 8″) or a kidney basin (emesis basin) can be used as the pan. Two stacks of ten 4″ × 4″ gauze sponges are placed side by side in the pan. An indicator strip should be placed in the middle of the sponges. A right hand glove (size 7–7 1/2) can then be laid on top of the sponges (Figure 3.28). The pan is double wrapped using the envelope style of wrapping and is steam sterilized. Some clinics prefer to use sterile packaged gauze and a fresh pair of sterile gloves, which is an acceptable adaptation.


Figure 3.28 Sterile prep set with squeeze bottles of solutions.

In addition to the prep set, squeeze bottles of the prep solutions are needed. The solutions and prep set should be set up in the surgery room when the rest of the packs and equipment are placed in the room. Once the patient is placed on the table and positioned, the prep set can be opened. Both wraps are aseptically opened to reveal the sterile contents. Before proceeding, the caps of the solution bottles should be opened. If a glove was not included in the sterile prep set, a pair of gloves should now be aseptically opened and using the open gloving technique, put on one glove on the dominant hand. If a glove was included, it is now aseptically placed on the dominant hand. Having one sterile and one non-sterile hand allows the technician the versatility to perform the sterile prep without assistance. The non-sterile hand is available to pick up the solution bottles to apply the product as well as to stabilize the suspended limb in the event of an orthopedic case.

With the sterile gloved hand, two sponges are picked up. The non-sterile hand picks up the surgical scrub bottle and aseptically applies some scrub solution to the sterile sponges. Care must be taken to ensure the cap of the bottle does not touch the sponges. The prep now continues using the same pattern as was used with the initial prep. New prep sponges should be retrieved as needed. The rinsing agent is aseptically applied to the sponges as needed. Be sure to save a few dry sponges to be used for the application of the final paint solution.

Once the final paint is applied, the draping may begin. Every effort should be made to allow the final solution to dry prior to draping to encourage optimal efficacy.

Personnel preparation


Any person entering the surgery room must have on the appropriate attire. Clean scrubs, with the top tucked into the pants, an appropriate head covering and shoe covers or facility dictated footwear should be a minimal dress code. Personnel in the operating room, whether they are scrubbed in or not, must also adhere to several personal hygiene rules. Bathing or showering should occur everyday. The use of fragrance or cologne should be minimal if at all. With increased sensitivity to fragrance by many people, it is a simple consideration not to heavily apply a fragrance. More importantly, if the room or area is filled with the odor of cologne, the anesthetist will have a difficult time detecting any odor of inhalant gas, which may indicate a leak in the anesthetic system. Finally, due to the increased sensitivity of the smelling sense of animals, heavy odors may be irritating to the patients.

Jewelry worn should be minimal and simple. If acting as the surgical assistant, no rings, watches, or bracelets can be worn. Even necklaces such as a simple chain are discouraged. Earrings should be removed or not worn at all. Some facilities allow small post-style earrings to be left in the ear lobes, but never should hoops or large dangling earrings be worn. Circulating technicians may have simple band style rings and watches left on. Rings with large precious gem stones risk damage from chemicals or getting caught on equipment and would best be left at home. Earrings may be left in and should be a small post-style earring. Simple single chain necklaces may be left on.

Fingernails of all surgical team members should be short, well groomed, and clean. Nails should not be longer than the pad of the finger. Long fingernails can cause pain to feline patients while scruffing them and can puncture surgical gloves. Artificial nails and/or nail polish are strictly prohibited. Chipped or flaking nail polish may contaminate the field, or worse, harbor bacteria that may infect the patient.

