Written by Ren on Wednesday June 12, 2019
The importance of reliable equipment in the surgical sector can't be overstated. Between the delicacy required for surgeries and the accuracy a surgeon needs to make these procedures a success, a lot rides on surgical equipment. A surgeon can only be as sharp as their equipment, and proper maintenance is essential to the equation.
To keep surgical equipment in its best usable condition, you need to know how to maintain it. Cleaning, sterilization and proper storage are essential to keeping surgical instruments at their best for sustained use. By following this guide, you can increase surgical equipment lifespan and get the best out of your surgical tools for years to come.
The Basics of Surgical Equipment Care
There are multiple options for keeping your instruments in tip-top shape. If you know how to maintain your surgical instruments, you can extend their usable life while ensuring they provide the best service over time. Most surgical instruments can last years if you give them proper care at regular intervals. The care of instruments consists of three distinct steps — cleaning, disinfecting and sterilizing.
Cleaning Surgical Equipment
Cleaning removes dirt and any biological material from your surgical instruments before you move on to sterilization and disinfection. If dirt, bodily fluids or tissue make it onto your surgical instruments, they can damage the surface in addition to making the tool harder to clean. Instruments should be rinsed in cool water rather than hot since the heat can cause substances to coagulate if they contain enough protein.
Oftentimes, people place instruments into a cool water bath that contains an enzymatic detergent. The detergent helps dissolve any proteins present and break down oils so the instruments can be cleaned.
Manual Surgical Equipment Cleaning
For the most part, manual cleaning takes place when there are no methods of mechanical cleaning available. You're more likely to need manual cleanings for your equipment if you're working with instruments that are easily damaged. Manual cleaning may be a stepping stone to mechanical cleaning if the instruments are complex and require disassembly. If you plan to take on manual cleaning, you'll need these supplies:
- Heavy-duty rubber gloves
- Plastic apron
- Eye protection
- pH-neutral detergents
The pH-neutral detergents keep your stainless steel instruments from picking up stains. Using detergents with a low pH can result in your instruments getting black stains. If you use an alkaline detergent, the high pH can leave deposits on the surface that lead to brown stains. Deposits of this nature also create a texture that makes smooth operation more difficult. Proteases or other enzymes can be added to a pH-neutral solution to help remove any organic material.
For manual cleanings, soft plastic brushes are the best tool to use. Scrub the instruments thoroughly, but don't rely on abrasive materials like steel wool or wire brushes, which will degrade your instrument's protective coating. Just one vigorous scrub with the wrong cleaning tool can dull an instrument, and repeated incidents will shorten its lifespan dramatically.
Rinse and Inspect Surgical Equipment
After giving a gentle and thorough cleaning with the proper detergent and soft brush, you should look closely to make sure the instrument is in good working condition. Here are some indicators to look for during instrument inspection:
- Scissors and hemostats should never have loose joints
- Hemostats should lock and unlock with ease
- When putting needle holders up to the light, a gap means the tool is worn
- Bladed instruments should be sharp with no chips
Once you've made sure your instruments are in good condition, the next step is a thorough drying. Be sure to use a soft cloth to avoid water spots or corrosion. Hinges should be treated with a spray lubricant to ensure joints retain good function.
Mechanical Surgical Equipment Cleaning
When instruments go through mechanical cleaning, the machine usually runs through a number of cycles. Typically, a cold rinse comes first to remove any debris from the instrument. This prevents any tissue or soiling from harming the instrument during cleaning. Then comes a hot soaking and rinse cycle, and the process concludes with a hot air dry. Some mechanical washers also have a disinfection function. These machines use boiling water in the soak and rinse.
Ultrasonic Surgical Equipment Cleaning
Ultrasonic is the preferred method for cleaning surgical instruments mechanically, and it works via cavitation. These machines harness the vibration of sound waves, which create micron-scale bubbles in the cleaning solution. Those bubbles grow with the repetition of alternating pressure, ultimately imploding with enough force to shake dirt and other debris loose. Ultrasonic cleaning is especially effective because it can dislodge debris in places manual cleaning can't always reach.
To perform an ultrasonic cleaning on surgical instruments, you'll follow these steps:
- Mix detergent according to manufacturer specifications, using deionized water when possible.
- Warm up the cleaning machine for a few minutes to reach the right temperature and degas your solution.
- Place instruments into the cleaner, ensuring they are in open position.
- Allow the cleaner to work for five to 10 minutes.
- Remove the instruments and rinse them in cool water to remove the cleaning solution and dislodge any debris.
- Dry instruments with a soft towel and lubricate hinges.
This method of cleaning is quite simple, but keep these tips in mind to get the most out of your ultrasonic cleaning process:
- Ensure instruments are fully submerged.
- Don't place instruments of different metals in the same cleaning cycle.
- Don't let bladed instruments touch any other instruments.
Ultrasonic cleaning is ideal for preparing instruments for the next maintenance steps because it's so hands-off. Even with a soft brush and a steady hand, human error can result in premature wear for your instruments. The power of sound allows you to get your surgical instruments clean without any possibility of abrasion impacting your tools. For instruments with blades, ultrasonic cleaning can greatly prolong usable life.
