Chapter 34

Cleaning and Sterilization

P. 956


Al l anest hesi a pract i ti oners should be concerned wi t h the cl eanl i ness of thei r
equipment , both to prevent spread of infecti on bet ween pati ents and to ensure that
t hey themselves do not cont ract an i nfecti on. Nosocomi al i nf ect ions conti nue t o be
a si gni f i cant drai n on human and economic resources, produci ng suf feri ng and
hi gher heal th care costs. Inf ect ion cont rol has become an i mportant focus of t he
Joint Commissi on on Accredi tat ion of Heal thcare Organi zati ons (JCAHO).
Definitions (1,2,3)
Ant i microbi al : A chemical or mat erial capabl e of destroyi ng or i nhi bi t ing the
growt h of microorgani sms.
Ant i septi c: A chemi cal germicide t hat has ant i microbial act ivit y and t hat can
be safel y appl i ed to l ivi ng ti ssue. Anti septi cs are regulated as drugs.
Asepsi s: A scheme or process that prevents contact wi t h mi croorganisms.
Bacteri a: Mi croscopic unicel lul ar organi sms.
Bacteri ci de: A chemical agent or compound that ki l ls bacteri a.
Bacteri ostat : An agent that wi l l prevent bacteri al growth but does not
necessari l y ki ll t he bacteri a. Bacteri ostat ic acti on i s reversible; when t he
agent i s removed, the bact eri a wi l l resume normal growth.
Bi oburden (Bi ol oad, Mi crobi al Load): The number and t ypes of vi able
organisms contami nati ng an obj ect. The l evel of bi oburden i s relat ed to the
anatomi c si te where t he device was used.
Bi ol ogi cal Indicator: A steri l izati on-process moni tori ng devi ce consisti ng of a
standardized, viable popul at i on of microorganisms (usual l y bact eri al spores)
t hat are known t o be resi stant t o t he mode of st eri l i zati on being moni t ored.
Subsequent growt h or f ai lure of the microorganisms to grow under sui tabl e
condi ti ons i ndi cates whether or not condi ti ons were adequate to achieve
steri l i ty.
Cei l ing Value: Concent rati on of an ai rborne contami nant above whi ch a
person shoul d not be exposed even moment ari l y.
Chemi cal Indi cator (chemi cal moni tor, st eril i zer cont rol , chemi cal cont rol
device, st eri l i zat i on-process moni tori ng devi ce): A steri l izati on-process
moni tori ng devi ce desi gned to respond wi t h a characteristi c and vi si bl e
chemical or physical change t o one or more paramet ers of a steri l i zat i on
process.
Chemi cal Integrator: Chemi cal indi cat or t hat reacts t o a vari et y of
steri l i zat ion parameters.
Chemosteri l i zer (chemi cal steri l ant): Chemical used for the purpose of
destroyi ng al l f orms of microbiol ogical l if e, i ncl uding bact eri al spores. The
same chemi cal used f or shorter exposure peri ods and/or at a l ower
concentrati on may be used f or di si nfect ion.
P. 957


Cl eani ng: Removal of f orei gn materi al f rom an i tem.
Contami nat i on: Stat e of actuall y or potenti al l y havi ng been i n contact wi t h
mi croorgani sms.
Cri t ical I tem: It em t hat penetrates the ski n or mucous membranes or i s i n
contact wi th normal l y steri le areas of the body.
Decont aminat ion: A process that renders cont ami nat ed inani mate i tems saf e
f or handl ing by personnel who are not weari ng protect ive att i re (i .e.,
reasonabl y f ree of t he probabi l i ty of t ransmi tt i ng i nfecti on) (2, 3,4).
Decont aminat ion can range f rom simpl e cl eani ng to st eri l i zati on.
Di si nfect ant : Chemi cal germicide f ormulated t o be used on i nani mate obj ects.
Di si nfect ion: Process capabl e of dest royi ng most mi croorgani sms but, as
ordi nari l y used, not bact erial spores. A disinf ectant i s usual l y a chemi cal
agent , but some processes (such as pasteuri zati on) are di si nf ecti ng. The
Centers for Disease Control and Prevent i on (CDC) has adopted a
cl assif i cat ion t hat incl udes three level s of di si nf ect ion.
Hi gh-level Di si nf ecti on: A procedure that ki l l s all organi sms wi th t he
excepti on of bacteri al spores and cert ai n speci es, such as the Creut zf el dt-
Jakob prion. Most high-l evel di si nf ectants can produce st eri l i zati on wi th
suff icient contact t ime.
I ntermediat e-level Di si nfect i on: A procedure t hat kil l s vegetat i ve bacteri a,
i ncl udi ng Mycobacteri um t uberculosi s, most f ungi , and vi ruses but not
bacteri al spores (5).
Low-l evel Disi nfecti on: A procedure that ki l l s most vegetat ive bacteria (but
not M. tubercul osi s), some f ungi , and vi ruses but no spores (5).
Di sposabl e: I ntended f or use on one pati ent duri ng a si ngl e procedure.
Fungi ci de: An agent or process t hat kil l s fungi .
Germi ci de: An agent that dest roys mi croorganisms.
Mechani cal Moni tor (physi cal moni tor, physi cal indicator): St eri l i zer
component that gauges and records t i me, temperature, humi di ty, or pressure
duri ng a steri l i zati on cycl e.
Noncri t ical I tem: An i t em that does not ordinari l y touch the pati ent or onl y
t ouches intact skin but not mucous membranes (5).
Nosocomi al : Pertai ni ng to a heal th care f aci l i t y. A nosocomi al i nf ect i on is
one acqui red in a heal th care f aci l i ty.
Permi ssi bl e Exposure Li mi t (PEL): The ti me- wei ghted average maxi mum
concentrati on of an ai r cont ami nant to whi ch a worker can be exposed
accordi ng to Occupat i onal Saf ety and Heal th Admi ni st rati on (OSHA)
standards.
Pri ons: Protei naceous i nf ect ious agents wi th no associated nucleic acids.
Processi ng: Al l of the steps performed to make a cont ami nat ed devi ce ready
f or pati ent use.
Pseudoi nfect i on: A posi t i ve cul ture wi thout cl i ni cal i nf ect i on.
Pyrogens: Subst ances that can produce f ever.
Reprocessi ng: Decontaminati on and repackagi ng of a devi ce t hat has been
used for i ts i ntended purpose and is l abeled f or single use (6).
Resteri l i zat i on: St eri l i zat i on of an unopened (i .e. , i nner wrap sti l l i ntact ,
and theref ore, the devi ce i s presumabl y unused) steri l e devi ce or an
unused wrapped steri le devi ce that i s past the expi rati on date.
Reusabl e: I ntended for repeated use ei ther on the same or dif f erent pati ents,
wi th appropri at e reprocessing between uses.
Sani t i zat i on: Process of reduci ng the number of mi crobi al contaminants to a
rel ativel y saf e l evel . In general , sani t ati on i s used for noncri ti cal surfaces or
f or appli cat i ons i n which stronger mi crobi al agents may cause devi ce
materi al s to deteri orate (4).
Sani t i zer: A l ow-l evel disinfectant.
Semi cri t i cal I tem: A devi ce that i s intended t o come in contact wi t h mucous
membranes or i ntact ski n but wi l l not normal l y come i nt o contact wi t h steri l e
t i ssues.
Short -t erm Exposure Li mi t (STEL): A 15-minute t i me-wei ghted average
exposure that shoul d not be exceeded at any ti me duri ng a work day.
Spore: The normal rest ing stage i n the l i f e cycl e of cert ai n bacteria.
Spori ci de: An agent that ki l l s spores.
St andard Precauti ons: Pol ici es promulgated by the Centers f or Di sease
Control and Prevent ion (CDC) i n 1996 that i ncl ude uni versal precaut ions,
ai rborne precaut ions, dropl et precaut i ons, and contact precauti ons. Standard
precauti ons appl y to al l pati ents, regardl ess of thei r diagnosis or known or
presumed inf ecti on stat us.
St eri l ant /Di si nf ectant : Term appl i ed by the Envi ronmental Prot ect ion Agency
(EPA) t o a germi ci de that i s capable of steri l i zati on or hi gh-l evel di si nfect ion.
St eri l e/Steri l i ty: St ate of bei ng f ree f rom al l l ivi ng mi croorgani sms. In
pract i ce, steri l i ty i s usual l y described i n terms of the steri l i ty assurance
l evel .
St eri l i ty Assurance Level (SAL): Probabi l i t y that mi croorgani sms wi l l survive
af ter a terminal steri l i zat ion process. Bef ore a manufacturer can l abel a
product as steri l e, i t must have a steril i ty assurance l evel of 10
- 6
, whi ch
means that the possi bi l i t y that mi croorgani sms have survived on the i tem
exists but is no great er t han 1 10
- 6
or 1 i n 1,000, 000.
St eri l i zat i on: Process capabl e of removing or destroyi ng al l vi abl e f orms of
mi crobi al l if e, i ncl udi ng bacteri al spores, t o an accept abl e steri l i t y assurance
l evel .
P. 958


