Care and Handling of Basic Surgical Instruments

Article Outline

• After Surgery: Cleaning
• Specialty Instruments
• Preparation for Sterilization or Disinfection
• Sterilization
• Disinfection
• Repair Considerations
• Summary
• Reference
• Copyright

A well-made, properly cared-for instrument can be expected to last 10 years. The most important considerations in extending the life of an instrument are appropriate use, careful handling, and proper cleaning and sterilization. Every instrument is designed for a specific purpose. Using it for an unintended purpose is a sure method of damaging an instrument. Examples of misuse include securing surgical drapes or opening a medicine vial with an instrument designed to grasp tissue.

The proper cleaning of instruments during and after surgery can help to prevent stiff joints, malfunctions, and deterioration of the instruments’ material, including stainless steel. During surgery, instruments contaminated by blood or tissue should be properly wiped and rinsed in the sterile distilled water in the sterile field. Thorough rinsing is important to ensure removal of blood and other contaminants from hinges, joints, and crevices. Blood and foreign matter that are not removed or are allowed to dry and harden may become trapped in jaw serrations, between scissor blades, or in box locks, making final cleaning more difficult and the sterilization or disinfection process ineffective. It can cause instruments to become stiff and eventually break.

Channels, or lumens, within instruments such as suction tips should be irrigated periodically to prevent blood from drying and adhering to the inside of the lumen. Neglecting this action can cause blood and other debris to remain in lumens throughout the postoperative cleaning, decontamination, and sterilization processes. A syringe should be present in the sterile field for the purpose of flushing lumens with water throughout the procedure. Flushing the lumen should be done below the surface of the water to prevent the aerosolization of debris.

Instruments should be rinsed in distilled water. Saline should not be used for this purpose. Prolonged exposure to saline can result in corrosion and can eventually lead to the pitting of stainless steel. Pitting can permit entrapment of debris, interfere with sterilization, and result in the destruction of an instrument.

Instruments should be handled carefully and gently, either individually or in small lots, to avoid possible damage caused by their becoming tangled, dented, and misaligned. During and after surgery they should be placed, not tossed, into the basin. Heavy instruments should be on the bottom, with the lighter, more delicate and fragile ones on top. Rigid endoscopes and fiberoptic cables should also be placed on top or separated. Fiberoptic cables should be loosely coiled, never wound tightly. When the procedure is complete, instruments that can be immersed are disassembled and all box locks are opened. Care should be taken to ensure that they are not tangled or piled high. Instruments should be returned to their respective containers or baskets to prevent sets from becoming incomplete, and they should be covered for transport to the decontamination area. All disposable blades and sharps should be removed and placed in a designated sharps container. Delicate instruments, endoscopes, and other specialty instruments may have to be separated and transported to the decontamination area in containers specifically designed to prevent damage to these devices. Instruments with cutting edges, pointed tips, or other sharp components should be placed in such a manner that sharp edges are protected and personnel responsible for cleaning and decontamination are not injured when reaching into the container.

Back to Article Outline

After Surgery: Cleaning 

Whenever possible, instruments should be taken apart at the point of use. Anything that can be disassembled must be disassembled before cleaning. After surgery, instruments are transported in leak-proof containers or trays encased in plastic bags to a designated area for cleaning and decontamination. Instruments should not be transported in basins containing water because the water may spill. The decontamination area may be within the operating suite or, more commonly, in the central processing department. Instruments that cannot be cleaned immediately should be treated with an enzymatic foam or gel to prevent formation of biofilm. All instrumentation should be cleaned according to the instructions of the devices’ manufacturers.

All instruments placed in the sterile field for use in a surgical procedure are considered contaminated and should be cleaned whether or not they were actually used. Blood, saline, or debris can be splashed or inadvertently deposited on any of the instruments; therefore, they all require decontamination and processing. There are several methods of decontaminating instruments, but all begin with thorough cleaning.