Surgeons hand scrub

Members of the surgical team that are scrubbing in need to perform a surgeons hand scrub or rub. A hand rub can be employed for subsequent surgical cases, after a hand scrub has been performed for the first surgery of the day. Details regarding the hand rub are discussed later in this section. A surgical scrub or hand rub is performed in addition to the use of the sterile gown and gloves. The hand scrub is a specific method of cleansing the hands, wrists, and forearms of a person who will be wearing a sterile gown and gloves. A surgical scrub, or cleansing, is performed in addition to the use of the sterile gown and gloves. It has been reported that the overall incidence of glove defects is 23% and glove defects increase as the duration of the procedure increases. Since the presence of glove defects can often be undetected, the surgical hand scrub is an essential step. Products used for a hand scrub must be rapid acting, should be effective against a broad spectrum of bacteria, and should be nonirritating as well as effective at inhibiting bacterial growth. There are three products that may be used for this procedure – Povidone-Iodine, Chlorhexidine and Chloroxylenol (PCMX).Other newer products are available, but will be discussed under the hand rub (brushless scrub) section. Povidone-Iodine has a broad spectrum of activity but it is inactivated by organic material. Additionally, it requires a minimum 2-minute contact time, which can be easily achieved using either method of surgical hand scrub patterns. Chlorhexidine also has a broad spectrum of activity and has the best residual effect due to it binding to keratin. It is not inactivated by organic material and causes less skin irritation than Povidone-Iodine (Sigler, M. 2001). Chloroxylenol is available as scrub impregnated sponges and traditionally has been outperformed by chlorhexidine.

Before a surgical scrub can begin, all jewelry must be removed from the hands and arms. Nails should be inspected and if too long, they must be trimmed. Neither nail polish nor artificial nails are permitted. Appropriate head and face attire must be put on and the surgical scrub top must be tucked into the scrub pants. If shoe covers are used, they must be placed on the footwear prior to the scrub beginning.

There are two options of procedure for performing the surgeons hand scrub. One method is the anatomical timed method and the other is the counted stroke method. Both the methods start with a thorough washing of the hands and arms with an antimicrobial product. While leaving the lather on the hands and arms, the nails can be cleaned (Figure 3.29). Nail cleaners can be found in either the package of a disposable scrub brush or purchased commercially and left in a receptacle near the scrub sink. In either case, the nail cleaner is disposable and should be used only once and then thrown away. After cleaning under the nails, the hands and arms can be rinsed. If an antiseptic-impregnated disposable sponge is used, it can be saturated with water and squeezed to produce lather. If a reuseable brush is used, it is aseptically removed from the sterilized brush dispenser. The foot-operated pedal for dispensing the soap is then depressed and the scrub brush is saturated with the scrub product. The surgical scrub should be approached systematically and always performed the same way to avoid missing any of the steps. As the scrub begins, the elbows must remain bent, with the fingers pointing toward the ceiling. Not only does this allow the water to run from the finger tips to the elbows, (clean to dirty) but it also insures that the hands and arms do not touch the scrub top. The anatomic timed method usually lasts 3–5 minutes, depending on the facility policy. As soon as the subungual area of the nails is cleaned, timing is started. Scrub each finger, in between the fingers, and both the front and back portions of the hand for 2 minutes. Then each side of the arm is scrubbed for 1 minute. The arm is rinsed by passing the bent arm under the running water moving from finger tips to elbow. The other hand and arm are scrubbed using the same timed method. The second arm is rinsed in the same fashion as the first and then the hands are aseptically dried with a sterile hand towel. For the counted stroke method, as soon as the nails are cleaned, the scrub begins with the nails. Starting with either hand, the scrub brush is moved back and forth (which equals one stroke) on the nails for 30 strokes. Care should be taken to ensure that the brush reaches under the nails as well as the


Figure 3.29 Cleaning nails.

nails themselves (Figure 3.30). Once the nails are done, the fingers are scrubbed next. It really doesn’t matter if the scrub starts with the thumb or the little finger, as long as the same process is always used to avoid mistakes. The little finger is divided into four sides. Start the scrub on the lateral side moving from the tip of the finger to the base of the finger, counting as one stroke (Figure 3.31

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Dec 15, 2022 | Posted by in NURSING & ANIMAL CARE | Comments Off on Asepsis and Infection Control

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