Termi nal Steri l i zat i on: Steri l i zati on process that i s carri ed out af t er an i tem
has been pl aced i n i ts f inal packagi ng.
Threshol d Li mi t Val ue Cei l ing: Concent rati on of an ai r contaminant t o whi ch
i t is beli eved that nearl y al l workers may be repeatedl y exposed day af t er
day wi t hout adverse ef f ect .
Ti me-weighted Average (TWA): I ntegrati on of al l the concentrat ions of a
chemical t o which a worker has been exposed duri ng a sampl i ng period,
reported as an average.
Transmi ssion-based Precauti ons: Recommendati ons by t he CDC for pati ents
wi th known or suspected i nf ect i on or col onizati on wi th hi ghly t ransmi ssi bl e or
epi demiol ogical l y i mport ant pat hogens that can be t ransmi tt ed by ai rborne or
dropl et t ransmi ssi on or by cont act wi t h dry ski n or contami nated surf aces.
Tubercul oci de: An agent or process that ki l l s tubercl e baci l li .
Uni versal Precaut i ons: Recommendati ons made by t he CDC that heal t h care
workers consi der bl ood and certai n body f l ui ds to be potenti al l y i nf ect i ous f or
bl oodborne pat hogens and use protecti ve barri ers and workpl ace practi ces t o
reduce t he risk of exposure. I n 1996, uni versal precauti ons were
i ncorporated i nto standard precaut ions, whi ch expanded the coverage to any
body f l ui d that may contai n contagious microorganisms.
Vegetati ve: Active growt h phase of a microorgani sm.
Vi rucide: Agent t hat i nacti vates vi ruses.
Vi rus: Submi croscopi c, noncell ul ar part icle composed of a protei n shel l and a
nucleic acid core, and, in complex t ypes, a surrounding envel ope. In broad
t erms, vi ruses are ei ther l i pophi l i c (envel oped) or hydrophi l i c (naked) (7).
Role of the Federal Government and Professional
Associations
The EPA regi sters and regul ates chemi cal germi ci des (8,9). It requi res
manuf acturers to test f ormul ati ons of chemi cal germicides for microbi ci dal pot ency
(eff i cacy), stabi l i ty, and toxi ci ty. It also approves steri l i zat i on devi ces.
The Food and Drug Admi nistrat ion (FDA) regul ates medical devices and consi ders
l i quid chemi cal germi ci des used to reprocess medi cal instruments as accessories to
medi cal devices. The FDA requi res t hat t he manuf acturer of a devi ce marketed as
reusable provide the user wi th adequat e i nst ructi ons f or cl eaning and di si nfecti ng
or steri l i zi ng the i t em.
I n 1993, the FDA and EPA signed a memorandum of understandi ng that states t hat
t he agenci es wi l l di vi de t he premarket cl earance of germi ci des so that t he FDA
woul d cl ear l i qui d chemi cal steri l ants and the EPA woul d register general -purpose
di si nf ectants bef ore marketi ng (9A).
OSHA regul at es occupat i onal exposure t o chemi cal di si nf ectants and steri l i zers.
The CDC does not approve, regulate, or test germi ci des or steri l i zers. Rather, i t
recommends broad st rategi es to prevent transmi ssion of i nfecti ons i n the heal th
care envi ronment.
Pract ices and procedures to reprocess reusabl e devices have been publ i shed by
several prof essional organizati ons, i ncl udi ng t he Ameri can Soci ety of
Anesthesi ol ogi sts (ASA), t he American Associ ati on of Nurse Anest het i sts (AANA),
and the Associ ati on of Operat ing Room Nurses (AORN) (2, 10,11).
Resistance of Microorganisms to Disinfection and
Sterilization
Mi croorgani sms can be categori zed into groups accordi ng to t hei r i nnate resi stance
t o a spect rum of physical processes or chemi cal germicidal agents. Fi gure 34.1
shows a general descendi ng order of microbial resistance l evel s. Resi stance to
di si nf ect ion and st eri l i zati on i s not equi val ent t o resi stance to ant ibi ot i cs. For
exampl e, ant i bi oti c-resi stant st rai ns of staphylococci do not appear t o be more
resi st ant to chemi cal germicides than nonresi st ant bacteri a (8).
Cleaning
The f i rst and most i mportant st ep i n decontami nati on i s thorough cl eani ng
(12,13,14). In some cases, cl eaning may be suf f i ci ent t o render an i tem sui table f or
reuse. If an art icle i s not clean, retained sal ts and organi c soi l could i nacti vat e
chemical germi ci des or protect microorganisms duri ng the di si nf ect ion or
steri l i zat ion process. Even i f the i t em is rendered steri l e, resi dues may interf ere
wi th t he device's f uncti on or cause a react ion in a pat i ent .
I t i s i mportant to prevent blood or ot her body f l ui ds f rom dryi ng on devi ces.
Enzymat ic f oam sprays t hat prevent dryi ng, break down blood and protein, and
i nhi bi t bacteri al growt h are avail able. Fl ushi ng l umens wi th enzymat i c cl eaner wi l l
break up debri s. It ems that can be i mmersed shoul d be soaked i n wat er plus an
enzyme presoak wi t h or wi thout detergent for at l east 3 mi nutes (15). Stainless
steel or other metal devi ces shoul d not be soaked in sal i ne or sodi um hypochl ori te
solut i ons, because the chl oride i ons i n these two substances wi l l cause the met al t o
corrode (13). A closed contai ner should be used to move contami nated devices to
t he decontami nati on area.
P. 959



View Figure

Figure 34.1 Descending order of resistance of organisms.

Cl eani ng shoul d be performed i n a desi gnated l ocati on that i s separat e f rom other
parts of the f aci l i t y to mi ni mi ze i nadvertent personnel exposure or exposure of
ot her i t ems to contami nants. The area shoul d be restricted t o aut hori zed personnel
as much as possi bl e. It shoul d be away f rom t raf f ic, pat ients, and cl ean-i tem
storage. The f l oors, wal l s, cei li ng, and work surface should be made of non-porous
materi al s that wi l l not support t he growth of mol d. These surfaces shoul d be
washed f requentl y. The area shoul d have adequate l i ghti ng wi th no shadowed or
dark areas. The f l oor should be desi gned t o prevent sl i ppi ng but be easy to cl ean.
Hori zont al work surf aces shoul d be cl eaned and di si nf ected dai l y. Fl ui d spi l l s
shoul d be cl eaned up qui ckl y to prevent sl i ps and f al l s. If the spi l led materi al was
contaminated wi t h blood, the spi l l area should be t reated af t er i t has been cl eaned
up wi th a tubercul ocidal germicide.
The heat ing, venti lati on, and ai r-condi t i oni ng systems shoul d be designed t o
mi nimi ze spreadi ng contami nants to adj acent spaces. The ai r pressure wi thi n the
decontami nat ion space shoul d be negati ve rel ati ve t o the surrounding spaces so
t hat ai r does not f l ow out of the area. There shoul d be a minimum of 6 to 10 total
ai r exchanges each hour wi t h 100% f resh ai r. Ai r f rom thi s area shoul d be
exhausted t o the outside wi t hout reci rcul at ion or to a fi l tered part i al reci rculat i ng
system.
The area shoul d be di vided i nto di rt y and cl ean areas. Si gns showi ng where di rt y
equipment i s to be pl aced should be promi nentl y di spl ayed. Si nks shoul d be bi g
enough to contai n large i nst ruments, and t here should be enough sinks to
accommodate concurrent soaki ng, washi ng, and ri nsing. Si nks shoul d have
at tached count ers or adj acent work surf aces on which t o pl ace soi l ed and cl ean
i tems separatel y. Hand-washi ng f aci l i ti es shoul d be conveni ent l y locat ed in or near
t he decontami nati on area. Personnel shoul d wear a f ul l compl ement of protect ive
at ti re (hai r covering, f lui d-resistant mask, eyewear, wat erproof gown or apron,
appropri at e gloves, and wat erproof shoes or boots wi t h nonski d soles) (13, 16).
Personnel shoul d be caref ul not to i nj ure t hemsel ves wi th contaminated
i nst ruments.
Each devi ce manuf acturer' s i nstruct i ons shoul d be consul ted t o det ermi ne the
appropri at e cl eani ng met hods and agents t o remove soi l wi thout damagi ng the
device. Tape shoul d be removed and adhesi ve resi due di ssolved by usi ng an
appropri at e sol vent.
P. 960


