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Surgical Instrument Cleaning, Decontamination, and Packaging Notes

Instrument Care Overview

  • Roles: technicians and assistants are responsible for cleaning, disinfecting, inspecting for damage, sharpening, lubricating, and sterilizing surgical instruments. These steps protect instrument longevity, patient safety, and clinic costs.
  • Exposure risks: instruments are exposed to water, moisture, tissue, blood, and debris; air drying can cause damage. Inappropriate detergents or improper use can also harm instruments.
  • Water considerations: literature recommends distilled water to prevent mineral buildup on instruments (vs tap water which can cause mineral deposits).
  • Cost considerations: instruments are expensive; damage and replacements raise clinic costs.

Instrument Anatomy

  • Jaw (tip): main working part; jaws may have teeth with various shapes and angles; types include traumatic vs atraumatic.
  • Box locks: hinge area; difficult to clean; typically cleaned with ultrasonic cleaner.
  • Shank: connects box locks to ring handles; varies in size/length.
  • Ratchet: mechanism that locks the instrument in place or opens/closes it.
  • Ring handles: user grip for manipulation.
  • Note: instruments vary in shape, size, teeth, and features; these differences affect cleaning and sterilization considerations.

Cleaning and Decontamination Process (four basic steps)

  • Summary: cleaning occurs in lab with a prescribed protocol; a handout is provided for reference.
  • Steps in order:
    • Pre soaking
    • Rinsing with distilled water
    • Decontamination (manual cleaning)
    • Rinsing
    • Ultrasonic cleaning
    • Lubrication
  • Pre soaking rationale:
    • Do this as soon as possible, ideally within t \le 10\ \text{minutes} after surgery, to prevent blood/tissue from drying on instruments.
    • Purpose: remove debris slowly to simplify later cleaning; as a scrub nurse described, keep instruments clean to prevent drying during surgery and aid assistants.
    • Water choice: use distilled water for pre soaking to avoid mineral buildup; some places use tap water for cost, but mineral buildup is a downside.
    • Soaking duration: at least t = 5\ \text{minutes} with distilled water.
  • Decontamination (manual cleaning):
    • Mechanics: mechanical friction with approved detergent to remove tissue and blood.
    • Tools: brushes (special instrument brushes with plastic bristles; do not use wire brushes as they scratch and damage instruments).
    • Focus areas: jaws, box locks, and ratchet (grooves or bumps where tissue can hide).
    • Water: warm water and detergent in a basin; open box locks and unlock ratchets; wash all surfaces with a soft bristle brush; follow with a distilled water rinse.
  • Ultrasonic cleaning:
    • Purpose: enzymatic cleaner with surfactant to reduce surface tension and improve cleaning, especially in hard-to-reach areas.
    • Mechanism: ultrasonic cavitation (bubbles) loosens debris.
    • Typical processing time: t_{ultra} \in [3,6]\ \text{minutes}; follow manufacturer recommendations.
    • Temperature: maintain around T \in [110,130]\°C (temperature-dependent). Use heaters inside the unit.
    • Troubleshooting tips:
    • Use an aquarium thermometer to verify temperature.
    • Test cavitation with a piece of aluminum foil; after processing, foil should have small bumps from bubbles indicating cavitation (helps confirm proper cleaning).
    • Practical notes: keep instruments unhinged and box locks open; use a metal tray for loading/unloading.
  • Rinse after ultrasonic cleaning:
    • Final rinse cycles are performed to ensure all detergents are removed before lubrication.
  • Lubrication:
    • Method: after final rinse and ultrasonic cleaning, dry instruments and apply lubricant (white milky substance) by spraying; allow to air dry.
    • Alternative method: milk bath (dip-and-dwell) for a couple of minutes; change the solution frequently to avoid harboring bacteria/debris; not as preferred as spray).
    • Purpose: prolong instrument life, reduce wear/friction, prevent staining and corrosion.
    • Note: do not wipe off lubricant after it dries; ensure even coating for preservation.