Cleaning is the removal of adherent visible soil from the surfaces, crevices, serrations, joints, and lumens of instruments. Cleaning may be manual or automated and is accomplished with detergent, water, and friction. Proper use of the detergent is essential. Detergents should always be mixed according to the proportions indicated on the label or in the manufacturer's instructions for use. If enzymatic detergents are over- or underconcentrated or have been improperly rinsed off the instruments, interference with subsequent disinfection and sterilization can occur.¹ Regardless of how heavily soiled instruments appear to be after use, adding more detergent to the water is inappropriate. To ensure proper detergent concentration it is advisable to obtain an exact measuring device for the detergent and to mark the sink with a piece of tape or a nontoxic, permanent marker to indicate the correct water level. When a choice is made to switch to an alternative detergent, it is important to ensure that all personnel responsible for instrument processing receive the appropriate notification and information.

Mechanical cleaning. When possible, mechanical cleaning is preferred. However, some specialty instruments and those that cannot tolerate immersion or mechanical processing require manual washing. Some instruments, because of their design, require manual as well as mechanical cleaning. Examples are laparoscopic instruments and bone reamers. Debris and tissue can easily become trapped in these devices, and mechanical cleaning alone may not be sufficient to remove the debris. Soaking in an enzymatic detergent can help to break down organic soil. Reamers with many crevices tend to trap debris and may have to be soaked and manually brushed before automatic cleaning. Much will depend upon the capability of the automatic cleaners in the decontamination area.

Laparoscopic and other lumened instruments should be flushed and brushed. Flushing can be achieved by attaching a Luer-Lok syringe filled with an enzymatic detergent solution to one of the instrument's ports. Brushing must be carried out using a brush that is long enough to exit the distal end of the shaft and wide enough in diameter to cause friction on the walls of the lumen so soil is loosened. Mechanical washers and ultrasonic irrigators designed for laparoscopic and lumened devices do an excellent job of cleaning and are preferable.

When instruments cannot tolerate immersion, high temperatures, or the pressures of mechanical cleaning units, or if no such unit is available, the instruments must be cleaned manually. Instruments that are washed manually should always be completely immersed and allowed to soak in a cleaning agent intended for manual cleaning of surgical instruments. Instruments should be disassembled and box locks, hinges, and joints should be opened. Serrations, box locks, crevices, and lumens must be brushed to remove imbedded particles. Scouring pads, stiff brushes, abrasive powders and soaps, and sharp implements should not be used to remove debris because they can destroy the protective coating on surgical instruments.

Manual washing. Instruments that are washed manually should always be washed one at a time beneath the surface of the water to prevent the aerosolization and splashing of debris. Personnel responsible for cleaning must wear personal protective attire to prevent contact with blood or with fluid that might contain blood and or other body fluids.

Ultrasonic cleaning. Ultrasonic cleaning is another component of instrument cleaning. Ultrasonic cleaners should be used only on devices that can tolerate this process and only after gross debris has been removed. Ultrasonic washers use a process called cavitation to remove fine soil from difficult-to-reach areas of a device that manual cleaning may not remove. High-frequency sound waves are captured and converted into mechanical vibrations in the solution. The sound waves generate microscopic bubbles that form on the surfaces of the instruments. These bubbles expand until they become unstable and collapse or implode (collapse inwardly), creating minute vacuums that rapidly disrupt the bonds that hold debris to instrument surfaces. The tiniest particles are rapidly drawn from every crevice in the instrument. Ultrasonic cleaning is especially effective for box locks and instruments with serrations and interstices that are not easily accessible.

Instruments made of dissimilar metals can be damaged if cleaned together in the ultrasonic cleaner. In addition, some instruments cannot tolerate the energy waves of the ultrasonic cleaning process, and manufacturers of delicate instruments do not always recommend ultrasonic cleaning. Personnel responsible for processing instruments should check with the manufacturers of both the instrument and the ultrasonic cleaner before employing this process.