The next step i s di sassembl y (i f not done at the source). An ini t ial wat er ri nse or
soaki ng wi th a speciali zed product (e. g., a protei n-dissolvi ng solut i on) can prevent
bl ood coagul at i on on the devi ce and remove gross debris. The wat er t emperature
shoul d not exceed 45C, because hi gher temperatures cause proteinaceous soi l t o
coagul ate (17). An al ternati ve i s to use a spray-on precl eaner t o hel p di ssolve t he
soil (12).
Af ter the equi pment has soaked l ong enough to l oosen organi c mat ter, i t should be
t horoughl y scrubbed i nsi de and out. Part i cul ar at tenti on shoul d be pai d to l umens,
crevi ces, corners, grooves, and knurl ed or t extured surf aces. It is i mportant to have
a vari ety of brushes (18). Brushes and ot her cl eani ng impl ements shoul d be
di sposabl e or shoul d be cl eaned and steri l i zed or undergo hi gh-l evel di si nf ect i on at
l east dai l y.
I mmersi bl e devices cl eaned under water to prevent aerosol i zati on of
mi croorgani sms. A cl ot h soaked i n detergent and water can be used to cl ean i tems
t hat cannot be i mmersed. Detergents should be l ow sudsi ng and ri nse off wi t hout
l eavi ng a resi due. Detergent resi dues can lead to st ai ni ng and may i nterf ere wi t h
t he act ion of some chemi cal disi nf ect ants (13).
Cl eani ng may be accompl i shed manual l y, mechani cal l y, or by a combi nat i on of
both. Usi ng mechanical equi pment may i ncrease product i vi ty, i mprove cleani ng
ef fectiveness, and off er greater protect ion for t he worker.
A variety of washi ng machines are avai labl e (12, 19). They are hi ghl y automated,
usual l y wi th mi croprocessor cont rol . Washer-st eri l i zers are desi gned to wash, ri nse,
and then steam steri l i ze i tems (4,13). Washer-decontami nat ors/di si nfectors use hot
wat er i n the range of 60C to 95C. They are desi gned to wash, ri nse, and dry t he
same i tems as a washer-steri l i zer but can process i t ems that would be deteri orated
by t he hi gh temperature used i n steam steri l i zati on.
Some equipment t hat has j oi nts, crevi ces, lumens, and other hard-to-reach areas
can be t reat ed in an ul t rasoni c cl eani ng syst em af t er gross soi l has been removed.
I n an ul t rasoni c cl eaner, hi gh-f requency sound waves passi ng t hrough a solvent
produce submi croscopi c bubbles. These bubbl es col lapse on t hemselves,
generati ng t iny shock waves t hat knock debri s of f surf aces. A detergent i s of ten
added to the ul trasonic l i qui d. The water may be heat ed. Ul t rasoni c cl eaning t anks
are avai l abl e i n a vari ety of si zes and conf igurati ons. The equipment t o be cl eaned
i s placed i n a basket or t ray and into the ul trasonic tank f or a preset peri od of
t i meusual l y 3 t o 6 mi nutes. Ul t rasoni c cl eani ng moni tors are avai l able (20). Some
manuf acturers of del i cate inst ruments, incl udi ng l aryngoscopes, recommend that
t hey not be subj ected to ul trasonic cl eani ng because t he process may l oosen fi ne
screws and adversel y aff ect ali gnment (21).
Af ter cl eani ng, ri nsi ng shoul d be perf ormed to remove soi l and resi dual det ergent
and to keep i t f rom reset tl i ng on the equi pment . Lumens and channels shoul d be
wel l f lushed duri ng each ri nse. Inadequate ri nsi ng can cause i rri t at ion and burns in
pati ents (22). Some i tems (such as those undergoi ng pl asma steri l i zat ion) shoul d
be rinsed wi th al cohol or disti l l ed or demineral i zed water.
The cleaned i tem shoul d be thoroughl y dri ed. Even i f an i tem i s to undergo no
f urt her processing, dryi ng is i mportant because a humid envi ronment may
encourage t he growth of certai n organi sms. If a l i qui d chemi cal agent is t o be used,
wat er on t he equipment wi l l di l ute the agent and make i t l ess ef fecti ve. If water
dropl ets remai n on equipment t hat i s to be gas st eri l i zed, et hylene oxi de (EO) wi l l
di ssolve i n the water and f orm et hyl ene gl ycol , whi ch is both t oxi c and di f fi cul t t o
remove. Most i tems may be towel - or ai r-dri ed. Ai r-drying cabi nets and hot -ai r
ovens are avai l abl e (Fi g. 34.2). I f an i tem i s t o undergo EO steri l i zat ion, unheated
ai r shoul d be used.
Af ter cl eani ng, each i tem shoul d be inspected to verif y cl eanli ness and tested for
f uncti onal i ty (23). Al l accessi bl e surfaces shoul d be exami ned under normal
l i ghti ng. Swab tests f or detecti ng resi dual protein on surf aces are avai l abl e.
Di sassembl ed devices must be reassembl ed t o perform f uncti onal i t y testi ng. Af ter
f uncti onal i ty i s veri f i ed, some devi ces must again be di sassembled to ensure that
t he steri l ant can contact al l the surf aces.
Disinfection and Sterilization Methods
Pasteurization
Wi th pasteuri zat i on (hot wat er di si nf ecti on), the equi pment i s i mmersed i n wat er at
an el evated temperature (but bel ow 100C) f or a specif i ed ti me. The t i me and
t emperat ure vary. A t ypi cal sequence is 30 mi nutes at a temperature of 70C.
Contact ti me is i nversel y rel ated to t emperat ure, that i s, f or equival ent mi crobi al
ki l l , a l onger exposure ti me is requi red when t he temperature is reduced. CDC
gui del i nes ref er to pasteuri zati on as a hi gh-l evel disi nfecti on process, al t hough
some f eel i t i s i ntermedi ate-l evel (13,24).
Pasteuri zi ng machines come i n dif f erent si zes (Fi g. 34. 3). Many al so wash the
equipment . They are si mpl e to load and operate. Speci al dryers that are equipped
wi th f i l ters are avai l abl e.
Pasteuri zat i on has been used f or breathi ng t ubes, reservoi r bags, t racheal tubes,
f ace masks, ai rways, laryngoscope bl ades, st yl ets, bi te bl ocks, Y-pieces, el bows,
adapt ors, and venti l at or bel l ows.
A maj or advantage of pasteuri zat i on i s that t he l ower temperature i s l ess damagi ng
t o equi pment than t he hi gher temperatures employed duri ng aut ocl avi ng. There are
no toxi c fumes or resi dues. It i s si mpl e,
P. 961

i nexpensive, and rel iable. Thi s technol ogy may resul t in consi derabl e savings
compared wi t h throwi ng equipment away. The main di sadvant age i s that the treated
equipment i s wet and must st i ll be dri ed and packaged, duri ng whi ch t ime i t may
again become contami nated. The heat may damage some material s.

View Figure

Figure 34.2 Forced-air drying cabin for equipment. (Picture
courtesy of Olympic Medical.)

Steam Sterilization
St eam st eri l i zati on (autocl avi ng) uti l i zes saturated steam under pressure
(19,25,26, 27, 28,29). I t is t he most wi del y used and i nexpensive of the steri li zat i on
t echni ques.
At sea level , wat er boi l s at 100C. When i t i s boi l ed wi t hi n a closed vessel at
i ncreased pressure, t he t emperat ure at whi ch i t boi l s and that of the steam i t f orms
wi l l exceed 100C. The i ncrease in t emperat ure depends on the pressure wi t hi n the
chamber. Pressure per se has l i t tl e or no steri l i zi ng ef fect. I t i s the moist heat at a
sui tabl e temperature, as regul ated by the pressure i n the chamber, t hat bri ngs
about st eril i zat ion.
I ncreasi ng t he temperature dramatical l y reduces the t i me needed t o achi eve
steri l i zat ion. The mi ni mum t i me f or st eri l i zati on by steam at 121C is 15 mi nutes. If
t he temperature is 126C, the t ime i s reduced to 10 minutes.
P. 962

I t i s 3. 5 minutes at 134C and onl y a f ew seconds at 150C.

View Figure

Figure 34.3 Pasteurization machine. (Picture courtesy of
Olympic Medical.)

I ncreasi ng t he temperature dramatical l y reduces the t i me needed t o achi eve
steri l i zat ion. The mi ni mum t i me f or st eri l i zati on by steam at 121C is 15 mi n. If the
t emperat ure i s 126C, t he ti me is reduced to 10 mi n. I t is 3.5 mi n at 134C and onl y
a few seconds at 150C.
Aut ocl aving i s ef fecti ve because the steam t ransf ers heat to materi als rapi dl y on
contact. Microbial dest ruct ion wi l l be most eff ect i ve at l ocati ons where saturated
steam can contact t he mi croorgani sms. At locat ions i naccessi bl e to steam
penet rat i on (as mi ght occur wi t h compl ex devi ces, improperl y packaged i tems or
i ncorrect l oad confi gurati ons), some mi crobi al dest ructi on may occur, but dry heat
i s not as eff ici ent at steri li zi ng as saturat ed steam.
Equi pment to be steri l i zed i s cl eaned, and then may be packaged i n a materi al
easi l y penet rated by steam. Af t er steri l i zat ion, the packagi ng mat eri al prevents
recontami nat i on duri ng subsequent handl ing and storage.
P. 963


Autoclave Design
A steam steri l i zer can range f rom a smal l , manual l y-operated tabletop steri l i zer to a
l arge, comput er-control l ed, f l oor-l oadi ng model (26,28,29,30,31). Steri l i zers are
descri bed by the method of ai r removal , temperature and the t ime t he chamber i s
hel d at t he speci f i ed t emperat ure (e.g., vacuum, 130C, 4 mi nut es) (28).
The chamber (pressure vessel ) i s where mat eri al s to be steri l i zed are placed and
t hrough whi ch steam is ci rcul ated. I t must be constructed t o wi t hst and t he hi gh
pressures requi red to bri ng the steam up t o the temperatures requi red and f i tt ed
wi th a saf et y valve to prevent devel opment of excessi ve pressure. Chamber si ze
vari es f rom less than 1.5 cubi c feet in small tabl etop st eri l i zers to more than 70
cubic f eet in l arge f l oor-l oading model s (28). The j acket i s the port i on surroundi ng
t he chamber. It f uncti ons to maintai n the temperature in t he chamber.
The steri l i zer may be equi pped wi t h one or t wo doors. Doors may be hi nged or
sl i ding and are opened and cl osed manual l y or by power (el ectric, pneumat ic or
hydraul i c). I tems are pl aced on a shel f i n the chamber, and t he door cl osed and
secured.
Ai r must be displ aced f rom the chamber. Thi s i s cal l ed the condi ti oni ng or heat-up
phase (Figure 34.4). I ts l ength varies, dependi ng on t he l oad. In the gravi ty-
di spl acement t ype of st eri l i zer t he i ncomi ng steam displ aces t he ai r through a port
or drai n in or near t he bot tom of the chamber. The steri l i zer chamber drai n remai ns
open unt il t he t emperat ure i n the drai n is t he same as the t emperat ure of t he steam
entering the chamber, i ndi cat i ng that the ai r has been removed. The pre-vacuum
steri l i zer depends on one or more pressure and vacuum excursi ons to remove ai r.
The steam-f lush pressure-pul se steri l i zer uses a repeat ed sequence of a st eam
f lush and a pressure pul se. No vacuum i s requi red. A pre-vacuum or steam-f lush
pressure-pulse steri l i zer resul ts i n shorter cycl es because ai r is removed more
rapi dl y.
I n t he gravi t y-displacement type of steri l i zer, the i ncomi ng steam displaces the ai r
t hrough a port or drai n in or near t he bot tom of the chamber. The steri l i zer
P. 964

chamber drai n remai ns open unt i l the temperature in t he drain i s the same as the
t emperat ure of the steam entering the chamber, i ndi cat i ng that the ai r has been
removed. The pre-vacuum steri l i zer depends on one or more pressure and vacuum
excursi ons to remove ai r. The steam-f l ush pressure-pul se st eri l i zer uses a repeat ed
sequence of a st eam fl ush and a pressure pul se (Fig. 34. 4). No vacuum i s requi red.
A prevacuum or st eam-fl ush pressure-pul se steri l i zer resul ts i n short er cycl es
because t he ai r i s removed more rapi dl y.

View Figure

Figure 34.4 Typical steam sterilization cycle. Conditioning
phase (A); sterilization phase (B); exhaust phase (C); dry
phase (D). (Redrawn from a figure in
Young JH. Steam sterilization: scientific principles. In:
Reichert M, Young JH, eds. Sterilization Technology for
the Health Care Facility. 2nd ed. Gaithersburg, MD: Aspen
Publishers, Inc., 1997:124133
.)

