By Kelly M. Pyrek
Consideringthat surgical instrument trays for major surgeries can bear price tags of$20,000 or more and that individual instruments can cost several hundred dollarseach, sterile processing (SP) technicians must be well versed in the care andhandling of surgical instruments and must engage in preventive maintenance. Aproperly cleaned and reprocessed instrument is to a surgeon what a chisel andhammer is to a sculptor: a set of tools worthy of respect and critical to theoutcome of the professional's surgical or creative endeavor. Surgicalinstruments, especially those manufactured in Germany, are hand-crafted byhighly skilled artisans. In fact, a mosquito hemostat requires 27 steps in themanufacturing process, proving that even the deceptively simple instrument canbe complex in its creation and demand detailed care.
Proper care of instruments starts with appropriate cleaning protocol, whichincludes a maintenance schedule followed per facility policy. Frequency of useshould dictate this schedule; busy ORs and SP departments normally scheduleinstrument maintenance every six months. According to Spectrum SurgicalInstruments Corp., instruments that may require more frequent adjusting,sharpening or repair include knives, punches, scissors, needleholders, bonecutters, hemostats and osteotomes.
RFQ, the Tuttlingen, Germany-based instrument maker and a world leader ininstrument manufacturing, emphasizes that all instruments should be examinedcarefully for breaks, cracks or malfunctions before use. Special attentionshould be paid to critical places such as blades, stops, locks, points and allmovable parts. Damaged instruments should not be used, and SP techs should notattempt to repair them. Rather, faulty instruments should be separated from setsand sent out for repair.
The enemies of surgical instruments include blood, tissue and other surgicalresidue that cause staining, pitting and corrosion of instruments."Instruments start out gorgeous when they're new but soon the blood andguts will attack and stain instruments," says Alex Vrancich, operationsmanager for Spectrum Surgical Instruments. "The chlorine ions in blood actlike salt, which can corrode, pit and stain instruments. That's why it'scritical for instruments to be kept moist until they can be cleaned. Moistinstruments are the friends of the decontamination process."
According to Sklar Instruments' instrument troubleshooting guide, no steel istruly "stainless," and is subject to both water spotting and staining.What SP techs identify as rust may actually be something else, such as a staincaused by a surface deposit, and once the cause is found and eliminated, theproblem diminishes. According to Slar, "Stainless steel is ideally suitedfor the surgical suite because it is rust-resistant, it can be honed to anextremely sharp edge or fine point and it can be hardened to maintain thedelicate yet precise requirements of the surgeon. But it is this hardenedquality -- the amount of carbon used during the manufacturing process -- coupledwith harsh chemicals and improper care that renders stainless steel susceptibleto corrosion."
In addition, cleaning instruments with bleach, household disinfectants andother inappropriate solutions can damage them. Vrancich emphasizes that SP techsmust understand how adverse conditions develop and use approved methods ofcleaning.
Vrancich says his company has seen beat-up instruments come in for repairthat would horrify an instrument craftsman. "One of the worst things wehave seen is a terribly worn needleholder with a cracked and missing tungstencarbide insert," Vrancich says. "The disturbing thing about thisinstrument was that it was able to go unnoticed through the OR, then decontam,through the clean side and eventually it re-entered the sterile field before itwas identified. This is a great example of why we always have to be alert andinspect each and every processed instrument. Who knows the whereabouts of thisbroken insert?"
Despitebeing manufactured from 300 and 400 series stainless steel, surgical instrumentsare not indestructible and can stain, corrode, pit and crack. He explains thatbodily fluids such as blood contain chloride ions that show up as orange-brownspots and can lead to corrosion if left on the instruments for an extendedperiod of time and allowed to dry. This is why surgical instruments must bethoroughly cleaned and dried after use -- the washing process should beginwithin 10 minutes after surgery, even if sterilization will take place later --and only sterilized when spotless because autoclaving an instrument with debrison it bakes the bioburden into the instrument and can make stains permanent.Corrosion, pitting and staining can be caused by acid- or alkaline-basedsolutions, so instruments should be washed with a neutral pH soap for optimalresults. Using an instrument cleaning brush is recommended, especially forcleaning jaw serrations, teeth and hinged areas.
Some hospitals use ultrasonic cleaning, which can be up to 16 times moreefficient than hand cleaning. For manual cleaning, RFQ recommends using softbrushes and standard solutions with tepid water. Manufacturer's instructions onhow to use cleaners as well as directions on concentration and duration shouldbe followed. Instruments that can be taken apart should be cleaned in adisassembled state, according to RFQ. Keep parts together and avoid mixing partsmade by different manufacturers. Follow the manufacturer's instructions forreassembly.