Cleaning machines. The most common automated cleaning machine in use is the washer-decontaminator/disinfector. Washer-sterilizers are also available. These machines offer a variety of cycles, including cool-water rinse, enzyme soaking, washing, sonication (ultrasonic cleaning), hot-water rinse, germicide rinse, and drying. Washer-decontaminators have, to a great extent, replaced manual cleaning and the use of washer-sterilizers.

In a washer-sterilizer, the instruments are washed and rinsed and then subjected to a short flash-sterilization process. Debris that may not have been removed during the wash phase may become hardened onto the instrument during the sterilization phase. For this reason, washer-decontaminators/disinfectors are generally preferred.

Detergent should be selected according to the type of debris and the tolerance of the instrument. The manufacturer of both the instrument and the mechanical cleaner should be consulted. A detergent's pH can be alkaline, neutral, or acidic. Acidic and heavily alkaline detergents should not be used routinely because they can destroy the passivation layer and promote corrosion. As a general rule, a low-foaming detergent with a neutral pH is preferable. High-foaming detergents may not be completely rinsed off and can leave spots and stains on instruments. In areas where the water is hard, a water-softener should be used to minimize scum and scale formation.

As a final step before inspection and packaging for sterilization, instruments should be lubricated with a nonsilicone, water-soluble lubricant. The manufacturer's instructions for dilution of the lubricant should be followed and the expiration date after mixing should be noted and indicated on the instrument milk bath.

Back to Article Outline

Specialty Instruments 

Specialty instruments require exceptional handling. Instruments used in microscopic surgery should be handled separately from those used for general surgery. They easily become tangled or misaligned when the heavier instruments used in general surgery are placed on top of them. Other specialty instruments, such as powered hand pieces and telescopes, will be destroyed if subjected to ultrasonic cleaning or to a washer decontaminator or washer cycle and should be meticulously cleaned by hand. Powered instruments, such as saws and drills, should never be immersed in solutions or come into contact with saline solutions, detergents with high or low pH levels, or chemical disinfectants. Manufacturers’ instructions for their care and handling should always be followed.

Flexible endoscopes contain long narrow lumens and are inherently difficult to clean. A number of infections have been reported in patients as a direct result of inadequate cleaning and processing of endoscopes. Instructions for cleaning flexible endoscopes are quite detailed and specific and are beyond the scope of this review. The endoscope manufacturers’ guidelines should always be consulted for design features specific to the scope in question. Manufacturers usually provide inservice education in the cleaning and sterilization of these devices.

Back to Article Outline

Preparation for Sterilization or Disinfection 

Classification of surgical instruments. In 1972, Dr. E. Spaulding classified medical devices and instruments into three categories, based on the risk of infection involved in their use. The categories are critical, semicritical, and noncritical. This classification was accepted by the Centers for Disease Control and Prevention and is used today to determine the processing strategy for surgical instruments. Critical devices are the devices that penetrate mucous membranes and enter normally sterile areas of the body. Examples of critical devices are instruments used in surgery, needles, and scalpels. Critical devices must be sterile. Semicritical devices contact intact mucous membranes and must be disinfected at the high level, at a minimum. Examples of semicritical devices are bronchoscopes, thermometers, and endotracheal tubes. Noncritical items contact intact skin and require low-level disinfection or cleaning with soap and water. Examples of noncritical devices are crutches and blood pressure cuffs.

Whenever practical, contents of instrument sets should be standardized. Standardization reduces the need for inventory, facilitates instrument replacement, and makes it easier to identify and locate sets needed for a surgical procedure.

Back to Article Outline

Sterilization 

Steam sterilization is the most commonly used method for sterilizing instruments. Instruments that can tolerate repeated exposure to the moisture and high temperature of steam should be steam sterilized. Steam sterilization is an economical and reliable method available in almost every healthcare facility. Items sensitive to heat and moisture are sterilized using alternative methods, such as ethylene oxide and hydrogen peroxide gas plasma. Cutting instruments and other instruments with sharp edges, although they can be processed in steam, will hold their edges longer if sterilized in low-temperature sterilization systems.