As steam enters the chamber, i t enters the l oad to be steri l i zed and gi ves up i ts
l atent heat. Once the int ended temperature i s reached, the steri li zat i on ti me is set.
Thi s i s cal led t he exposure or steri l i zat i on phase. By conventi on, steri l i zati on
cycl es in heal th care set ti ngs have been standardi zed at a few t emperature-t i me
rel ati onshi ps (29). The lowest t emperat ure f or a st eril i zer i s 121C (250F). Cycles
may al so be programmed at 132C (270F), 134C (275F), or 145C (285F),
dependi ng on the st eri l i zer. In general , wrapped i tems shoul d be steri l i zed f or 30
mi nutes and unwrapped i tems f or 20 mi nutes at 121C (32).
Af ter the steri l i zat i on phase, i tems must be dri ed before bei ng removed f rom t he
steri l i zer. Thi s is call ed the postexposure (exhaust , dry) phase and consi sts of
exhausti ng the chamber to atmosphere f ol l owed by ci rcul ati ng f i l t ered ai r t hrough
t he chamber or by drawi ng a deep vacuum (27). Some t abl et op autocl aves requi re
t hat the door be cracked, but newer model s may al l ow cl osed-door drying (33,34).
Fl ash steri l i zat i on al l ows i tems to be steam steri l i zed f or immediat e use (35, 36).
The i tems to be processed are usual l y unwrapped. The ti me and temperature wi l l
depend on t he st eri l i zer and the conf i gurat ion of the l oad. The processed i t ems are
t ransferred immediatel y f rom the autocl ave t o t he point of use, usual l y t he steri l e
f iel d i n an ongoi ng surgi cal procedure.
Problems with Steam Sterilizati on
Problems with the Steam
St eam qual i ty or saturati on refers to t he percentage of l i quid i n steam. Current
standards cal l for a steam qual i t y great er t han 97% (l ess t han 3% l iqui d water).
Vari ati ons i n steam pressure may af f ect the ti me needed to at tai n the proper
t emperat ure and t emperature uni f ormi ty wi t hin t he chamber. Cl ogged f il ters, poorl y
engineered pi ping, or excessi ve demands on t he steam supply may cause pressure
vari ati ons. St eam is saturat ed when i t has the proper bal ance of pressure and
t emperat ure. If the pressure i s too high, the steam wi l l change t o l i qui d, causi ng
packs t o become wet ; i f t he pressure is too l ow, t he st eam wi l l be superheated.
Superheat ed steam is l ess able t o transf er i t s heat energy to t he cool er i t ems bei ng
steri l i zed than sat urated steam and wi l l i nt erf ere wi t h achi eving a unif orm
t emperat ure i n the chamber.
Air in the Autoclave Chamber
The presence of ai r in t he chamber wi l l i mpai r steri l i zat i on. Ai r conducts heat poorl y
and retards steam penet rati on. The autocl ave evacuates much of the ai r at t he
beginni ng of the cycle (Fig. 34. 4). Al l of t he ai r does not have to be removed, but
al l surf aces requi ring steri l i zati on must be exposed to adequate moi sture (27).
I mproper steri l i zer l oading and incorrectl y prepared i ndivi dual packages can aff ect
t he abi li t y of the steri l i zer to remove ai r f rom the load (37).
Many autocl aves have a bui l t -in vacuum l eak test (37). Such steri l i zers are capable
of running a speci al cycl e that pauses when the maximum vacuum is achi eved. For
ot hers, t he ef f i cacy of the ai r removal process can be tested by a Bowi e-Di ck test .
Thi s i s run wi th a si ngl e test pack in t he chamber. Thi s should be run each day
before the f i rst steri l i zati on cycle (20,38). Ai r detect i on devi ces may be added t o
t he steri l izer pl umbi ng and control syst em.
Equipment Malfunction
Examples of equipment mal f unct i on i nclude out -of -cal ibrati on temperature or
pressure gauges and cont rol l ers, i ncorrect steam suppl y pressure, f aul t y or
mal adj usted control val ves, l eaks, cl ogged vent l i nes or drai n screens, f aul ty
vacuum pumps, def ecti ve steam traps, and mal f unct i oni ng cycle sequence
control lers.
Personnel Errors
Personnel errors i ncl ude i nadequate cl eani ng, i ncorrect pack preparat ion or
packagi ng methods, and poor l oading t echni ques (39). I tems i n the steri l i zer must
be posi t i oned so that ai r cannot be t rapped. It ems shoul d not be crowded or stuff ed
i nto t he autoclave. Crowdi ng may i nterf ere wi t h both ai r el i minati on and dryi ng. If
t he shape of an i tem woul d al l ow water t o col l ect i n any part , that i tem shoul d be
posi t i oned on i ts side or upsi de down so that the water can run out . If water can
pool , then ai r coul d be trapped agai nst the surf ace.
Steam Sterili zati on Monitori ng
St eri l i zati on val i dati on is achi eved by usi ng a combi nat i on of mechani cal , chemi cal ,
and biol ogical i ndi cators (19,40). Using t hese i n concert wi l l give t he greatest
possi bl e conf i dence t hat i t ems are steri le.
Mechanical Indicators
Mechani cal moni tors i ndi cat e ti me, t emperat ure, and pressure (37). Most
autocl aves provi de a permanent record of these parameters. The t emperat ure i n a
f loor-l oadi ng st eri l i zer i s typical l y measured i n t he chamber drai n pipi ng. In small
t abl etop steri li zers where the steam i s generated wi t hi n t he chamber, the
t emperat ure i s usual l y measured i n the chamber. Some tabl etop st eril i zers do not
have a recorder. Wi th
P. 965

t hese, i t is i mportant to moni tor physi cal condi t i ons duri ng the cycl e (39).

View Figure

Figure 34.5 Autoclave tape is an example of an external
process indicator. The exposed tape is at top.

Chemical Indicators
Chemi cal i ndi cat ors are di vi ded i nto f i ve cl asses (41,42,43,44). The hi gher t he
cl ass, the more sensi ti ve the i ndi cator.
Cl ass 1 i ndi cators are i nternal and external process indicators. These i nf orm the
user that the i t em has been exposed t o the steri l i zat ion process. The most common
exampl e of an external process i ndi cator i s autocl ave tape (Fi g. 34.5). Most tapes
do not respond t o al l the parameters of steri l i zati on but do of f er vi sual proof that
t he pack has been through the process. Internal process indicat ors usual l y exhi bi t a
color change f rom whi t e to bl ack. Li ke autoclave tape, t hey have l i mi ted sensi tivi t y
t o t he paramet ers of steri l i zati on but do i ndi cat e exposure to steam.
Cl ass 2 i ndi cators rel at e to the Bowi e-Di ck test f or vacuum steam st eri l i zers. They
do not determi ne i f the steri li zati on parameters have been met but onl y assess
vacuum pump ef f i ci ency and detect the presence of ai r l eaks and/or gases in t he
steam. The indicator i s placed i n a pack of towel s (handmade or purchased) on the
f ront bot tom shel f over the drai n and a 3.5- to 4-mi nute cycl e is run. Many new
steri l i zers are equipped wi th l eak t est cycl es, so these i ndi cat ors do not need to be
used.
Cl ass 3 i ndi cators are si ngl e parameter. An example i s the t emperature tube t hat
contai ns a chemi cal t hat mel ts and someti mes changes col or when the appropri ate
t emperat ure i s att ai ned. These indicators are hel pf ul i n determi ni ng if the
appropri at e temperat ure was achi eved i n t he center of l arge packs. Fal se-posi ti ve
resul ts have been report ed (43).
Cl ass 4 i ndi cators respond t o one or more st eri l i zati on parameters. They contai n an
i nk that changes col or when exposed to the correct combinati on of steri li zati on
parameters.
Cl ass 5 i ndi cators are al so known as i ntegrati ng i ndi cators or i ntegrators. They
respond to al l parameters of st eri l i zat i on over a speci f i ed range of temperatures.
Fal se-posi ti ve and f al se-negati ve resul ts have been report ed (41).
Chemi cal i ndi cat ors can detect fai l ures or errors i n packagi ng, pack densi t y,
l oadi ng, insuf f i ci ent humi dif i cat ion, i nadequat e exposure ti me at t he sel ect ed
t emperat ure, or st eri l i zer mal f unct i on. An i mportant advant age i s that they can be
read as soon as the packs have been opened. Another advantage i s that they are
so i nexpensive that one can be used i n every pack.
The CDC and al l major U.S. organi zati ons that i ssue steri l i zati on-rel at ed standards
or guidel ines advocate that a chemi cal i ndicat or be at tached t o every package t hat
goes through a steri l i zat i on cycle and wi t hi n each package to be st eri l i zed i n what
i s expected to be t he most di f fi cul t -t o-steri l i ze l ocati on.
There are both U.S. (45,46, 47) and i nternati onal (48,49,50,51,52,53) standards for
chemical i ndi cat ors.
Biological Indicators
Bi ol ogi cal indicators are standardi zed preparat i ons of spores (t ypical l y st ri ps or
ampoul es) t hat are pl aced i n the most di f fi cul t -t o-steri li ze l ocati on(s) i n the l oad
(37,43). Al t ernat ivel y, a bi ol ogi cal indicator that i s encl osed in a commerci al t est
pack can be used. The i ndicators are exposed to t he steri l i zat ion cycl e, ret ri eved,
i ncubated, and exami ned f or mi crobi al growt h. A posi t ive biological i ndi cator i s
i ndi cat i ve of a possi bl e steri l i zat i on process f ai l ure. Commerci al mai l -i n biol ogical
moni tori ng servi ces el i mi nat e the need for on-si te i ncubati on.
One t ype of biological i ndi cator cont ai ns a rapi d det ecti on system t hat i s based on
t he i nteract i on of an enzyme i n t he bacteri al spore wi t h a subst rate i n the growt h
medi um. Fluorescence occurs when the vi able bi ol ogi cal indicat or i s exposed to
ul traviol et l i ght . Thi s type of i ndi cator can be read in 3 hours wi th a wrapped i tem
or i n 1 hour wi t h an unwrapped i t em. It may be parti cul arl y usef ul i n the operati ng
or ambul atory sett ing where products are of t en steri l i zed unwrapped i n a gravi ty
di spl acement steri l i zer (43,54).
The mai n probl em wi t h biological i ndi cators i s the ti me needed for i ncubati on.
Bi ol ogi cal moni tors should be used at l east once a week but pref erabl y dai l y and
af ter maj or repai rs t o the st eri l i zer (37, 43).
There are both U.S. (55,56, 57,58,59) and i nternati onal (60,61,62,63) standards for
bi ol ogi cal indicat ors.
Advantages and Di sadvantages of Autoclavi ng
St eam autocl avi ng can ki l l all bacteri a, vi ruses, and spores. Advantages i ncl ude
speed, good penet rati on, economy, ease of use, absence of toxic products or
resi dues, and rel i abil i ty. The mat eri al can be prepackaged and kept st eri l e unti l
used. I t poses no harm t o
P. 966

