Complex Surgical Instruments
ANES 1502
ANESTHESIA TECHNOLOGY FUNDAMENTALS
COLLEGE OF DUPAGE
Objectives:
As a result of successfully completing this chapter, students will be able to:
Provide an overview of and discuss procedures to care for and effectively process powered surgical instruments.
Explain basic concerns important when handling and processing endoscopic instruments.
Discuss detailed information about flexible endoscopes.
Review general processing and inspection requirements for rigid and semi-rigid endoscopes and laparoscopic instruments.
Identify basic protocols important at each step in the loaner instrumentation process.
Powered Surgical Instruments (PSI’s)
What We See and Don’t See
Powered Surgical Instruments
Look Simple – Are Complex
Look Durable – Are Delicate
Look Plain – Are Expensive
Look Easy to Clean – Are Difficult to Clean
Electrically Powered Instruments
Cable attached to a motorized hand piece.
Electrical Powered Instruments
Require a cable that can be sterilized. One end attached to the instrument handpiece and the other to a motor or adapter that is connected to a 110 volt outlet.
Pneumatic Powered Instruments
Powered by Compressed Gas.
Pneumatic Powered Instruments
Powered by compressed gas. They require a hose that can be sterilized. One end attaches to the instrument handpiece and the other to a stand alone cylinder tank or a wall or column mounted regulator panel.
Battery Powered Instruments
Least cumbersome because there is no cord or cable. Requires batteries and a battery charger.
Battery Powered
Example of a Battery Powered PSI and Two Styles of Batteries
PSI Processing Concerns
PSIs are complex instruments that are difficult to clean and easy to damage.
Central Service Technicians should follow manufacturer’s processing instructions carefully.
Fluid Invasion
Occurs when water or cleaning solution is allowed to enter PSIs.
Fluid invasion can severely damage a PSI.
Decontamination Batteries and cords can protect PSIs from Fluid Invasion
Attachments are Complex Instruments Too!
PSI Accessories
ChucksKeysBurr GuardsCordsBatteries…and much, much more!
Common PSIs
Dermatomes/Dermabraiders – used to harvest skin grafts or reshape skin surfaces
Cebatomes – used to remove cement Sternal Saws – used to split the sternum for open heart surgery Dental Drills – used for teeth and jawbones Micro Drills – used for middle ear bones and to drive very small wires Wire Drivers, Drills and Saws – come in various sizes and are used
to work on small to large bones. Saws - designed to perform specific cutting actions such as
reciprocating or oscillating
PSI Instrument Cleaning
PSI’s must be processed manually.
Care MUST be taken to prevent Fluid Invasion.
Basic PSI Processing Procedure(You MUST Follow Manufacturer’s Specific Instructions)
Remove all bits, burrs and blades from the unit, disconnect from the power source.
Disassemble and remove debris at point of use, keep the instrument moist.
Separate devices with internal mechanisms from simple devices. Generally, simple components can be soaked.
Attach handpiece to a hose of specialized cleaning attachment to reduce the risk of fluid invasion during cleaning.
Clean the exterior with an approved germicidal detergent.
Pay special attention to recessed areas, moving levers, switches, etc.
Clean recessions and cannulas using a stiff bristle brush.
Basic PSI Processing Procedure(You MUST Follow Manufacturer’s Specific Instructions)
Clean, rinse and inspect the hose, cable or battery pack. Look for signs of damage or excessive wear.
Lubricate and test as required by the manufacturer.
Dry all components.
Package and sterilize as recommended by the manufacturer.
Endoscopy Instruments
Endoscopes greatly reduce patient trauma when physicians perform minimally invasive surgery.
Endoscopeman**with permission from Lighthouse Imaging Corporation
Rigid Endoscopes
Provide an optical view and in some cases minimal access through a rigid instrument. The scope is inserted through a sheath inserted via a small incision.
Flexible Fiberoptic Endoscope
Provides optical access using a flexible, maneuverable scope most commonly inserted through a mucous membrane opening.
Regulations and Guidelines
Several regulatory agencies and professional associations provide input into proper scope handling and processing practices.
For a list, please refer to pages 207-209 in the text.
Infection Control Concerns
Flexible endoscopes pose significant infection control challenges. Their configuration makes them difficult to clean and dry and they can harbor bacteria.
Infection Control Issues
Inadequate training of employees who clean and handle scopes.
Adequate time for thorough processing.
Commitment of employees (and policy writers) to safely reprocess scopes.
Failure to adequate inspect scopes prior to processing.
Failure to follow manufacturer’s instructions for reprocessing.
Infection Control Issues
Failure to follow label direction on processing chemicals.
Using the scope without a leak test.
Poor manual cleaning habits.
Failure to use automatic endoscope reprocessors in accordance with manufacturer’s instructions.
Improper drying and storing procedures.
Additional Concerns:
Failure to leak test correctly.
Failure to manually clean all channels.
Failure to flush all channels with disinfectant solution.
Failure to fully immerse.
Failure to adequately time the length of disinfectant contact.
Use of disinfectant solutions after their expiration date.
Additional Concerns:
Failure to process all scopes in the same manner (Standard Precautions).
Failure to sterilize biopsy forceps.
Inaccessible manufacturer’s instructions.
Variations in staff training.
