HEADER TEXTGeneral Rodent Surgical Training

University Animal Care: https://uac.arizona.edu

Introduction to Aseptic Technique and Surgery Area Preparation

Estimated Course Time: 1:15

• It is Imperative that you understand how to access your approved protocol.– https://esirius3g.arizona.edu/eSirius3g/

https://rgw.arizona.edu/compliance/IACUC/policies-procedures-and-guidelines

Outline & Learning Objectives

Module 1: Introduction to Aseptic Technique and Surgery Area Preparation At the end of this module you will be able to differentiate between sterile and non-

sterile techniques, as well as compose a sterile surgery area.

Module 2: Preparing Instruments, the Animal, and Surgeon

Module 3: The Surgical Procedure and Post-operative Monitoring

Module 4: Surgical Cases and Compliance

Aseptic/Sterile Technique

• Aseptic technique is used for all survival surgeries including “practice” surgeries AND non-survival surgeries lasting longer than 3 hours, or when a body cavity is opened.

• Creating and maintaining a controlled environment free of bacteria, viruses and fungi

• Also known as sterile technique

PRACTICE SURGERIES MUST BE APPROVED IN THE PROTOCOL

Aseptic/ Sterile Technique

• Consists of:– Sterilized instruments/ equipment– Disinfected surgical area– Sterile gloved hands

• Sterile field:– Contains arranged sterile

instruments and area prepared on animal for surgery

– Areas above, below, and surrounding the animal in front of the surgeon

STERILE FIELD

STERILE FIELD

Surgery Area Set-up

• “The design of a surgical facility should accommodate the species to be operated on and the complexity of the procedure to be performed.”

• For most rodent survival surgeries, “an animal procedure laboratory is recommended; the space should be dedicated to surgery… and appropriately managed to minimize contamination from other activities conducted in the room at other times.”

– The Guide (p. 144)

Put up a Stop Sign

• Minimize traffic in the surgery area.

• No visitors/staff leaning close without caps and masks.

• No touching of the sterile field or instruments without sterile gloves.

• Sharps and Biohazard Containers are required.

NO ADMITTANCE WITHOUT PROPER

ATTIRE

Click here to access the Procedures with Care Video - Aseptic Technique Tutorial

Surgery Area Setup

• The day before surgery, remove anything from the area that is not applicable for surgery.

• If there are shelves above, remove everything from them.

• Spray area with a disinfectant the day before AND re-spray the area the day of surgery.

• Equipment which will contact the surgeon or patient should also be disinfected – stereotaxic device, etc.

*ALCOHOL is NOTa sterilant

ALCOHOL

Surgery Area Setup

• Select an area that has the least traffic• Dedicated for at least the day before and

day of surgery.• Area where patient is prepped MUST be

separate from the area where you will operate.

• Hoods are excellent for prep and/or surgery

• Sharps and biohazardous waste containers

Preparation Area

Separate Surgery Area

Recovery Area

Thermal Support – Surgery & Recovery

• Particularly important in rodents– Thermoregulation – heated water recirculating

blankets preferred, or isothermal pads.– Highest incidence of thermal injury with electric

pads/blankets.– Always need cloth between source and animal

Isothermal pad

Water recirculating blankets

*Highest incidence of thermal injury with electric pads/blankets.

HEADER TEXTGeneral Rodent Surgical Training

University Animal Care: https://uac.arizona.edu

Preparing Instruments, the Animal, and Surgeon

Outline & Learning Objectives

Module 1: Introduction to Aseptic Technique and Surgery Area Preparation

Module 2: Preparing Instruments, the Animal, and Surgeon Upon completion of this module you will be able to assist in preparation of

instruments, the animal, and surgeon for aseptic surgery.

Module 3: The Surgical Procedure and Post-operative Monitoring

Module 4: Surgical Cases and Compliance

Click here to access the Procedures with Care Video - Instruments

Instrument and Device Preparation

• Sterile disposable instrument, i.e. surgical blades

• Sterile drapes or Glad Press’N Seal

• Sterilized non-disposable instruments

• Sterilized methods are not always effective on grossly contaminated soiled instruments

Sterilization Methods | IACUC 304

• Autoclaving – standard instrumentation, most use peel pouches– Autoclave effectiveness must be monitored

• Ethylene oxide gas (performed by UAC for a fee)

• Vaporized hydrogen peroxide (performed by UAC for a fee)

• Ionizing radiation (commercial service)

• Cold sterilization – MUST use commercial disinfectant

• Bead sterilizer*ALCOHOL is NOT a sterilant

Autoclaved peel pouches

Instrument Sterilization cont.

• Wet or damaged packages are not sterile.

• Bead Sterilizer: Used with multiple same-day surgeries– Only TIPS are sterile– Instruments must be replaced with a new set of sterilized

instruments after 7 uses in the glass bead sterilizer.

• A new scalpel blade is required for each surgery– i.e., a new blade between EACH animal

Bead Sterilizer

Click here to access the Procedures with Care Video – Preparation of the Animal

Patient Preparation

• Surgical Assistant: Preparing animals for surgery (a non-sterile process)

• Ensure animal appears healthy.