t he envi ronment . A maj or advantage i s that at l east one autocl ave is avai labl e i n
every modern operati ng t heat er.
The pri nci pal disadvantage of autocl avi ng is t hat many pi eces of equi pment are
damaged i f subjected to st eam. Autoclavi ng can cause bl unted cut t ing edges, metal
surf ace corrosi on, and short ened l if e of el ectroni c components. Fiber-opt ic
l aryngoscope blades show a decrease i n l i ght t ransmi ssi on wi th repeated
autocl aving (64).
Dry Heat Sterilization
Dry heat i s used f or i t ems that might be damaged by moi st heat (65, 66, 67). Whi l e
sl ow, t hi s techni que penet rates wel l and does not corrode metal and sharp
i nst ruments (68). I t is usef ul f or nonaqueous l i quids or semi soli ds such as talc,
gl yceri n, oil s, petrol eum j el l y, waxes, and powders.
Ti mes and temperat ures f requentl y used for dry heat steri l i zat ion are 170C for 60
mi nutes, 160C f or 120 mi nutes, and 150C for 150 mi nutes (32,68). Some of the
newer dry heat steri l i zers can at t ai n t emperat ures up to 210C (65). Convecti on hot
ai r st eri l i zers i mprove heat t ransfer by usi ng f orced ai r. These uni ts have
comparati vel y f ast cycl e ti mes.
There are both U.S. and internat i onal standards f or bi ol ogi cal indicators f or dry
heat steri l i zat ion processes (69).
Chemical Disinfection and Sterilization
Chemi cal (col d) di si nf ect ion/steri l i zati on invol ves i mmersing an i tem i n a sol ut ion
t hat cont ai ns a disi nf ectant (3). This method i s especi al l y usef ul f or heat-sensi t ive
equipment . It can be accompl ished by automated equi pment , whi ch t ypi cal l y
provi des a cycl e of cl eaning, ri nsi ng, di si nfect ion, ri nsi ng, and someti mes dryi ng.
Regulati on and Label ing
The EPA regul at es f ormul at i ons and l abeli ng of chemi cal germi ci des (70). The
l abel i ng must provide cert ai n i nformat ion, i ncl udi ng precauti onary stat ements,
di recti ons for use, t he requi red contact ti me, recommended use temperat ure, use
pat tern, use l if e, and shelf l i f e. The EPA al so requi res t hat t he l abel show t he
abi l i t y of t he chemical agent t o dest roy certai n organi sms such as M. tubercul osis.
I t i s i mperat ive t hat the user st ri ct l y fol l ows the di recti ons provi ded by t he
manuf acturer.
The FDA cl ears l iquid chemi cal steri lants. The current l i sti ng of cl eared l i qui d
chemical st eril ants and the ti me-temperature cl ai ms f or steri l i zati on and hi gh-l evel
di si nf ect ion can be accessed at ht tp:/ /www.f da.gov/cdrh/ ode/germl ab.ht ml .
Factors Influencing Chemical Disi nfecti on
Concentration of the Chemical
I n general , hi gher concent rati ons of t he acti ve i ngredi ents increase the
di si nf ectant ' s bacterici dal abi l i t y. An excepti on is t he al cohol s. However, ext remel y
hi gh concentrati ons i ncrease the potent ial for damage both to i nanimate objects
and to the ski n and mucous membranes of personnel . For best resul ts, products
shoul d be used accordi ng to t he manuf acturer' s recommendat i ons.
Water l ef t on equi pment wi l l di l ut e the chemi cal and render i t l ess ef fecti ve. Di l ut i on
can become si gnif icant wi t h f requent reuse and can reduce the concent rati on to a
l evel that i s t oo l ow to be ef f ecti ve. For t hi s reason, equi pment should be dri ed
before undergoing chemi cal disi nfecti on or steri l i zat i on. I n some cases, t he
t echni que (manual or automat ic) may det ermi ne how f ast t he concentrat ion f al ls
(71).
Temperature
Hi gher temperatures usual l y i ncrease t he ef f ect iveness of chemical agents. Speci al
devices are avai l abl e f or heati ng some chemi cal sol ut ions. Too hi gh a temperature
may cause t he act ive ingredients to evaporate or degrade. The label shoul d tell
whi ch temperature shoul d be used.
Evaporation and Light Deactivation
I f the sol uti on i s in an uncovered cont ai ner, evaporati on can occur. Usual l y,
evaporat ion i s not as serious as di luti on. However, i f the chemi cal agent i s more
volat i le than the di l uent, l oss by evaporati on can be very import ant . Chl ori ne
products are especi al ly suscepti bl e to evaporat ion and deacti vati on f rom exposure
t o l i ght .
Bioburden
I n general , the higher t he l evel of microbi al contami nati on, the l onger the exposure
t o t he chemical germi ci de necessary before the enti re mi crobi al popul at ion i s ki l l ed.
Thus, i tems shoul d be scrupulousl y cl eaned. Li qui d agents vary wi del y i n thei r
ef fectiveness agai nst various types of mi croorgani sms. Tabl e 34.1 shows t he
capabi l i t ies of some commonl y used agents.
pH
The rel ati ve acidi t y or al kal i ni ty of disi nfectants can inf l uence the bi ocidal act i vi ty.
An i ncrease i n pH tends to decrease the ef f i cacy of phenol s, i odi ne, and
hypochl ori tes. In cont rast, i t wi l l i mprove t he anti microbi al activi t y of gl utaral dehyde
and quaternary ammoni um compounds. Solubl e cal cium or magnesium i n the water
suppl y can react wi t h det ergents to form insol ubl e preci pi tates, whi ch tend to
neutral i ze some di si n-f ectants (4).
Characteristics of the Item to Be Disinfected
A di si nfectant soluti on wi l l be ef f ecti ve onl y i f i t can contact al l surfaces (i nner and
outer) of the i tem to be disi nf ected (72). Uneven or porous surf aces resist chemical
di si nf ect ion. Ai r
P. 967

ent rapment can prevent contact bet ween t he l iquid and parts of the device.
TABLE 34.1 Capabilities of Disinfecting Agentsa
,
b
Disinfectant Gram-
Positive
Bacteria
Gram-
Negative
Bacteria
Tubercle
Bacillus
Soores Virusus Fungi
Quaternary ammonium
compounds
+ 0 0
Alcohols + + + 0
Glutaraldehydes + + + + +
Hydrogen peroxide-
based compounds
+ + + + +
Formaldehyde and
other agents
+ + + - + +
Phenolic compounds + + 0
Chlorine + + + - + +
a
From Chatbum RL. Decontamination of respiratory care equipment what can be
done, what should be done. Respir Care 1989:34:98; and Berry AJ. Infection control in
anesthesia. Anesth Clin North AM 1989;7:967981.
b
+, good; , fair, 0, little or none.

Use Pattern, Use Life, and Storage Life
The product l abel should be exami ned f or i nformati on on the use pat tern, use l i f e,
and storage l i fe. Use pat tern ref ers to how many ti mes the sol ut ion can be used.
Use l if e commonl y appl ies but i s not l imi ted to di si nf ectant products that appl i es,
but is not l i mi ted t o, requi re mi xi ng of t wo i ngredi ents for act ivati on. Once a
di si nf ectant sol uti on i s mixed, there wi l l be a l imi ted peri od of t i me duri ng whi ch t he
acti vated solut i on may be used. The cont ainer shoul d be marked wi t h the date the
solut i on was prepared and t he date i t expi res. The storage l i fe i s the t i me peri od
af ter whi ch the unused and/ or unact ivated product is no l onger deemed eff ect ive.
Time
The t i me requi red f or dif f erent chemical agents to f unct i on eff ecti vel y vari es f rom
seconds to hours and wi l l depend on the factors j ust menti oned. Some
mi croorgani sms are ki l l ed faster than others. Cont act ti me may make the dif f erence
bet ween steri l i zati on and hi gh-l evel di sinf ecti on. For hi gh-l evel di si nfecti on, a
mi nimum contact t ime of 20 to 30 mi nutes is recommended (3). A l ower l evel of
di si nf ect ion can be achieved i n l ess t i me. Leavi ng devices in the di si nfectant t oo
l ong can make i t harder t o ri nse of f the chemi cal (22).
Safe Practices
Desi gnat ed areas f or chemi cal di si nfecti on shoul d be st rongl y encouraged
(2,5,73,74,75,76,77,78, 79,80,81). Ideal l y, the area used for cl eani ng shoul d be
separate f rom t he space where the chemical i s used. Both of these spaces shoul d
be separate f rom pati ent procedure and personnel support areas. Traf fi c shoul d be
l i mi ted t o trai ned personnel .
Chemi cal di si nf ectants should be used in an area that i s large enough t o ensure
adequate vapor di l uti on wi th an ai r exchange rate not less than 10/hour. The f resh
ai r i nl et shoul d be placed across the room from t he l ocal exhaust venti l at i on.
Local exhaust venti l ati on (ei ther a ductl ess system or a duct ed fume hood) shoul d
be i nstal l ed to capture chemi cal vapors. A duct ed f ume hood shoul d be connected
t o a non-reci rcul at ing exhaust syst em that goes to the outside atmosphere at a
l ocat i on away f rom peopl e and ai r i ntake ducts. Self -cont ai ned (duct less) f ume
hoods (Fig. 34.6) encapsulate the soaki ng contai ner and have a bl ower that draws
f umes away f rom t he operator and del ivers t hem to a system t hat chemi cal l y
i nact i vates the germi ci de and ret urns cl ean f i l tered ai r t o t he room. This el i minates
t he need to i nstal l a duct .
The employer shoul d provi de trai ni ng to each empl oyee who handl es germi ci des
and veri f y t hat each employee has received and understood the requi red trai ni ng.
Aut omat ed processi ng equipment can reduce exposure to germi ci des. Hoods
designed f or automat i c washi ng machines are avai labl e.
Personnel shoul d wear appropri ate prot ective equi pment desi gned to prot ect t he
ski n, eyes (goggles or full face shi el ds), and cl ot hi ng f rom spl ashes when using
chemical germi ci de sol ut ions. I mpervi ous gl oves and gowns should be worn. The
user shoul d doubl e gl ove and/or change si ngl e gl oves f requentl y. Protect ive
cl othi ng should be removed qui ckl y if i t becomes saturated and shoul d be
l aundered bef ore reuse. There shoul d be ready access to means to decontami nate
t he eyes and ski n in the event of contact wi t h the soluti on.
During preparati on and activati on of germi ci de sol ut i ons, every ef f ort shoul d be
made t o mini mi ze spl ashing, spil l i ng, and personnel exposure. The chemi cal shoul d
be kept i n a cl osed contai ner wi t h a ti ght -f i tt i ng l i d. Agi t ati on and spl ashi ng shoul d
be avoi ded when t he sol ut ion is poured. Saf et y nozzl es can be used t o
P. 968

