Each instrument category requires different type of care

September 15, 2008

Proper care of surgical instruments is essential to patient safety and surgical outcomes.

Key Points

Dallas-In the fall of 2005, a large number of cases of toxic anterior segment syndrome (TASS) were reported in the northeast United States and found to be linked to an irrigating solution subsequently withdrawn from the market. That series of events heightened awareness of TASS and increased reporting of cases in the following year. A task force formed to investigate the outbreak was unable to identify a single product associated with the cases not caused by the irrigating solution.

During the investigation, site visits revealed considerable variation in instrument cleaning and sterilization practices and the failure, in many facilities, to follow the manufacturers' directions for cleaning. A group was then formed to develop recommended practices for cleaning and sterilizing intraocular surgical instruments. The group included nurses from various specialties, ophthalmologists, and representatives from the Centers for Disease Control and Prevention, FDA, and industry. Their recommendations were published in 2007 in the Journal of Cataract and Refractive Surgery and in Insight, the journal of the American Society of Ophthalmic Registered Nurses.

Some ophthalmologists might have missed that article, however, as instrument cleaning and maintenance is primarily the responsibility of the operating team, including the nurses, surgical and scrub technicians, and instrument technicians, said Sue Clouser, RN, MSN, CRNO, an operating room nurse at two Dallas-area surgery centers and a consultant on TASS.

"Secondly, cost is always an issue when it comes to instrument care; even though such a small number of instruments are required now to do cataract surgery, they can still run into the hundreds of dollars, and that doesn't includes items such as phaco handpieces and irrigation and aspiration devices," she continued. "Taking good care of your instruments decreases complications in your surgery, you can have a decreased infection rate if they're taken care of properly, and also a decreased chance of TASS."

Follow directions

Offering some suggestions on instrument care, Clouser said that each category of ophthalmic instrument requires a different type of care. Considerations include the composition of the metal, whether the instrument is cannulated, and the manufacturer's directions for use.

Manufacturers' directions for use accompany each specialized instrument, but they are often discarded by the person who unpacks the box.

"Those directions for use are critical," Clouser said. "They tell you the right way to take care of your handpiece and to maintain its quality and to keep it in service as long as possible. They should be kept on file somewhere, at least in a notebook, so they can be used for reference."

Cleaning of noncannulated instruments is fairly basic, and good standards have been drawn up. Class 1 instruments such as scissors, forceps, and hooks seldom come with instructions. They require manual cleaning, and a soft bristle brush is effective at removing ophthalmic viscosurgical devices (OVDs), which denature during the sterilization process if left on an instrument and can chip off and cause TASS.

Cleaning phaco handpieces is somewhat more complicated, since each manufacturer specifies in their directions for use the amount of fluid to be pushed or aspirated through the instrument. This can vary from 120 to 150 ml/lumen. Enzymatic cleaners are not recommended for phaco handpieces because of the lumens and the possibility that all of the product cannot be rinsed out. Once the handpieces are flushed, the lumens should be dried with forced air or medical grade nitrogen.

I&A strategy

The same cleaning strategy is applied to handpieces and tips used for irrigation and aspiration (I&A). They should be flushed according to the manufacturer's directions.

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