Instruments, pans, containers, and any packaging material, as well as any padding or protective material used in the pan, must be compatible with the sterilization method. For example, placing a cotton surgical towel in the bottom of a pan or container is useful in steam sterilization to absorb condensate and facilitate drying. However, cotton or other cellulose-containing materials cannot be used in hydrogen peroxide gas plasma sterilization. Cellulose absorbs the hydrogen peroxide, causing the sterilization cycle to cancel.

Although one sterilization cycle may be appropriate for the majority of instruments, there are many instrument sets that require extended or unusual cycles. In addition, some manufacturers’ instructions concerning recommendations and instructions for flash sterilization of devices have been omitted. Sterilization cycles should be selected according the device-manufacturer's instructions for use and the sterilizer manufacturer's instructions for use. Any discrepancy between the two should be resolved before sterilization.

Instruments should be dry before sterilization. Processing wet instruments by steam sterilization may cause difficulties in obtaining a dry set. Sterile items that are not completely dry at the end of the cycle are considered contaminated because the moisture inside the package can breach the sterile barrier and create a pathway for microorganisms to enter the package. An exception to this occurs when instruments with small lumens are to be steam-sterilized. In these cases it may be necessary to place a few drops of distilled water in the lumen to create steam that will force air out of the lumen during the heat-up phase of the sterilization cycle. Placing wet instruments into ethylene oxide can lead to the formation of ethylene glycol (antifreeze), a byproduct of water and ethylene oxide. This chemical byproduct is not removed during the aeration process and can harm patients. Wet instruments processed in hydrogen peroxide gas plasma will cause the sterilization cycle to cancel because the hydrogen peroxide vapor dissolves in water, lowering the concentration of the hydrogen peroxide below effective levels.

Some facilities may choose an automated sterilization system that uses a liquid chemical sterilant such as peracetic acid. These systems are commonly used to process flexible gastrointestinal endoscopes that cannot tolerate steam or that have lumens too long for hydrogen peroxide gas plasma and that require faster turnaround than is possible with ethylene oxide sterilization.

Back to Article Outline

Disinfection 

Common liquid chemicals used to disinfect surgical instruments include glutaraldehyde, hydrogen peroxide, peracetic acid, and ortho-phthalaldehyde. Each has unique characteristics and should be chosen in accordance with department needs and instrument compatibility.

Instruments to be disinfected should be clean and dry before placement into the disinfectant. Moisture from instruments that are not dry can dilute the disinfectant, causing it to lose its effectiveness. The disinfectant solution should be tested for minimum effective concentration according to the manufacturer's instructions. This is usually done on a daily basis using test strips specific to the product selected. The immersion time required for high-level disinfection is indicated on the product's label and should be strictly adhered to. Following disinfection, items should be rinsed with copious amounts of water according to the manufacturer's instructions. Disinfected instruments should be allowed to dry and should be stored in a clean dry area.

Back to Article Outline

Repair Considerations 

Preventive maintenance coupled with careful handling and proper use are the best ways to prevent deterioration and equipment failure and to extend the lives of instruments. Regardless of the care in handling and use, some instruments will need replacement or repair. The facility may choose to send the item to the original manufacturer or an outside contractor or may use the services of an independent service manufacturer that repairs instruments and performs preventive maintenance on site. When selecting a repair facility or service the following should be considered:

Back to Article Outline

Summary 

Surgical instruments are a major financial investment in every surgical facility, and processes should be in place to protect this investment. The life of a surgical instrument is dependent upon the way it is used and the care it receives. It is the responsibility of the surgical team and the personnel who process the instruments to handle them carefully, use them for the purpose for which they were designed, and process and maintain them appropriately. The extra time it takes to care for instruments properly is well worth the investment and is always in the patients’ best interests.

Back to Article Outline

Reference 

1. Hutchisson B , LeBlanc C . The truth and consequences of enzymatic detergents . Gastroenterol Nurs . 2005;28(5):372–376
   • View In Article
   • MEDLINE
   • CrossRef