reduce t he exposure t o vapors created when pouri ng solut i ons.

View Figure

Figure 34.6 Glutaraldehyde user station. Fumes are drawn
away from the operator and into a filter, where they are
neutralized.

I f i t i s necessary to transport an acti vated sol ut ion, a method of t ransport at ion t hat
wi l l mi ni mi ze the potenti al for spi l l s and the possibi l i ty of personnel exposure to the
solut i on or vapor shoul d be sel ect ed. Transport ing sol uti ons i n contai ners such as
t rays or buckets should be avoi ded.
The disi nf ect ant sol ut ion shoul d be stored in a ti ghtl y cl osed contai ner i n a wel l -
venti l ated area. Contai ners that mi nimi ze the surface area should be used. The li d
shoul d be kept on the container at all ti mes except when i tems are placed i nto or
removed f rom t he sol ut ion.
I tems shoul d be immersed i n the chemi cal sol ut ion gentl y, taki ng care to di st urb
and agi t ate the surf ace as l i tt le as possibl e. When the soluti on must be manual l y
i rri gated or fl ushed through i nternal channel s or l umens, care shoul d be t aken t o
avoid spl ashi ng. The syri nge shoul d be caref ul l y f i l led wi t h t he sol ut i on and
securel y attached to the channel openi ng or al l -channel i rri gat or and t he sol ut ion
pushed sl owl y.
I tems shoul d be gent l y removed f rom the sol uti on and ri nsed t horoughl y i n cl ean or
steri l e wat er. Ri nse water shoul d be discarded prompt l y, not reused. Semicri ti cal
i tems shoul d be ri nsed wi t h st eri l e water to prevent organi sms t hat may be i n tap
wat er f rom contaminati ng t hem. Al ternatel y, the i tems may be ri nsed f i rst wi t h tap
wat er and then wi t h alcohol .
Di scardi ng a chemical solut i on i nvol ves hi gh risk of empl oyee exposure. The
solut i on should be discarded, al ong wi t h copi ous amounts of col d water i nto a drai n
connected t o a sani tary sewer. Chemi cal germi ci de solut i ons shoul d not be
di scarded int o septi c systems.
A spi l l contai nment response team shoul d be creat ed and be responsi bl e f or
devel opi ng and executi ng procedures for chemi cal spi ll s. I f there is a chemical that
can be used to neut ral i ze the germi ci de and reduce ambi ent vapor level s in spi l l
si tuat ions, i t shoul d be readi l y avail abl e.
Smal l spi l l s and dropl ets can be absorbed and neutral i zed by usi ng speci al mats
t hat are hi ghl y absorbent and t reated wi t h the neut ral i zi ng chemi cal . Al t ernatel y,
t hey can be wi ped up qui ckl y wi t h a sponge, t owel , or mop t hat has been
neutral i zed wi t h an appropri at e chemi cal agent and then wi ped up. The sponge,
t owel , or mop shoul d be thoroughl y ri nsed wi t h l arge amounts of wat er and the
wat er di scarded through the drai n.
Larger spi ll s are best t reat ed by usi ng chemi cal spi l l ki ts that incl ude an approved
deactivator/ neut ral i zer to pour over the spi ll . Personnel shoul d wear sui table
protect ive att i re. The spi l l should be contained and neutral i zed or contained and
coll ected f or di sposal . Af ter the soluti on i s removed, t he area where the sol uti on
was coll ected shoul d be thoroughl y ri nsed. The cleanup t ool s should be ri nsed wi th
a large amount of wat er and the wat er di scarded down t he drain.
To ensure a saf e work envi ronment and establ i sh compli ance wi t h recommended
l i mi ts and gui del ines on occupati onal exposure to germi ci des, several ai r sampl ing
and moni toring techni ques can be used. Sampl i ng should be conducted i n al l areas
where workers might be exposed to vapor. Moni tori ng shoul d be conducted duri ng
normal use and whenever there i s a maj or change in protocol , workpl ace
venti l ati on, case l oad, or maj or repai r t o washers or other automated equi pment .
Speci al at tenti on shoul d be gi ven to peri ods of ti me when ai rborne concent rati ons
of vapor mi ght be parti cularl y hi gh (e.g. , when the worker i s pouri ng the spent
solut i on down t he drain or pouring f resh sol ut i on i nto a contai ner). Moni tori ng
shoul d be documented and records mai nt ained.
Exposure can be determi ned by usi ng a sampl i ng pump to pul l a known quanti ty of
ai r t hrough a tube contai ni ng an absorbent medium. Thi s is anal yzed l ater by
P. 969

an i ndustri al l aboratory. A passive moni toring badge can be worn by personnel . The
germi ci de vapor is convert ed into a stabl e derivati ve and anal yzed.
Monitori ng Chemical Disinfection
St andard bi ol ogi cal preparati ons are avai l able only f or st eri l i zat i on processes and
cannot be appl i ed to di si nf ect ion. The onl y way t o assess t he lethal i t y of
di si nf ect ion i s to use the di rect -assay steri l i t y t est of the f i ni shed product (4). Thi s
t est i s di ff icul t and t ime consumi ng, renders the test ed obj ect unusabl e unt i l i t i s
subsequentl y recl eaned and decontami nat ed, and i s rel at ivel y i nsensi t ive i n i ts
abi l i t y to detect l ow-l evel contaminati on.
Because disi nf ect i on procedures cannot be ef fecti vel y moni tored bi ol ogical l y, they
must be moni tored physi cal l y. Records i ndicat ing exposure t ime, temperature, and
pressure (if appl icabl e) shoul d be mai ntained.
Agents
No chemical germi ci de is sui tabl e for al l purposes. A number of f actors should be
consi dered i n selecti ng one, i ncl udi ng t he degree of mi crobi al death needed; t he
nature and composi ti on of the i tem being t reated; whether the i t em i s cri t i cal ,
semi cri ti cal , or noncri ti cal ; and t he cost , saf et y, and ease of use. Anti septi cs are
not appropri ate f or di si nf ect ing inani mate surf aces or obj ects.
Glutaraldehyde
Gl utaral dehyde-based sol ut i ons have been wi del y used because of thei r excel l ent
germi ci dal propert ies, acti vi ty i n the presence of organi c matter, noncorrosiveness
wi th most equi pment, and l ack of coagul at i on wi t h protei naceous materi al
(3,5,8,68, 70,82,83,84). Gl utaraldehyde has an extensi ve shelf l i fe. It may be used
as l ong as 30 days af ter activati on, provi ded i n-use di luti on and organic st ress are
properl y cont roll ed.
Gl utaral dehyde i s ef f ecti ve against bacteri a, f ungi , and vi ruses at room
t emperat ure. High-l evel di si nf ect ion requi res 20 to 30 mi nutes (85,86,87, 88). I t i s
al so spori ci dal , provi ded adequate t i me i s al l ot ted. Three to 10 hours are requi red
f or steri l i zat ion. El evati ng the temperat ure can short en these t imes (89). The
manuf acturer' s i nstruct ions shoul d al ways be consul ted.
Di luti on of ten occurs duri ng use, and i t is i mportant to ensure that equi pment i s
di si nf ected wi th an acceptabl e concent rati on of agent . Gl ut araldehyde
concentrati on t est stri ps that are dipped into t he sol ut ion to determine t he acti ve
concentrati on are avail abl e. Probl ems wi th t hese strips have been report ed (90). It
i s general l y recommended t hat 1% t o 1.5% gl ut araldehyde be the mi ni mum
concentrati on f or hi gh-l evel di sinfecti on (88). Sol ut ion concentrat ion shoul d be
moni tored at l east once every day and a l og kept of each test (81).
A wi de vari et y of brand-name products is avai lable. They dif fer pri mari l y i n the
concentrati on of glutaral dehyde and addi ti ves. Most aqueous sol ut i ons are aci di c
and must be acti vated (made al kal ine) t o become spori ci dal (Fi g. 34.7). Acid
gl ut araldehydes are avai l abl e and do not requi re act ivati on, but some st udi es have
shown them t o have l ess mi crobi oci dal acti vi t y than al kal i ne preparati ons (88). The
pH needs to be between 7.5 and 8.5 to be spori ci dal (5).

View Figure

Figure 34.7 Glutaraldehyde. The small container contains
the activator, which must be added to the contents of the
large container.