Instrument Integrity and Quality Checks

  • During cleaning, inspect for damage and integrity:
    • Jaw alignment: tips should meet evenly.
    • Box locks: should not have cracks; functions should be smooth.
    • Ratchet: should ratchet easily; if it springs open, instrument may need repair.
    • Scissors: assess sharpness with cutting paper designed for specific scissor types; use appropriate test papers to verify cutting ability.
  • If issues are found, set the instrument aside for repair or re-cleaning as needed.

Packs, Packaging, and Sterilization Overview

  • Packs: organized groupings of instruments for specific procedures; not universal (depends on surgeon preference and caseload).
  • Major vs Minor packs:
    • Major pack: for major procedures (e.g., intestinal foreign body).
    • Minor pack: for smaller procedures (e.g., laceration repair).
    • Other categories: soft tissue, orthopedic, dental instruments, etc.
  • Count protocol:
    • Count gauze sponges (e.g., 10 per pack) and other items to prevent intraoperative retention.
    • Sponge counts must occur before packing and after procedures.
  • Orders and organization:
    • Each pack should have a dedicated, documented order to avoid omission.
    • Do not mix metals; typically surgical-grade stainless steel, though some instruments may be different metals.
    • Take photos of packs for reference and ensure consistent order and contents.
  • Example contents of a common surgical pack:
    • Metal tray with instruments, hot towel or absorber, gauze, sterile stainless steel bowl, sterilization indicator strip, outer wrap twice, and outer indicator tape.
  • Wrapping packs: four guiding qualities
    • Selective permeability: allows sterilizing agent to penetrate but blocks dust and contaminants.
    • Tear resistance: resistant to tearing.
    • Flexibility: can wrap around irregular shapes.
    • Memory: returns to original shape to lay flat for wrapping.
  • Wrapping materials:
    • Disposable (paper-based): generally single-use; lighter but may be less durable.
    • Cotton textiles (cloth): high thread count implies better selective permeability, stronger, more resistant to tearing, more flexible, and good memory; high laundry burden because reused after washing.
    • Synthetic wraps: disposable; may contribute to static electricity.
  • Drapes color rationale: blue/green drapes are used because they are easier on the eyes and/or blood shows up better against these colors.
  • Alternative wrapping options:
    • Checksum (paper/plastic composite): usable for oddly shaped instruments; can be used with autoclave or EO sterilization; caution with paper tearing and higher storage cost; best for specific shapes.
    • Denison textile-paper wrappers: moisture-repellent; durable but expensive; come in rolls; cut to size.

Packaging and Sterilization Validation

  • Sealing packs:
    • Tape with color-change indicator is used to seal packs on the outside.
    • Avoid regular masking tape due to poor adhesion after autoclaving and potential residue.
    • Color-change indicators show that the pack has undergone sterilization, but do not guarantee sterility.
    • Inside the pack, steam indicators (paper or plastic with chemical indicator) change color to show conditions were met for sterilization; does not guarantee sterility itself.
    • Placement of indicators inside the pack varies; preference described: place on top of contents to ensure steam penetrates deeper into the pack.
  • Biological indicators (BI): ultimate verification of sterility
    • BI are small test tubes containing bacteria; wrapped inside pack or inside a CheKSol wrapper.
    • After sterilization, BI are incubated for several days to check for bacterial growth.
    • BI should be part of a maintenance program; frequency depends on case load and implants usage (e.g., weekly or monthly for general use; higher frequency for implants/orthopedics).
  • Documentation and traceability:
    • Write name, date, initials, and contents on the tape/pack label to comply with sterilization guidelines.
  • Storage and shelf-life concepts:
    • Expiration dating (shelf-life): some autoclaved packs are considered good for
    • t_{exp} = 30\ \text{days} for autoclaved packs, after which re-autoclaving may be needed.
    • t_{exp} = 90\ \text{days} for gas-sterilized packs.
    • Event-related expiration: packs must be resterilized if a breach of sterility occurs (e.g., pack dropped, water spill, or other integrity issue).
    • Storage: packs stored in closed cabinets with proper ventilation and limited access; avoid open shelves.
    • Rotation/restocking: regularly rotate packs and check for damage or event-related exposure; this helps maintain sterility and readiness.
  • Institutional practice notes (example): some institutions store packs behind closed doors and rely on event-related expiration rather than fixed time limits.

