Chapter 21; Sterilization and Surgical Instruments

Ratchet

notched mechanism, usually at the handle end of an instrument, that clicks into position to maintain tension on the opposing blades or tips of the instrument

Disinfection

killing or rendering inert most but not all pathogenic microorganisms

Sound

long instrument for exploring or dilating body cavities or searching cavities for foreign bodies

Sanitation

maintenance of a healthful, disease-free environment

Scalpel

small, pointed knife with a convex edge for surgical procedures

Obturator

smooth, rounded, removable inner portion of a hollow tube, such as an anoscope, that allows for easier insertion

Forceps

surgical instrument used to grasp, handle, compress, pull, or join tissues, equipment, or supplies

Hemostat

surgical instrument with slender jaws used for grasping blood vessel

Needle Holder

type of surgical forceps used to hold and pass suture through tissue

Assisting with Minor Surgical Procedures while Maintaining Surgical Asepsis

• Become familiar with many types of surgical instruments. • Understand the principles and practices of surgical asepsis. • Understand and use disinfection and sterilization techniques. • Use equipment designed for sterilization, treatment, and diagnostic purposes. • Maintain accurate records and inventory of purchases related to surgical equipment and supplies.

Straight Scissors

Cut deep or delicate tissue and sutures.

Kelly Clamp

A curved or straight forceps or hemostat; those with long handles are widely used in gynecologic procedures.

Scalpels and Blades

A scalpel is a small surgical knife with a straight handle and a straight or curved blade. A reusable steel scalpel handle can hold different blades for different surgical procedures. Straight or pointed blades are used for incision and drainage procedures, while curved blades are used to excise tissue. Reusable handles are used only with disposable blades.

Surgical Instruments

A surgical instrument is a tool or device designed to perform a specific function, such as cutting, dissecting, grasping, holding, retracting, or suturing. Surgical instruments may be curved, straight, sharp, blunt, serrated, toothed, or smooth. Many are made of stainless steel and are reusable; others are disposable.

Hemostat

A surgical instrument with slender jaws used for grasping blood vessels and establishing hemostasis.

Suture Scissors

Cut sutures; they have a straight top blades and curved-out, or hooked, blunt bottom blades to fit under, lift, and grasp sutures for snipping.

Operating the Autoclave

All components of autoclaving - temperature, pressure, steam, and time - must be correct for the items to reach sterility. The temperature, pressure, and time required vary with the items being sterilized. In most cases, 250°F at 15 pounds of pressure for 20 to 30 minutes will be sufficient. The timer should not be set until the proper temperature has been attained. Do not handle or remove items from the autoclave until they are dry because bacteria from your hands will be drawn through the moist coverings and contaminate the items inside the wrapping.

Maintaining Surgical Supplies

As a clinical medical assistant, you should keep an up-to-date master list of all supplies, including purchases and replacements. Equipment records for each item should include the following: • Date of purchase. • Model and serial numbers of the equipment. • Time of recommended service. • Date service was requested. • Name of the person requesting the service. • Reason for the service requested. • Description of the service performed and any parts replaced. • Name of the person performing the service and the date the work was completed. • Signature and title of the person who acknowledged completion of the work. Warranties and guarantees should be kept with the equipment records, along with the name of the manufacturer's contact person. Parts and supplies for items that are vital to the operation of the facility should always be kept on hand. The shelf life of the item, the storage space available, and the time required to order and receive an item should be considered when deciding what items to keep in inventory.

Autoclave Indicator Tape

Autoclave tape is designed to change color in the presence of heat and steam. In extreme instances, the tape me change appearance when stored too close to heat sources. Most tapes have imprinted lines that darken after exposure, but sterilization of the package contents is not ensured buy a color change on the autoclave tape. Proper sterilization can be assumed only if accompanying sterilization indicators have registered that all elements of the sterilization process (time and temperature) have been achieved.

What is the difference between a sterilization indicator and autoclave tape?

Autoclave tape is used on the outside of a wrapped instrument or pack to identify the contents of the pack, the date the item was autoclaved, and initials for the person who wrapped the pack. After exposure to steam, dark brown or black stripes will appear on the tape, acknowledging that the pack has been processed in the autoclave or exposed to steam. Sterilization indicators are placed inside a pack to indicate sterility of the contents.

What should you do if you drop a surgical instrument accidentally?

Because surgical instruments are delicate, improper handling may easily damage sharp blades or pointed tips. If you drop an instrument, inspect it carefully for damage. Many instruments are expensive, but damaged instruments can usually be repaired.

Probes and Directors

Before entering a cavity or site for a procedure, the physician may first probe the depth and direction of the operative area. A probe shows the angle and depth of the operative area, and a director guides the knife or instrument once the procedure has begun.

Why is the properly working autoclave more effective at sterilizing equipment compared to boiling water?

