STERILIZATION OF SURGICAL INSTRUMENTS
Paige Allen, MS, RVT
College of Veterinary Medicine
Purdue University, West Lafayette, IN
Surgical instruments are used daily in veterinary practices across the country. They are a vital tool
used by veterinarians to perform surgery on patients entrusted to the veterinary team. They are also
one of the most expensive investments used in the veterinary facility. It is important that these
instruments be cared for, inspected, cleaned, and sterilized in a manner that will serve the patient’s
best interest and prolong the life of the instruments, thereby protecting the investment of the
veterinarian. The veterinary assistant or technician often carries the responsibility for the care and
cleaning of surgical instruments.
BASIC CLEANING
There are three steps in basic cleaning of surgical instruments: pre-cleaning, decontamination, and
ultrasonic cleaning. The first is the presoaking or initial cleaning of the instrument. The instruments
should be rinsed as soon after surgery as possible to prevent blood and tissue from adhering to the
instrument. If possible, this should occur at the point of use. This can be done by rinsing or soaking
the instruments in distilled water or in water mixed with an appropriate detergent for the cleaning of
surgical instruments. Instruments should not be soaked longer than 30 minutes as this can damage
them. Another option is to immediately spray the instruments with an enzymatic solution. This will
help prevent the remaining blood from drying. If this process can be done immediately after surgery,
it can make the cleaning process more efficient and better for the instruments.
The second step in basic cleaning is the decontamination of the instruments. This process includes
the manual scrubbing of an instrument in a detergent that is designed to assist in the breakdown of
biological material. Select a detergent that is specific for instruments. The detergent needs to have a
neutral or slightly alkaline pH and should be low-sudsing. If the pH is too acidic, it can damage the
protective coating on the instruments and a low-sudsing detergent allows you to see into the sink and
decreases injury to personnel.
When cleaning instruments by hand, it is important to use the appropriate cleaning instrument.
Wire brushes should not be used as they will damage the instruments. Soft, nylon bristle brushes
work well for the scrubbing of basic surgical instruments. It is important to pay close attention to the
grooves, box locks, and hinges of all the instruments. Debris can easily hide in these places. Scrub in
the direction of the grooves and away from yourself to prevent from splashing debris on your clothes
and face. Once all the instruments have been scrubbed, they need to be thoroughly rinsed. It is best to
use distilled water so that scale does not build up on your instruments.
If ultrasonic cleaning is not an option, then at this point, the instruments need to rinsed in or
sprayed with a lubricant. The appropriate surgical instrument lubricant will prolong the life of the
instrument and help prevent rust and corrosion. Then lay the instruments, with box locks open, on a
clean lint-free cloth. Once the instruments are dry, inspect them for functionality; box locks should
open and close easily, ratchets should function smoothly, the teeth or jaws of the instrument should
meet as designed, scissors should cut smoothly.
Ultrasonic cleaning is the third step in the process but not all clinics perform this step. It is not
necessary for the maintenance of surgical instruments but is a bonus if the clinic has one. Ultrasonic
cleaning uses distilled water and enzymatic solutions. The enzymes in the solution help to break
down the bioburden that the naked eye cannot see. There are several types of cleaners on the market
and it is important to follow the manufacturer’s directions regard amount and temperature of the
water.
Ultrasonic cleaners work by creating sound waves that in turn create tiny bubbles. As these
bubbles form and then implode, thousands of times per second, they suck the debris off the
instrument. This effect is called cavitation. Cavitation is a scrubbing effect on the surface of the
items in the liquid. These particles that have been scrubbed from the instruments by this process are
suspended in the solution and then are subjected to negative pressure or suction. The proteins are
coagulated, the cell walls are broken, and the microorganisms are destroyed.
Time in the ultrasonic machine can vary but is usually around 5 minutes. Again, it is important to
follow the manufacturer’s instructions for the machine and the ideal temperature of the water in the
machine for the cleaning solution. Once instruments are removed from the ultrasonic cleaner,
lubricant is applied; the instruments are allowed to dry and then are checked for functionality as
discussed above.
PACK WRAPPING
Most clinics have some sort of “recipe” or instructions for how packs are put together. Ideally
there should be a picture of the completed pack, a list of instruments and the quantity of each
instrument. There should also be notations about other supplies that are included in the pack (i.e.,
sponges). The instructions should also specify wrapping material including the types and size. A
recipe makes standardization and staff training more efficient for the practice.
Most wrapping material is made from cotton, linen or synthetic material. These materials are
specially formulated to withstand the heat and moisture associated with the sterilization process. The
ideal wrap should have the following qualities: selective permeability, resistance, flexibility,
memory. Selective permeability refers to the ability of the steam (or gas) to penetrate the material
and then to be removed once sterilization is complete. It also must prevent dirt and microbes from
penetrating the material. The resistance of a material refers to its ability to withstand handling
without tearing or puncturing. The material should be flexible enough to conform to the items it is
wrapping and also have memory to be able to return to a flat position so to avoid accidental pack
contamination.
Cotton wraps have good resistance, permeability, flexibility and memory. The problems with
cotton wraps are that they MUST be laundered between each use and people are often reluctant to
discard them when they are worn out. Any thread that is torn or worn leaves a spot of microbes to
enter. Crepe paper wraps may have a problem with memory. They can have a tendency to bounce
back onto the opened pack and contaminate the site. They are a one-time use item and should NOT
but re-sterilized as the integrity of the fibers is destroyed with multiple sterilizations and microbes
will be able to enter the material.