Gl utaral dehyde soluti ons evaporat e at room temperat ure. Exposure t o
gl ut araldehyde can resul t i n a vari et y of react ions in heal th care workers, i ncl uding
headaches; ski n, eye, and mucous membrane i rri tati on; and ast hmal ike sympt oms
(91,92,93, 94). Sal ivary gland enl argement att ri buted to oropharyngeal ai r ways
i nadequatel y ri nsed af ter exposure to gl utaral dehyde has been reported (95). These
symptoms are usual l y t emporary and subsi de when the i ndividual l eaves the area of
exposure but may be exacerbat ed wi t h repeat ed contact. If i t contacts the eyes,
t here may be corneal inj ury. Unfortunat el y, some i nsti tuti ons have used
gl ut araldehyde i nappropri atel y to di si nf ect fl oors, wal l s, and l i nen (96).
Ductl ess f ume hoods are avai lable f or gl utaral dehyde (Fi g. 34.6). A neutral i zer
shoul d be added to the sol uti on when i t i s ti me for disposal . Thi s wi l l el i minate
P. 970

t he vapors that are created when di sposi ng of t he sol ut i on. In some local i ti es, i t i s
i l l egal to put un-neutral i zed glutaral dehyde i nto t he sewage system.
Gl utaral dehyde-neutral i zi ng absorbent mats can be pl aced under and around baths
and washers to absorb and neutral i ze spi ll s.
Orthophthalaldehyde
Orthophthal al dehyde (OPA or Ci dex OPA) can achi eve hi gh-level disinfecti on at
room temperature af t er a 12-mi nute exposure and af ter a shorter ti me at an
el evated t emperat ure (30,97,98,99). I t i s sporicidal wi th prol onged exposure (100).
I t i s of t en used i n an aut omat i c endoscope processi ng system, whi ch reduces the
processi ng ti me to 5 mi nut es (30). I t i s noncorrosive. Test st ri ps to measure the
mi nimum ef f ect ive concent rati on are avai lable and should be empl oyed pri or t o
each use. Some l ocal i t i es requi re that OPA be neutral i zed bef ore disposal .
Neutral i zers that change col or wi th deact ivati on are avai l abl e.
OPA has a number of advantages compared wi t h glutaral dehyde. These i ncl ude
f ast er di si nf ect ion, mi ni mal odor, no need for act i vat ion or mixing, and no OSHA
vapor l imi t . It can be di scarded through t he drai n. It is ef f ect ive i n the presence of
organic soi l . Whi le si gnif icant l y more expensive per gal l on than glutaral dehyde, i t
may be more economical at hi gh-vol ume cent ers (101).
Whi le si de ef f ects and hazards are l ess wi t h OPA than wi th gl utaraldehyde, eye
contact may cause st i ngi ng, excess teari ng, and redness. I t stai ns protei ns
(i ncludi ng unprotected ski n), and repeated cont act may cause dermati ti s. Lesi ons of
t he ski n, l i ps, mouth, and esophagus have been reported f ol l owi ng prol onged use of
a transesophageal echocardiograph probe that may have been i mproperl y
processed wi t h t hi s agent (102).
Quaternary Ammonium Compounds
Quaternary ammoni um compounds (quats) are l ow-l evel di si nf ectants (5). They are
bacteri ci dal , f ungi ci dal , and vi ruci dal at room temperature wi thi n 10 mi nutes but
have not demonst rated sporicidal ef fects. If a spore is coated wi t h a quaternary
ammoni um compound, i t wi l l not develop i nto a vegetat ive cel l as l ong as the
germi ci de remai ns, but i f t he coati ng i s removed, the spore can germi nat e. These
compounds are more eff ecti ve against gram-posi ti ve than gram-negat ive bacteri a.
Quats i nacti vate the human i mmunodef i ci ency vi rus (HIV) but some do not
i nact i vate the hepat i t i s vi rus. They are i nef fecti ve against M. t ubercul osis or
hydrophi l i c vi ruses (2,87).
Earl y generati on quats were af f ect ed by f act ors such as hard wat er, soap, ani oni c
resi dues, and prot ei naceous soi l s. They were i nact ivated by organi c materi al s (e. g. ,
cork, cot ton, and gauze pads). Some, ei ther used i n i nsuf f i ci ent concentrat ions or
i n sol uti ons deteri orated by age or deact i vat ed by the presence of organi c soi l , not
onl y f ai l ed to ki l l some microbes but actual ly supported t hei r growt h (8). Newer
ones are mi xed wi th vari ous subst ances to produce synergisti c ant imi crobi al and
detergent activi t i es whi le mai nt ai ni ng the hard wat er, protei n, and ani onic t ol erance
necessary i n envi ronmental di sinf ectants. They are quick acti ng, relat i vel y nontoxic,
and noncaust ic and do not produce noxious f umes. They are usef ul f or cl eani ng as
wel l as disi nf ecti on.
Phenolic Compounds
Phenol ic compounds (phenol i cs, phenols) are deri ved f rom carboli c acid (phenol ),
one of the ol dest germi ci des (2,5,8,87). They are somet imes combi ned wi th
detergents t o f orm detergent germicides. They are good bacteri ci des and are acti ve
against f ungi . They are acti ve i n the presence of organi c matter and soap. Phenols
are very stabl e and remain acti ve af ter mil d heat i ng and prol onged dryi ng. When
moi st ure i s appli ed to a surf ace t hat has been previ ousl y t reated wi t h a phenoli c
compound, i t can redi ssolve t he chemical so t hat i t agai n becomes bacterici dal .
Phenol ics remai n act i ve in contact wi t h organi c soi l and f or t his reason are of ten
t he di si nfectants of choice when deal i ng wi t h gross organi c contami nati on i n
general housekeepi ng.
Most phenol i cs have a bad odor and are i rri t ati ng to ski n. They are absorbed by
rubber and may damage the ski n or mucous membranes that t hey contact . They are
di ff i cul t to ri nse f rom most materi als, and resi dual di si nfect ant may cause t issue
i rri t at i on or hyperbi l i rubi nemi a i n neonates.
Phenol s are consi dered i ntermedi ate- t o low-l evel di si nf ectants. Most phenol ic
detergents are tubercul oci dal , f ungi ci dal , and bacteri cidal when used as di rected.
Certai n vi ruses, incl udi ng those associ ated wi th wi despread common respi ratory
i l l nesses, are resi stant to these compounds. The phenoli cs are not sporici dal
except at or above 100C. They are used mai nl y on envi ronmental surfaces and f or
noncri t ical devi ces.
Alcohols
Wi thi n heal th care f aci l i t i es, alcohol usual l y ref ers to ei ther ethyl or i sopropyl
al cohol , bot h of whi ch are water-sol ubl e compounds that are i ntermedi ate- or l ow-
l evel di si nfectants (3). The al cohol s are best used at concentrati ons of 70% to 90%
by volume. Both are ef f ect ive agai nst most vi ruses, i ncl udi ng those f or hepat i t is B
(HBV) and AI DS (or HIV). The CDC recommends exposure t o 70% ethanol for 15
mi nutes to i nacti vate HBV, but 1 mi nute shoul d be adequate f or HIV. Al cohol s
di spl ay hi gh activi ty agai nst gram-negati ve bacteri a, f ungi , and M. tubercul osi s but
cannot i nacti vate bacteri al spores. Isopropyl al cohol cannot ki ll certai n hydrophi l i c
vi ruses.
Al cohols have a cl eansing act ion, but wi pi ng a surf ace wi th an al cohol soluti on may
not maintai n a 1-mi nute contact t ime bet ween the surf ace to be disi nfected and the
solut i on (11). They are i nact ivated by protei n but not by soap. I t i s not necessary to
ri nse i t ems soaked i n alcohol , because i t evaporates rapi dl y. For thi s reason, an
al cohol f l ush cycle i s used i n some aut omati c processing
P. 971

machi nes. The fl ush cycl e may be usef ul t o di si nfect t he channel s of f lexi bl e f i ber-
opti c endoscopes. Af t er hi gh-level disinfecti on wi th a chemical germi cide and a tap
wat er ri nse, alcohol can remove mi nor wat er contaminants. I ts speed of evaporat i on
promotes rapi d dryi ng i n the channels. Al cohols are of ten used to cl ean t he external
surf aces of fi beropt i c cabl es and scopes.
An i mportant use of alcohol is i n hand rubs (103). These reduce t he bacteria count
on hands more rapi dl y than anti mi crobi al soaps or detergents. The Associati on for
Professi onals i n Inf ecti on Cont rol and Epidemiology (API C) gui del i nes urge use of
an al cohol -based rub bef ore and af ter pati ent contact and af ter any possi bl e
contact wi th body f l ui ds and substances, mucous membranes, broken ski n, or
contaminated obj ects.
Al cohol and agents contai ni ng al cohol must not be all owed to get i nto anesthesi a
gas sampl ing l i nes, as this can l ead to incorrect resul ts when measuri ng anesthet ic
agents (104). Al cohol s can damage the l ens mounts on instruments and tend to
swel l and harden rubber and certain pl asti cs wi th repeated use (2). Al cohol s are
f lammable, so care must be taken not to use t hem i n the presence of a heat source
t hat coul d i gni t e the vapor. Al cohol solut i ons shoul d be stored i n special f l ammable-
materi al s cabi nets (Fi g. 34.12).
Iodine Compounds
An i odophor i s a combi nati on of i odi ne and a sol ubi l i zi ng agent or carri er wi t h the
resul ti ng compl ex provi di ng a sust ai ned-release reservoi r of i odine and rel easi ng
f ree i odi ne i n aqueous sol ut ion (2,3, 5,8). I odophors are bacteri ci dal , vi ruci dal , and
t ubercul ocidal but may requi re prolonged cont act t i me t o ki l l cert ai n fungi and
bacteri al spores. Some i odophors do not ki l l M. t uberculosi s (87).
I odophors are used pri ncipall y as ant i sept i cs but are capabl e of i nt ermediate- and
l ow-l evel di si nf ect ion. I odophors formul ated as ant isept ics are not sui t abl e f or
di si nf ect ing medi cal i nst ruments or envi ronmental surf aces (8). Some iodophors are
unstabl e i n the presence of hard water, heat , and organic soi l , but most are rel i abl e
general -purpose disinfectants i f used in concentrat ions recommended by the
manuf acturer. Some met al l i c i nst ruments may become corroded i f they are rout i nel y
di si nf ected wi th i odophors; nonmetal l i c i tems are sel dom damaged but may be
stai ned or discol ored.
Peracetic Acid
Peraceti c (peroxyacet ic) aci d is bacteri ci dal , f ungi ci dal , vi ruci dal , and spori cidal at
l ow temperatures (3,5,68,105,106,107,108,109,110). I t remains eff ect i ve in the
presence of organic mat erial . I t may be eff ect ive agai nst pri ons (111). An i mportant
advantage i s that i ts decomposi t i on products (acet ic aci d, wat er, oxygen, and
hydrogen peroxi de) are not harmful . I t can corrode copper, brass, bronze, pl ai n
steel , and galvani zed i ron, but these ef f ects can be reduced by addi t ives and pH
modi f icati ons (88). A concent rated sol uti on can cause eye and skin damage, but i t
has no OSHA exposure l i mi t .
St eri s 20 i s a patented product t hat has been developed speci f i cal l y f or Steri s
processors. The act ive ingredi ent i s a concentrat e of 35% peraceti c aci d pl us
corrosi on and degradat ion i nhi bi t ors that are contained in a seal ed, si ngl e-use
contai ner. I t shoul d be used only i n a Steri s processing system. I t i s not i ntended
f or open-pan techni ques.
A Steri s system i s shown i n Figure 34.8. Equi pment to be steri l i zed must be cl ean
but need not be dry. The equi pment is pl aced i n a speci al t ray, whi ch is t hen
P. 972