Boiling water will reach a temperature of 212° F, which is not hot enough to destroy all microorganisms including viruses in spores. An autoclave increases the temperature of boiling distilled water converted to steam by increasing the pressure in the chamber, raising the temperature to 250° F or higher.

Curved Scissors

Dissect superficial and delicate tissues.

Forceps

Forceps are surgical instruments used to grasp, handle, compress, pull, or join tissue, equipment, or supplies. All forceps are available in many sizes, with or without serrations or teeth, with curved or straight blades, and with ring tips, blunt tips, or sharp tips. Many have ratchets in the handles to hold the tips tightly together; these are notched mechanisms that click into position to maintain tension. You should study the names and purposes of each type of forceps to assist the physician when a specific instrument is required.

Sterilization Methods

HEAT: Moist Heat (steam under pressure) 250°F or 121°C for 30 minutes Boiling 212°F or 100°C for 30 minutes Dry Heat 340°F or 171°C for 1 hour 320°F or 160°C for 2 hours LIQUIDS: Glutaraldehyde Follow manufacturer's recommendations or OSHA requirements and guidelines Formaldehyde Follow manufacturer's recommendations or OSHA requirements and guidelines GAS: Ethylene oxide 450 - 500 mg/L 50°C

Loading the Autoclave

Load the autoclave loosely to allow steam to circulate. If too many items are packed into the autoclave, steam will not penetrate the items in the center. Place all packs on their sides to allow for the maximum steam circulation and penetration.

Comparison of Medical and Surgical Asepsis

Medical Asepsis: Destroys microorganisms AFTER they LEAVE the body. Prevents TRANSMISSION of microbes from one person to another. Used during contact with a body part that is NOT normally sterile. Hands and wrists are washed for 1 - 2 minutes. Surgical Asepsis: Destroys microorganisms BEFORE they ENTER the body. Prevents ENTRY of microbes into the body in invasive procedures. Used during contact with a normally STERILE part of the body. Hands and FOREARMS are washed for 5 - 10 minutes.

OSHA

Occupational Safety and Health Administration

Bandage Scissors

Remove bandages; this type has a flattened blunt tip on the bottom longer blade that safely fits under bandages; most common type is the Lister bandage scissors.

Retractors

Retractors hold open layers of tissue, exposing the areas beneath. They may be plain or toothed; the toothed retractor may be sharp or blunt. Retractors may be designed to be held by an assistant or screwed open to be self-retaining.

How do sanitization, disinfection, and sterilization differ?

Sanitation is maintenance of a healthful, disease-free environment for removing organic matter and other residue. Disinfection is destruction of pathogenic microorganisms but not their spores. Sterilization destroys all microorganisms and their spores on an item or instrument.

Scissors

Scissors are sharp instruments composed of two opposing cutting blades held together by a central pin at the pivot. Scissors are used for dissecting superficial, deep, or delicate tissues and for cutting sutures and bandages. Scissors have blade points that are blunt, sharp, or both, depending on the use of the instrument.

Sterilization Equipment

Several types of sterilization equipment are used in clinics and medical offices. As a clinical medical assistant, it is your responsibility to do the following: • Become familiar with the uses and operation of each piece of equipment. • Schedule periodic preventative maintenance or servicing of the equipment. • Maintain adequate supplies for general operational needs.

Principles and Practices of Surgical Asepsis

Surgical asepsis requires the absence of microorganisms, infection, and infectious material on instruments, equipment, and supplies. Disinfection, or medical asepsis, is different from sterilization.

Sterilization Indicators

Tape applied to the outside of the material used to wrap instruments or supplies for the autoclave indicates that the items have been exposed to steam, but the tape cannot ensure the sterility of the contents. Sterilization indicators placed inside the packs register that the proper pressure and temperature were attained for the required time to allow steam to penetrate the inner parts of the package. Although most types of sterilization indicators work well, the best method for determining effectiveness of sterilization is the culture test.

Sterilization and Surgical Instruments

The goal of surgical asepsis is to free an item or area from all microorganisms, including pathogens and other microorganisms. The practice of surgical asepsis, also known as sterile technique, should be used during any office surgical procedure, when handling sterile instruments to be used for incisions and excisions into body tissue, and when changing wound dressings. Surgical asepsis prevents microorganisms from entering the patient's environment; medical asepsis prevents microbes from spreading to or from patients. Any break in sterile technique, no matter how small, can lead to infection the body cannot fight.