Disinfecting Surgical Equipment
Surgical instruments require high-level disinfection (HLD). There are thermal and chemical methods you can use, but boiling is the preferred method since surgical instruments are generally unaffected by heat. It's important to note that boiling is not a method for sterilizing equipment.
When boiling equipment, keep it below rolling. If instruments bounce around in the boiler because of a rolling boil, they could easily get damaged. Instruments need at least one minute in the boiling water before removal. Never leave instruments in water as it cools, or you run the risk of them becoming contaminated again. Using distilled water or adding a splash of vinegar to the boiler will help prevent lime from building up on your instruments.
If your instruments are delicate and may be damaged by heat, you'll need to disinfect them chemically. For surgical equipment, we recommend three chemical disinfectants:
- Chlorine: Chlorine dioxide can kill vegetative organism in three minutes after contact. It's a corrosive chemical and has to be less than 14 days old to work correctly. If any organic matter is present, it can hamper chlorine's activity.
- Hydrogen Peroxide: Hydrogen peroxide is effective but corrosive to the surfaces of your instruments. Extra care must be taken when rinsing.
- Chlorhexidine: Chlorhexidine is effective against many viruses, but it only kills a small spectrum of bacteria. However, it kills the bacteria within its spectrum very rapidly.
Sterilizing Surgical Equipment
Surgical equipment requires sterilization because it is categorized as "critical" according to the system devised by Earle H. Spaulding. The Spaulding classification has three categories that separate health-care items by their risk for infection:
- Noncritical: These items may contact intact skin but don't penetrate mucous membranes. Since skin is an effective barrier to keep out most microorganisms, noncritical items are the lowest sterilization priority.
- Semicritical: Semicritical instruments make contact with mucous membranes or broken skin. Only a few bacterial spores are permissible, and these items require some minimal HLD.
- Critical: These items penetrate tissue or the vascular system and are at the highest risk of becoming contaminated.
As critical items, surgical instruments need to be sterilized with great frequency. Luckily, there are multiple ways to go about this.
Chemical Surgical Equipment Sterilization
This form of sterilization is the most detrimental to surgical instruments, as it requires hours of soaking to completely sterilize them. There are a number of chemical formulations suitable for sterilizing surgical equipment:
- Glutaraldehyde ≥2.4%
- Glutaraldehyde 0.95% with 1.64% phenol/phenate
- Stabilized hydrogen peroxide 7.5%
- Hydrogen peroxide 7.35% with peracetic acid 0.23%
- Peracetic acid 0.2%
- Peracetic acid 0.08% with 1% hydrogen peroxide
To fully sterilize instruments using this method, you may need up to 10 hours. For this reason, chemical sterilization is usually only a viable option when other avenues are not available.
Dry Heat Sterilization
This form of sterilization cuts down significantly on time. There are two types of dry heat to consider — static air and forced air. Using a static air sterilizer, it takes between one and two hours to sterilize instruments at 160°C. Using forced air, you can sterilize instruments in just six to 12 minutes at 190°C.
Be sure to account for the extra time needed to preheat the oven when planning sterilization times.
The autoclave is a device that uses pressurized steam to sterilize instruments. The first autoclave was invented by a French physician in the late 17th century, and it was actually used strictly as a food preparation device. It was essentially just a pressure cooker. Charles Chamberland, a colleague of Louis Pasteur, updated the autoclave for medical use in the late 1800s.
When using an autoclave, keep instruments in the open position. If an instrument is locked, the steam won't be able to reach all areas of the tool. In some cases, the heat of the autoclave will cause metal to expand enough that the locked hinges may crack.
You can put instruments in a sterilization tray or wrap them up in paper or muslin pouches before starting the autoclave. Use of either a tray or wrapping helps keep the instruments from getting contaminated after you have finished sterilizing them. Don't stack the instruments. Arrange them carefully so the steam can circulate effectively within the machine and reach all surfaces of each instrument.
In order to be effective, autoclaving must meet one of these thresholds:
- A temperature of 121°C for 20 minutes at 15 PSI above atmospheric pressure (unwrapped instruments)
- A temperature of 134°C for three to four minutes at 30 PSI above atmospheric pressure (unwrapped instruments)
- A temperature of 121°C for 30 minutes at 15 PSI above atmospheric pressure (wrapped instruments)
- A temperature of 134°C for 15 minutes at 30 PSI above atmospheric pressure
Given the potential for burns with steam heat, exercise care when opening the autoclave. Once the cycle is complete and the machine is depressurized, open the door just a couple of centimeters and let out the steam. Follow manufacturer recommendations for the drying cycle. Most autoclaves will complete their dry cycle in around half an hour.
Remove the trays and packages from the autoclave with sterile tongs, and let them cool to room temperature before moving on to storage. If items were sterilized in an unwrapped state, they should be used immediately. Alternatively, you can store them in covered, sterile trays for a week or less. Wrapped instruments should be kept in a cabinet in a warm and dry environment. There's no expiration date on wrapped sterile instruments as long as their wrappings stay dry.