Packs should be sealed with chemical indicator tape and labeled, with the name of the pack, the
date and the initials of the person who packaged and sterilized the instruments.
Sterilization dates are important so that you can keep track of packs and make sure that they are
being appropriately rotated in the hospital. They are not necessarily used any longer to determine
“outdated” packs. The current standard is that a pack, if stored properly, is sterile until something
happens to it to contaminate it. Contamination occurs if the pack is opened, torn, or becomes wet
(strikethrough). Proper storage should be in a cupboard or drawer that closes so the sterilized item is
kept dust free and protected.
STERILIZATION INDICATORS
There are three sterilization indicators that are available for monitoring of the autoclave;
mechanical/visual indicators, chemical indicators, and biological indicators. All three must be used
together to be able to ensure that the parameters for sterilization have been met.
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Mechanical/Visual Indicators
These indicators are the gauges on the machine or any printout that the machine provides to you.
It is important to keep a record of the information so that there is a record that temperature and
pressure were appropriate for the load. If your autoclave does not have a printout, a log should be
kept next to the machine to record temperature and pressure.
Chemical Indicators
It is important for any item that is sterilized to place chemical indicators within the pack and on
the outside of the pack to indicate that the conditions have been met for sterilization. This does not
guarantee sterilization as there are no microorganisms to be killed. These are simply chemical
reactions that occur when the indicator is exposed to steam and time. Types of indicators are tape and
strips that are placed within the packs. There are several different manufacturers of these items. The
important thing to remember is that none of these guarantee that an item is sterile—only that the
conditions have been met that has allowed the chemical reaction to occur and that it also indicates
that microorganisms should also be killed. It does not take into account a high microorganism count,
items that may still have organic material from improper cleaning, or a malfunction of the sterilizer.
Biological Indicators
Biological indicators for steam sterilizers contain a non-pathogenic organism called Geobacillus
stearothermophilus. This bacterium is very resistant and so it provides a good margin of safety when
used as a test organism. This bacterium has a D-value of 2 minutes at 250°F or 20 seconds at 275°F.
What this means is that at 250°F within 2 minutes 90% of the bacteria are dead or within 20 seconds
at 275°F. The accepted standard is that at a six D-value, 99.9999% of the organisms are dead. This
means that 6 minutes at 250°F or 2 minutes at 275°F is sufficient to destroy most organisms. These
are minimum times that are used and you should always follow the manufacturer’s recommendations
for time and temperature with your autoclave.
Most veterinary facilities do not utilize biological indicators, citing expense and the fact that you
do not have results for 24 hours since you must wait for the bacteria to grow in an incubator.
However, these indicators are more sensitive to changes within the autoclave and will demonstrate a
problem more quickly than a chemical indicator. It would be ideal to run a biological indicator each
day but if a weekly or monthly test was run, it might catch problems with your sterilizer earlier.
Human hospitals are required to run biological indicators in each load they run.
STERILIZATION
Sterilization is the process of removing all living organisms. There are two types of steam
sterilizers (autoclaves). The most common in the veterinary practice is the gravity displacement
autoclave. These autoclaves depend on gravity to move the steam through a pack. They do utilize
pressure also but not in the same way as a high-vacuum (or pre-vacuum) sterilizer. A highvacuum
sterilizer has a pulse-cycle that actually pulls the air from the chamber creating a vacuum and the
steam is essentially pulled through the items in the chamber. This decreases the time of the cycle
because the unit does not have to depend on gravity for the steam to move through the items. The
high-vacuum sterilizers are more expensive and you will like only see them at veterinary schools.
Time and temperature should be set according to the manufacturer’s instructions for the items that
are loaded in the sterilizer. Packs and linens are usually a longer cycle time than individually
packaged instruments. It is important to pack the autoclave correctly to facilitate proper sterilization.
Items should not touch the walls of the chamber and individually packaged instruments should be
placed in a vertical position to prevent pooling of water. Always think about the D-value discussed
above when looking at the time and temperature of the sterilizer and what comprises the load.
Flash sterilizing is sometimes utilized to quickly sterilize an instrument that has been dropped.
This process is an abbreviated cycle because you do not wrap the instrument but it is place in a pan
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that is then transported directly into the surgery room. This type of sterilization is not recommended
to be used on a regular basis but in the emergency situation.
COMMON ERRORS
Common errors and misconceptions that may occur in veterinary facilities include:
• Re-using of paper wraps
• Re-using of steri-peel packages
• Not washing linens before re-use
• Using newspaper as a packaging material
• Using masking tape to save money
• Not placing a chemical indicator within the pack
REFERENCES
1. Fluke C, Ninemeir JD, Webb SB. Central Service Technical Manual, 4th ed. International
Association of Healthcare Central Service Material Management, Chicago, 1994.
2. Schneider PM, Reich RR, Kirckof SS, Foltz WG. Performance of various steam
sterilization indicators under optimum and suboptimum exposure conditions. Am J
Infection Control. 2005;33(5):S55-S67
3. https://www.continuinged.purdue.edu/iahcsmm/ This website contains self-study series on
many of the topics covered in this talk.
4. Samantha Stevenson, CST/CFA, Director of Central Supply, Purdue University Veterinary
Teaching Hospital, [email protected]
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