The Autoclave

The most frequently used piece of equipment for sterilizing instruments today is the autoclave. The autoclave has two chambers: an outer one where pressure builds and an inner one where the sterilization occurs. Distilled water is added to a reservoir, where it is converted to steam as the preset temperature is reached. The steam is forced into the inner chamber, increasing the pressure and raising the temperature of the steam to 250°F or higher. The pressure has no effect on sterilization other than to increase the temperature of the steam. The high temperature allows for destruction of all microorganisms, including viruses and spores. An air exhaust vent on the bottom of the autoclave allows the air in the chamber to be pushed out and replaced by the pressurized steam. When no air is present, the chamber seals and the temperature gauge begins to rise. Most automatic autoclaves can be set to vent, time, turn off, and exhaust at preset times and levels. Sterilization is required for surgical instruments and equipment that will come into contact with internal body tissues or cavities that are considered sterile.

What are the most common instruments used in a medical office?

The most widely used surgical instruments used in the medical office are forceps, scissors, scalpels, and clamps.

What types of instruments are used to remove tissue during a biopsy?

The physician may use forceps to remove tissue for biopsy.

Why is it important to set the timer on the autoclave during a cycle only after the correct temperature has been reached?

The time indicated for sterilization should be started only after the appropriate temperature has been reached, since the temperature and time are both important for destruction of microorganisms and their spores. Items that have been exposed to the high temperature for less time than indicated by the manufacturer of the autoclave may not be sterile.

What 6 items should be included on a sterilization record?

These records should include the following: • Date and time of the sterilization cycle. • General description of the load. • Exposure time and temperature. • Name or initials of the operator. • Results of the sterilization indicator. • Expiration date of the load (usually 30 days).

Care and Handling of Surgical Instruments

To ensure that surgical instruments always function properly, follow these guidelines: 1. Do not toss or drop instruments into a basin or sink. Surgical instruments are delicate, and the blade or tip is easily damaged by improper handeling. Should you drop an instrument accidentally, carefully inspect it for damage. Damaged instruments can usually be repaired and should not be discarded unless repair is not feasible. 2. Avoid stacking instruments in a pile. They may become tangled and be damaged when separated. 3. Always store sharp instruments separately to prevent dulling or damaging the sharp edges and to prevent accidental injury. Disposable scalpel blaze should be removed from reusable handles and placed in puncture proof sharps biohazard containers. If a disposable scalpel is used, the whole unit is discarded into the sharps container. Syringes with needles attached and suture needles should also be discard in a sharps container and never in the trash or with other instruments for processing. Delicate instruments, such a scissors or tissue forceps or those with lenses, or kept separate to be sanitized a sterilized appropriately. 4. Keep ratcheted instruments open when not in use to avoid damage to the ratchet mechanism. 5. Rinse gross contamination from instruments as soon as possible to prevent drying and hardening, which makes cleaning more difficult. Always wear gloves and follow OSHA standards to prevent contact with possibly infected blood or body fluids. 6. Check instruments before sterilization to ensure that they are in good working order, and identify instruments in need of repair. 7. Use instruments only for the purpose for which they were designed. 8. Sanitize instruments before they are sterilized so that sterilization will work effectively.

Towel Clamps

Towel clamps are used to maintain the integrity of the sterile field by holding the sterile drapes i place, allowing exposure of the operative site. A sterile field is a specific area that is considered free of all microorganisms.

Spring or Thumb Forceps

Used for grasping tissue for dissection or suturing, such as tissue forceps and splinter forceps.

Needle Holder

Used to hold and pass a needle through tissue during suturing.

Sterilizer Forceps

Used to transfer sterile supplies, equipment, and other surgical instruments to a surgical field. May also be called sterile transfer forceps.

Storage and Record Keeping

When using and maintaining sterile instruments, equipment, and supplies, staff are responsible for correctly storing these items, keeping accurate records of warranties and maintenance agreements, and reordering information on hand. You should be familiar with the manufacturer's recommendations for each instrument or piece of equipment. Medical assistants are typically responsible for keeping accurate records of sterilized items and equipment. Information that must be recorded includes maintenance records and load or sterilization records.

Sterilization

While sterilization and disinfection are adequate for maintaining medical asepsis in the medical office, the practices are not sufficient to process instruments and equipment used during sterile procedures. Objects requiring surgical asepsis must be sanitized first and sterilized by either a physical or chemical process. Sterilization is the complete elimination or destruction of all forms of microbial life, including spore forms. Steam under pressure, dry heat, ethylene oxide gas, and liquid chemicals are principle sterilizing agents. Although in medical offices steam under pressure is the most frequently used method of sterilization, the method depends on the nature of the material to be sterilized and the type of microorganisms to be destroyed.

Autoclave

appliance used to sterilize medical instruments with steam under pressure

Ethylene Oxide

gas use to sterilize surgical instruments and other supplies

Serration

groove, either straight or crisscross, etched or cut into the blade or tip of an instrument to improve its bite or grasp

Sterilization

process, act, or technique for destroying microorganisms using heat, water, chemicals, or gases

Sanitize

reduce the number of microorganisms on a surface by use of low-level disinfectant practices

Scissors

sharp instrument composed of two opposing cutting blades, held together by a central pin on which the blades pivot