• Anesthesia: Induce as described in the approved IACUC protocol.

• Apply sterile, ophthalmic ointment to the eyes to prevent drying.

• Analgesia: Administer as described in your protocol. – Early administration provides preemptive pain management.

Surgery Area Setup

• Remove hair at least 2-3 cm around the surgical site.

– Use well maintained clippers and/or depilatory.

– Remove debris and hair.

• Three alternating rounds of scrub:

– Chlorhexidine (preferred) or Betadine: Scrub followed by a rinse of warmed sterile saline or alcohol. Use new gauze/cotton tip each time.

– Using clean gloves, scrub the shaved skin with gauze pad soaked in betadine or chlorohexidine.

– Starting in the center, work in a concentric, circular pattern toward the outside edge of the shaved area.

– Repeat two more times (3 scrub rounds).

– End by placing a betadine/chlorohexidine soaked pad on the surgical site.

Click here to access the Procedures with Care Video – Preparation of the Surgeon

Surgical Attire

• Cap

• Mask/beard cover

• Freshly laundered lab coat, surgical scrubs, or sterile surgeon’s gown

• Sterile surgical gloves

Surgeon Preparation

• Required for survival surgery

• AND for a non-survival surgery that:1) Opens a body cavity

OR2) Lasts for more than 3 hours

• Remove jewelry from hands and wrists

• Tie back long hair

• Roll up long sleeves

But I was just talking

NABP: * Photo courtesy of Francis P. Mitrano, MS, RPh, Director of Pharmacy, Beth Israel Deaconess Medical Center,Boston, MA, November, 2005.

Hair and Jewelry DO Matter

• Uncovered hair - head shake • Covered hair – head shake

NABP: * Blood agar cultures courtesy of Francis P. Mitrano, MS, RPh, Director of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, November, 2005.

Wash Well

• Hand hygiene is paramount to sterile surgery performance as this agar imprint of an unwashed hand shows.

1 http://www.cdc.gov/handhygiene/2 E Larson. Am J Nurs, AJN. July 1989: 935

1Unwashed hand • 2Washed hand

Surgical Scrub for Hands and Hand Drying Technique

• Best Practice – Surgical scrub– 5-10 minutes– Start with fingers– Work towards the elbows

• Dry with a sterile hand towel• Starting with the fingers and

working to the elbows• Once dry, THEN don sterile

gloves

Click here to access the Procedures with Care Video – Preparation for Surgery

Surgical Table Preparation

• Use sterile, waterproof drapes underneath instruments and under the animal.

• Cover all devices to be handled by the surgeon.

• Drape the animal.

Drape Options

• Clear drapes allow easier concurrent anesthetic monitoring.

• Glad Press’N Seal Drape– The sticky part is placed over the animal, making

sure not to occlude the nose.– The “non-sticky” side is considered the “sterile

side”.

HEADER TEXTGeneral Rodent Surgical Training

University Animal Care: https://uac.arizona.edu

The Surgical Procedure and Post-operative Monitoring

Outline & Learning Objectives

Module 1: Introduction to Aseptic Technique and Surgery Area Preparation

Module 2: Preparing Instruments, the Animal, and Surgeon

Module 3: The Surgical Procedure and Post-operative Monitoring At the conclusion of module 3 you will be able to explain the surgical procedure and

demonstrate post-operative monitoring.

Module 4: Surgical Cases and Compliance

Click here to access the Procedures with Care Video – The Surgical Procedure

During a Procedure

• Be sure to check on the animal at regular and FREQUENT intervals.

• Monitoring the animal continuously throughout the procedures is imperative

• Depth of Anesthesia– Absence of a pedal withdrawal reflex

– Supplement anesthesia if necessary

• Temporary increase in inhalation isoflurane

• Addition of ketamine alone to the injectable cocktail of Ket/Xyl or Ket/Xyl/Ace

No pedal withdrawal reflex

Tissue Handling

• Gentle: Handle tissues gently– Keep tissues moist– Minimize the creation of tissue pockets– Avoid unnecessary dissection– Magnification improves surgical outcomes

Effective Hemostasis

• Goal: Decrease bleeding– Vasoconstriction– Platelet plug formation– Clotting of blood

• Achieved by:– Gentle tearing of tissue vs cutting– Compression (manual pressure)– Application of hemostatic agent

• Gel, thrombin or collagen

Tissue Closure

• Tissue Apposition– Decreases wound dehiscence– Improves wound healing

• Suture– Monofilament required

• Staples/Clips– Pinch, not push

• Tissue Glue– Needs to be medical grade, not commercially

available superglue

Suture Type

Why Monofilament?