Safety, OSHA, and Handling Sharps

  • Hazard awareness:
    • Surgical sharps, chemical spills, and pathogens require careful handling and PPE.
  • Mayo stand safety:
    • When handling instruments on the Mayo stand after a procedure, expect sharps (blades, needles, towel clamps, scissors) and proceed with caution.
  • Chemical spills (e.g., formalin):
    • Clean up with appropriate PPE; contain and neutralize as needed.
  • Sharps disposal:
    • Use one-handed needle recapping techniques or remove the blade from scalpel handles before handling.
    • Follow protocol to minimize injuries during disposal.

Final Packaging Preparation before Sterilization

  • After cleaning and lubrication, ensure instruments are dry and free of debris.
  • Inspect for any remaining residue or damage; re-clean if needed.
  • Prepare for wrapping and sterilization per the protocol reviewed in lab.
  • Note: wrapping packs will be practiced in lab; focus will be on autoclave use and instrument cleaning techniques.

Practical Lab and Study Tips

  • Practice points drawn from the transcript:
    • Work quickly but carefully to prevent blood/tissue from drying; aim for pre soaking within 10 minutes post-surgery.
    • Use cataloged, non-wire brushes for decontamination; avoid metal scratchers.
    • Confirm cavitation by aluminum foil test to validate ultrasonic cleaner operation.
    • Maintain coated lubrication and avoid wiping dry—the coating helps protect metals.
    • Keep packs simple and well-documented; photos help standardize pack contents and order.
    • Use proper wrapping materials based on their advantages and disadvantages, balancing cost, durability, and sterility compatibility.
  • Real-world relevance:
    • The practices ensure safety for patients (increased sterility), reduce infection risk, and protect staff from sharps injuries and chemical exposures.
    • Efficient instrument care reduces long-term costs by extending instrument life and reducing replacement needs.

Quick Reference Formulas and Timelines

  • Pre soaking: within t_{pre} \le 10\ \text{min} after surgery.
  • Initial soaking duration: t_{soak} = 5\ \text{min} (minimum).
  • Ultrasonic cleaning time: t_{ultra} \in [3,6]\ \text{min}.
  • Ultrasonic temperature: T \in [110,130]\°C.
  • Gauze count per pack: n_{gauze} = 10.
  • Autoclave expiration: t_{exp, autoclave} = 30\ \text{days}.
  • Gas sterilization expiration: t_{exp, gas} = 90\ \text{days}.
  • Coverage for wrapping materials: ensure selective permeability, tear resistance, flexibility, and memory (no numerical unit; qualitative criteria).

Glossary / Quick Definitions

  • Box locks: hinge mechanism of instrument that must be kept clean and accessible.
  • Cavitation: process in ultrasonic cleaners where microbubbles form and collapse to dislodge debris.
  • BI (Biological Indicator): a test device containing dormant bacteria used to verify sterilization effectiveness.
  • Indicator tape/strips: chemical indicators that change color to show a pack has undergone sterilization, not a guarantee of sterility.
  • CheKSol: a wrapping/packaging concept mentioned in lab discussions.
  • Denison textile-paper wrap: moisture-repellent, single-use, hydrophobic wrap option; more expensive.
  • Selective permeability: property of wrap allowing sterilizing agents to penetrate while keeping contaminants out.
  • Memory: wrap material’s ability to return to its original shape for easier wrapping and storage.
  • Suture and gauze counts: critical for preventing retained items in body cavities; strict inventory control in packs.