Improper reprocessing of reusable cleaning supplies.
Inadequately trained personnel.
Additional Concerns:
Lack of competence reviews for scope processing and procedures.
Improper storage and transport.
Pressure from physicians to process scopes more quickly so they can perform more procedures on more patients.
Difficulties processing these complex instruments.
Space constraints.
Additional Concerns:
Absence of, or an inadequate quality control program.
Poor water quality.
Facility processing equipment.
In order for endoscope processing to be successful, each of these concerns must be addressed.
Liquid Chemical Processing Systems
Glutaraldehyde
High Level Disinfectant
Can be used manually or in automatic processors.
Must be tested.
Takes Time.
Employee Safety Concerns (ventilation a must!)
Ortho-Phthaladehyde (OPA)
High Level Disinfectant
May be used manually or in an automatic processor.
Must be tested.
Automatic Endoscope Reprocessors(AERs)
Automated equipment designed to clean, disinfect, and rinse flexible endoscopes.
Advantages of AERs
Process consistency Reduced staff exposure to chemicals Timed cleaning Consistent exposure to the cleaning
agent Timed contact with liquid
disinfectants An air flush cycle to remove excess
moisture Use of copious and consistent
amounts of rinse water
When using AERs:
Follow manufacturer’s instructions to connect the scope to the AER
Place removable parts in the AER if possible
Attach channel cleaning connectors to all channels
Follow manufacturer’s instructions for using disinfectants
Set the machine for the recommended time
Staff Education
All staff must be thoroughly educated in the proper cleaning, processing, and handling of endoscopes.
Page 215 in the text contains a sample competency checklist for endoscope training.
A Closer Look at Endoscopes
Although they look similar, endoscopes vary greatly in configuration.
Some scopes are only used to visualize and do not have channels, while others have internal channels.
Endoscope Channels
Instrument Channel
OpticalChannel
Air/WaterChannel*Suction
Channel
*Some Flexible Scopes have separate Air and Water Channels
Distal Tip
Flexible FiberopticEndoscope
Video Monitor
Water Bottle Light Source
Suction Canister
Common FFE’s
Bronchoscope
Used for the direct visualization of the tracheobronchial tree.
CystoscopeUreteroscope
Used to visualize the urethra and bladder (cystoscope) and to look for obstructions such as kidney stones (ureteroscope).
Gastroscope Esophagoscope
Used for the visual inspection of the upper GI tract (gastroscope) and for the direct visualization of the esophagus and the cardia of the stomach (esophagoscope).
Colonoscope Sigmoidoscope
Used for the visual inspection of the entire large intestine (colonoscope) and the visual inspection of the lower part of the large intestine (sigmoidoscope).
Care & Handling
Steps in Endoscope Processing
1. Preclean
2. Leak Test
3. Clean
4. High-Level Disinfect or Sterilize
5. Dry
6. Store
Fluid Invasion
Fluid invasion can cause damage to flexible fiberoptic endoscopes.
Leak Testing
Detects leaks that can compromise the safety of the scope.
Scopes that fail a leak test must be removed from service and repaired.
Storage
Scopes must be dry when stored.
Do not kink or bend.
Endoscope Accessories
Diagnostic Accessories
Therapeutic Accessories
Follow manufacturer’s instructions for the proper processing of each type of accessory.
Rigid and Semi-Rigid Endoscopes
An Important Note:
The term “Rigid” is misleading! Rigid Endoscopes are VERY DELICATE and can be easily damaged.
Rigid Endoscope Guidelines
Always follow manufacturers’ recommendations.
Never soak instruments for cleaning or high level disinfection in a metal soak pan.
Instruments may need to be soaked in a vertical position.
Utilize flush ports when available to circulate (under pressure) enzymatic detergent through the channels.
Lenses must never be placed in an ultrasonic cleaner.
Rigid Scope Guidelines - continued
Gently brush clean the exterior and accessible lumens with the appropriate brush.
Thoroughly rinse with distilled water and rough dry.
Inspect instruments for cleanliness, missing parts, and damage.
Thoroughly air-dry instruments.
Remember that these instruments are fragile and must be handled carefully.
Clean carefully and check for missing parts.
Inspection
Check surfaces of the telescope for visible damage
Inspect for clarity using white paper with writing on it
Check the eyepiece seal for visible damage
Laparoscopic Instruments
Minimally Invasive Instrumentation
Inspect Insulation for Damage or Wear
Insulation Testers are available
Loaner Instrumentation
Owned by the vendor and brought in for a specific case.
Can have a significant impact on Central Service workload.
Loaner Instrument Processes
Log Receipt of Loaner Instruments and Implants. Include the following information: Date Time Signature of delivery person Initials of receiving person Doctor’s name Patient’s last name Number of trays Inventory check of tray(s) for completeness Inventory check of tray(s) for damaged items.
Loaner Instrument Processes
ALL Loaner instruments must be decontaminated by the receiving facility before use.
Loaner Instrument Processes
After cleaning and decontamination, inspect and assemble instruments for sterilization. Defective instruments should be documented.
Sterilize according to manufacturer’s instructions.
Loaner Instrument Processes
After sterilization, place in a low traffic area and handle as little as possible before use.
As technology advances, instruments (and the Central Service Technician’s job) become more complex.