• Non-absorbable

• Less local tissue reaction to suture itself

• Does not wick material into the healing incision

• Readily accessible, many fine sizes

• Simple interrupted sutures• Most common in rodent surgery• Placed 1-2mm from incision edge• Spaced 2-3mm apart along incision

• Square Knot– Strong knot that provides the appropriate

strength

Knots & Suturing Patterns

**If more complex patterns are needed, please contact UAC Veterinarians for assistance.

Basic Suturing Technique

Click here to access the Basic Suturing Technique YouTube Video

Post-operation & Recovery

• Recover in warm recovery cage– Half warmed – half normal– Bedded with towel or drapes – no bedding

material

• Return only after animal is moving normally

• Provide wetted food, or diet/hydration gel – if not up and eating normally

• Monitor

Post-op Procedures

• Antibiotics are not a substitute for proper aseptic surgery.

• Minimum 48 hours analgesia:– Protocol approved analgesic type– Follow written protocol– Document: What, when, dosage, WHO– Monitor for pain

• A normal animal is Bright, Alert and Active (BAA)

• Pain may present as: depressed, anorectic, sluggish

Post-op Monitoring

• Food and fluid intake:• Easy to access: Long sipper tubes, food placed on cage bottom• Soften food with water• Provide a ‘gel’ diet to increase eating and drinking• Must acclimate 2 or more days prior to surgery• May contain the analgesics• Monitor incision• Wound staples/clips or sutures must be removed 10-14 days post surgery

Recent Advancements in Pain Assessment

• Grimace Scoring– Mouse– Rat

HEADER TEXTGeneral Rodent Surgical Training

University Animal Care: https://uac.arizona.edu

Surgical Cases and Compliance

Outline & Learning Objectives

Module 1: Introduction to Aseptic Technique and Surgery Area Preparation

Module 2: Preparing Instruments, the Animal, and Surgeon

Module 3: The Surgical Procedure and Post-operative Monitoring

Module 4: Surgical Cases and Compliance When complete, you will be able to discuss surgical cases and compliance issues.

Record Keeping and Approvals

• Maintaining up-to-date records– Surgery

– Postoperative

– Drug storage and usage

• Submission of IACUC Amendment before implementing ANY change

– Protocol

– Personnel

Documentation

• Training• Surgical records

– Anesthetic– Analgesics– Any other drugs

• Post-op care

Surgical Records & Recovery Monitoring Samples

Common Problems

• Surgical area:– Not dedicated– Not cleaned

• Non-sterile prep of animals• Breaking sterility during the surgery:

– Using devices that are not sterile. Such as drills, stereotactic devices, operating microscopes, etc.

• No analgesics given or not following protocol.• Not documenting analgesic administration.• Lack of post-op monitoring • Not calling us with questions

**Description

Be Thoughtful with Your Patient

• Suture clip applied with too much pressure

Be Thoughtful with Your Patient

• Thermal burn

Be Thoughtful with Your Patient

• Overuse of surgical glue resulting in corneal defect

Be Thoughtful with Your Patient

• Dehiscence due to not shaving

Be Thoughtful with Your Patient

• No shaving, resulting in infection and hair sloughing

• Expired medical materials– Prohibited: Anesthesia, analgesia, Euthanasia– Other medical materials may be used in non-

survival/acute procedures, but MUST get prior approval from IACUC

IACUC Policies, Procedures, & Guidance

http://rgw.arizona.edu/compliance/IACUC/policies-procedures-and-guidelines

• Rodent surgery and instrument sterilization• Use of drugs and compounds in animal studies, including non-pharmaceutical grade.

– And other important references can be found at:https://rgw.arizona.edu/compliance/IACUC/policies-procedures-and-guidelines

IACUC Policies, Procedures, & Guidance

Good Surgical Technique

• Asepsis• Correct depth of anesthesia• Warm patient• Gentle tissue handling• Minimal dissection of tissue• Appropriate use of instruments• Effective hemostasis• Correct use of suture materials and patterns

Goals of Research & Animal Welfare

A Good Surgical Outcome• Preoperative preparation and surgical support• Asepsis, or sterile technique, which is used to reduce the chance of infection:• Surgery room setup • Instrument/tool sterilization• Surgeon preparation• Appropriate anesthesia

– Includes selection of drugs and anesthetic monitoring

Goals of Research & Animal Welfare

• Good surgical technique• Includes gentle tissue handling, correct use of surgical instruments and adequate

knowledge of anatomy and procedure being performed.• Adequate post-operative care and pain management• Consistent recordkeeping • Identifies trends that can be used for surgical refinements• Necessary for documentation of scientific data• Prior IACUC approval of all procedures: all changes approved by amendment prior to

implementation.

UAC Veterinary Staff

• Veterinary Technicians:– Lierin Cox AAS, CVT, RLATG– Nicole Porqueras, BA, CVT, LAT– Jen Yoon, CVT– Jenn Holberg

• Veterinarians:– Dr. CJ Doane, DVM, DACLAM– Dr. Karuna Patil, VMD, MS, DACLAM– Dr. Jareca Giles, DVM– Dr. Matt McDaniel, DVM– Dr. Paula Johnson, DVM, MS, CPIA– Dr. Dave Besselsen DVM, PhD, DACLAM,

DACVP