No matter the cleaning method used, all surgical instruments must besterilized prior to surgery to avoid infection. Ratchets should be left open toallow better steam penetration during sterilization and to prevent box locksfrom cracking. A perforated tray also facilitates steam penetration and aids thedrying process. Heavier instruments should be placed on the bottom of the traywith lighter ones on top to prevent damage. For all instruments without otherindications, steam autoclave sterilization at 270 degrees F (132 degrees C) for15 minutes is recommended by RFQ. Other temperatures and terms should bevalidated by the autoclave manufacturer. Sterilization temperatures should notexceed 280 degrees F (137 degrees C). Sterilization with hot-air orflash-autoclave is not recommended by RFQ because isolations or non-metalhandles may be destroyed. Cold sterilization is not recommended by SpectrumSurgical because immersing instruments in solutions for long periods of time canbe damaging. Instruments with tungsten carbide inserts (gold handles) should notbe immersed in solutions containing benzyl ammonium chloride, as it is known toloosen the tungsten carbide.
One of the most important steps in preventive maintenance, in addition to theproper cleaning and sterilization procedures, is lubrication of instrumentsafter every cleaning. Proper lubrication keeps instrument parts from rubbing andscraping together, thus preventing dulling and strain to joints and hinges.Moving parts such as joints, box locks, ratchets and screw joints should bethoroughly lubricated with an appropriate surgical lubricant.
Instruments also should be tested regularly for sharpness and optimalperformance.
"Preventive maintenance helps us to find small cracks before they becomemajor cracks that could lead to complications in the OR," Vrancich says."Testing scissors for sharpness will help to ensure that procedures gosmoothly, but preventive maintenance will never replace the repair process, astesting will often lead us to find instruments that require repair orreplacement. Our mission is to test and inspect and one of the best ways to dothis is what I refer to as 'taking the instruments for a walk.' Simply put, itis the action of opening and closing the ratchets of a needle holder orhemostat, pressing and releasing a tissue forcep, or cutting with ascissor."
A rubber-like material called Theraband, available from Spectrum, can be usedto test scissors' sharpness, especially at the distal tip where scissors oftendull most quickly. Instruments needing the most frequent sharpening includescissors, bone cutters, osteotomes, rongeurs, chisels, knives and punches.Scissors should have complete and precise cutting actions and needleholdersshould have intact tread at the distal tips. Rongeurs should take a clean biteout of an index card, while bone cutters should be able to cut through a woodtongue depressor. The use of tissue paper on a biopsy punch will determinesharpness; a clean punch should occur.
According to Vrancich, proper inspection and maintenance of surgicalinstruments ensures the highest quality performance during surgery and protectsthe considerable investment a hospital has made. Instruments must be treatedwith care and carefully checked for potential problems.
"Technicians have to look in all the right places," Vrancich adds."Every instrument must be inspected for missing needle holder jaw inserts,missing teeth from tissue forceps, cracked hemostats and the like. Propertraining and education is key to ensuring that each instrument in each set isfunctioning to its highest performance level. The OR personnel, the surgeon, andmost importantly, the patient require that this be the case.
If an instrument is not functioning properly when we 'take it for a walk'it's not going to get better in the OR or after we sterilize it. Testing shouldbe followed by action. If an instrument needs to be replaced, replace it. If aninstrument needs to be repaired, repair it."
Vrancich says every instrument poses unique challenges to inspection andmaintenance.
With hemostats, the tips, ratchet and box lock are of greatest concern.Cracks can develop due to expansion and contraction during sterilization, aswell as due to misuse. Ratchets can be tested by rapping them on a surface tosee if they spring apart. When it comes to cleaning hemostats, the nooks andcrannies of the serrations must be thoroughly attended to. With scissors, lookfor pitting along the blades and dulling at the tips, as well as cracking in thehinge areas. "Scissor tips can break off and be lost during surgery andthese defective instruments can still be circulated," Vrancich says."Be sure to look for missing pieces."
Needleholders have complicated tips that can become brittle and break off,and forceps can have missing teeth. The base of these instruments should bechecked for cracks and the spring tension should be evaluated regularly. Thetips and serrations should always be checked for debris. Vrancich adds thatthese kinds of long, slender instruments with detailed tips and jaws should becarefully inspected for tiny flaws that can soon escalate into bigger problems.
And when the instruments are completely reprocessed, according to RFQ, theymust be stored in a dry and clean environment without direct solar irradiationand be stored in stainless steel or aluminum containers. Instruments should belaid out in their individual packing or in protective trays. Protect tips withcloth, gauze or tubes while keeping the instruments in drawers.
The Sklar Instruments Troubleshooting Guide makes the following points regarding the identification of stains on surgical instruments:
Most obvious on dull-finish instruments, brownish stains are most likely to be a deposit of chromium oxide. The brownish film occurs naturally when stainless steel is heated. Improper cleaning compounds could contain polyphosphates that cause the copper components in the sterilizer to be deposited by electrolytic action on the instruments.
BLUISH GRAY STAINS
Cold sterilization solutions may be the culprit. Techs should follow manufacturer's directions for preparing solutions. To minimize discoloration, use distilled water and add a rust inhibitor.
LIGHT AND DARK COLORED SPOTS
Spotting can be caused by slow evaporation of water drops with a high mineral content. Eliminate water droplets by adhering to autoclave manufacturer's operating instructions.