Identifying Improper Use
When surgical instruments are mishandled, it often shows visually. If your instruments are discolored, there are several culprits you can identify by sight:
- Brown or orange stains indicate contact with high-pH materials.
- Dark-brown stains mean the instrument was exposed to low pH.
- Bluish or black stains indicate reverse plating caused by mixing metals during ultrasonic cleaning.
- Stains of multiple colors are a result of heat stress.
- Light and dark spots occur where water dried on the instrument's surface.
- Black stains indicate the instrument came in contact with ammonia.
- Gray stains are a result of using too much rust remover.
- Rust is the result of biological material or blood drying on the instrument.
If you spot any of these discolorations on an instrument, it can indicate that the equipment is no longer functioning at its original capacity. Heat stress stains, for example, are a warning that the instrument's metal may be weakened.
Storing Surgical Instruments
Even stainless steel's corrosion resistance can be ruined with improper storage. Surgical equipment storage needs to be organized so that bladed tools don't touch any other instruments. When the tray or other receptacle you keep instruments in stays dry and warm, your equipment will last longer and be less susceptible to becoming contaminated.
Inspecting Surgical Equipment
Even with regular surgical equipment maintenance, instruments will wear out with continued use. Inspecting surgical sets is key in making sure you replace equipment before its functionality affects surgical performance. Thorough inspections have two phases that are equally important — surface checks and function testing.
Inspecting Instrument Surfaces
Instrument inspection must be performed on equipment that has already been thoroughly cleaned and undergone decontamination. Ensure you have ample light and look instruments over for these criteria:
- Bent or misaligned shanks, ratchets and jaws
- Pitting, cracks or burrs in the metal
- Smooth edges on cutting surfaces
- Loose pins
- Chipping on plated surfaces or inserts
In short, look carefully for any visual defects. They may indicate that an instrument is reaching the end of its useful life.
Performing Function Tests on Surgical Equipment
As each instrument has a specialized function, there is no one-size-fits-all way to test that they are working correctly. Each instrument requires its own testing protocol. Here's how to test seven of the most common instruments for functionality.
Hold the scissors like you would during surgery. Open them up halfway and cut a test material, like a glove. There should be no snags, and the scissors should deliver a smooth cut. Next, open the scissors halfway once more, and then let one of the handles drop. At around the halfway point, you should feel tension.
You'll need a thick paper, like an index card or business card. When you cut the material, two-thirds of the rongeur should cut the material smoothly. There should be no tearing or snagging in the bite. If you're testing pituitary rongeurs, they should make an even impression on your material.
3. Needle Holders
The needle holder's jaws should meet at the tips without you applying any closing pressure. Close the jaw to one ratchet, and check to make sure there's no light coming through. Next, take a test material like aluminum foil and close the jaw to one ratchet again. Check that the jaw outline and serrations look intact. Then, open the needle holder and let one side of the handle drop. A needle holder in good condition should be about halfway closed.
Clamps are simple instruments and have an equally simple function test. Close the clamp at the first ratchet, and hold it up to check for any light leaking through. Perform the same handle drop test as you do with the needle holders.
Vascular clamps are a little bit different. You need to check the interlocking teeth, which you can do with a ziplock bag filled with water. Fix the clamp onto one of the bag's corners, turn the bag and see if the clamp prevents liquid from flowing into the corner you clamped. The clamp shouldn't create any holes or perforate the bag.
As a ratcheted instrument, forceps should be able to open completely and hold your test material at each ratchet stage. If inspecting thumb forceps that have a guide pin, see if the pin slides into the middle of the guide hole without any rubbing or jamming. If the forceps have teeth, ensure they engage evenly as you close them. Teeth must be sharp, and teeth of unequal size are an indicator that the instrument may need replacing.
6. Curettes and Osteotomes
Curettes and osteotomes have one extremely important job: Being sharp. You can test their sharpness with a syringe barrel, plastic rod or a dowel. Place the curette or osteotome at an angle of 45° and apply pressure. The cutting edge of the instrument should dig into the testing surface evenly. Any slippage indicates the instrument needs maintenance or replacement.
The Importance of Quality Surgical Equipment
With proper and diligent care, you can greatly increase surgical instrument lifespan. To treat your equipment right, be sure to follow manufacturer specifications for any machinery you use. Dialing in the wrong settings for an ultrasonic cleaning, for example, may mean that your instruments don't get completely clean. Exposing surgical instruments to undue heat by leaving them in an autoclave too long can also reduce the lifespan of equipment.
A huge factor in how long surgical equipment lasts is the overall quality of the instruments. A brand-name German-made instrument will last years longer than a no-name instrument made from substandard material. Make sure your cleaning and maintenance efforts pay off in the long run by starting out with a higher quality of instrument.
If you're looking for the best surgical equipment at the most competitive prices, QuickMedical is your source. Our immense product selection is populated with long-lasting equipment from scissors to suction tubes and beyond. We make buying equipment easy and hassle-free with online accounts and exceptional customer service. Not sure exactly what instruments will suit your needs most successfully? Our in-house product specialists are ready to answer your questions at (425) 222-5963.