pl aced i n the processor. The steri l izer has a vari et y of t rays, containers, and
adapt ors to accommodat e various medi cal devi ces. Each t ray has hol es f or f l ui d
ent ry and drainage and i s designed so that t here i s a conti nuous f l ow of steri l ant on
exposed surfaces and t hrough i nternal channel s of i nst ruments.

View Figure

Figure 34.8 The Steris system A: Items to be sterilized are
cleaned, then placed in a tray. The tray is then placed in the
sterilizer. B: After the lid is closed and the processing cycle
is started, the processor automatically opens the sterilant
concentrate and mixes it with filtered water. The use
dilution of the sterilant enters the tray, covering the
instruments, and is circulated for 12 minutes. It is then
drained from the chamber, and the chamber and tray are
rinsed four times with sterile water. Next, sterile air is
pumped into the chamber to displace the rinse water. A
printout is provided, confirming that the sterilization
parameters were met.


View Figure

Figure 34.9 The sealed package of sterilant is placed in the
processor, and the lid is punctured before the lid is closed.

Af ter the t ray i s posi ti oned i n the Steris processor, a seal ed package of steri lant
concentrate i s pl aced i n the steri li zer (Fi g. 34.9). The l i d is cl osed and the
processi ng cycl e started. Duri ng the cycl e, t he l i d i s seal ed. The processor
automati cal l y opens the steri l ant concent rate and mi xes i t wi th a controll ed volume
of f i l tered st eri l e water heated to between 50C and 56C. The di luted steri l ant
enters the t ray, covering t he i nst ruments, and i s ci rcul ated f or 12 mi nutes. It i s then
drai ned f rom the chamber, and the i nst ruments and chamber are ri nsed four ti mes
wi th st eri l e wat er. Then, steri l e ai r i s pumped int o the chamber to di splace the ri nse
wat er. The cycl e takes f rom 20 to 45 mi nut es, dependi ng on the i ni ti al temperat ure
of t he wat er and how ext ensivel y t he l ocal water suppl y must be f i l tered. Af ter t he
cycl e i s complete, t he uni t f l ushes the di l uted steri l ant and ri nse wat er di rectl y i nt o
a drain. The t ray can be transported di rectly t o a steri le f ield.
The St eris processor moni tors and mai ntai ns the parameters necessary t o ensure
steri l e processi ng. I t wi l l stop t he cycl e i f a process error i s det ected. At the end of
each cycle, a pri ntout conf i rmi ng that the steri l i zat i on paramet ers were met i s
provi ded. Spore st ri ps can be used as bi ol ogi cal moni tors. These go through the
steri l i zer and are then retrieved f or cul turi ng.
The St eris system provides a qui ck method of disinf ecti ng a wi de vari et y of heat-
sensi ti ve i mmersible i nst ruments, i ncl udi ng f iberscopes (112,113) (Fig. 34. 10). The
St eri s system has been f ound t o be ef fecti ve i n steri li zi ng t he lumens of
endoscopes when organi c soi l and sal t were present (114).

View Figure

Figure 34.10 Endoscope in Steris processor. Note the
tubings that are connected to the channels.

The St eris system i s l ess damagi ng to del i cat e i nstruments t han st eam steri l i zati on
and i s compati bl e wi t h a wi de vari et y of materi als, includi ng plast ics, rubber, and
most heat -sensi t ive i tems. I t i s i mport ant t hat the absence of l ong-term eff ects on
t he devi ces bei ng steri l ized by the St eris system are conf i rmed wi t h the i nstrument
manuf acturer. Pol ymers, glasses, coati ngs, adhesives, and seal ants t hat are
t ypi cal l y used i n medi cal devi ces are compati bl e wi t h the process. Unt reated met al s
such as copper, brass, sil ver, al umi num, and i ron are subj ect to oxidati on.
Al umi num anodi zed coat i ng can become dul l .
The St eris system i s especi al l y usef ul f or i tems requi ring a quick turnaround t i me. I t
i s faster than steri l i zati on wi th EO or gl ut araldehyde and can be used on wet or dry
i tems. No st eri l ant di l ut ion i s necessary, and personnel are not exposed t o any
t oxi c chemi cals. Consequentl y, i t can be locat ed in t he operati ng room sui t e. The
si te requi rements are a t ap wat er suppl y, a drai n, and electri ci t y. I t l eaves no
resi due. Wrapping i s not necessary.
Thi s system does have some di sadvant ages. Unl i ke some aut omat ed processors,
t he Steri s machi ne has no cl eani ng cycle. Costs per cycl e are greater than i f
gl ut araldehyde i s used (115). Onl y i tems t hat can be total l y i mmersed can be
steri l i zed, and onl y a smal l number of i nst ruments can be processed i n a cycl e. The
t rays cannot be used f or extended storage, so processi ng must be consistent wi th
j ust-i n-t i me del ivery.
Chlorine Compounds
Several chl ori ne compounds are avai l abl e for use as di si nf ectants, i ncluding
sodium and cal ci um hypochl ori te (household bl each), chl orine dioxi de, and
chlorami ne T (3, 5,116). The hypochl ori t es are
P. 973

t he most wi del y used. They are i nexpensive and fast acti ng. They are avai l abl e in
both l i quid (sodi um hypochl ori t e) and sol id (cal ci um hypochl ori te) f orm. Relati vel y
l ow concent rat i ons of sodi um hypochl ori te (50 ppm) exhi bi t rapi d act ivi t y agai nst
vegetati ve bacteri a. One hundred ppm i s eff ect i ve agai nst most f ungi . Many vi ruses
are inact ivated at concent rati ons of 200 ppm, wi t h HIV bei ng suscepti bl e at
concentrati ons as low as 50 ppm. HBV exhibi ts marked i nact ivati on at 500 ppm.
Concent rati ons of 1,000 ppm are consi dered adequate to achi eve hi gh-l evel
di si nf ect ion. A 1:5 t o 1: 10 di lut i on wi l l dest roy t he agent of Creutzf el dt -Jakob
di sease (CJD) af ter an exposure ti me of 1 hour (117).
TABLE 34.2 Preparation of Household Bleach for Disinfectionaa
Desired Chlorine Concentration 5,000 ppm1,000 ppm 500 ppm 100 ppm
Dilution for use within 24 hours 1:10 1:50 1:100 1:500
Dilution for use for 1 to 30 days 1:5 1:25 1:50 1:250
a
Starting with 5.25% NaOCl, which contains 50,000 ppm of free chlorine.

Table 34.2 shows the di l ut ion of 5. 25% NaOCl (househol d bl each) needed to
achieve the desi red chl ori ne concentrat ion. Sol ut ions that wi l l be used f or extended
peri ods (1 t o 30 days) shoul d have an i ni ti al concentrat ion twi ce as hi gh as actual l y
desi red and shoul d be stored in an opaque cont ai ner.
Chl orine sol uti ons are not of t en used for i nstrument di sinfecti on but have been
used wi del y i n envi ronmental di sinf ecti on. Current OSHA regulati ons consi der
di l uti ons of 1:10 to 1:100 chl ori ne to be acceptable f or use wi t h blood spi l l s. Other
uses incl ude spot di si nf ect ion of countert ops and f loors and decontaminati on of
resusci tati on mani ki ns.
Hi ghchl ori ne compound concent rat i ons are corrosive as wel l as i rri t ati ng t o
personnel , and thei r use should be l i mi t ed to si tuati ons in whi ch there are unusual l y
hi gh concentrati ons of microorgani sms (8). Thei r use i s l i mi t ed by t hei r
corrosi veness, inactivati on by organic mat ter, and rel at i ve instabi l i ty. They may
l eave a resi due and are i rri t at ing t o the ski n, eyes, and respi ratory t ract .
Chl orine dioxi de is used in a gaseous phase (118). I t i s not stored but i s generated
at t he point of use. Advantages are that i t leaves l i tt le resi due and is nonozone
depleti ng. Disadvantages i nvol ve materi al incompati bi li t y.
Hydrogen Peroxide
Hydrogen peroxi de i s an eff ect i ve bacteri ci de, f ungi ci de, vi ruci de, and sporici de
(2,3,5,119,120). It i s commerci al l y avai labl e i n several di ff erent concentrati ons. I t i s
not i nact ivated by organi c matter. There are no rest ricti ons on di sposal . I t rapi dl y
l oses ef f ecti veness when exposed to heat and l ight and requi res caref ul storage. It
can damage rubber and pl ast i c and may corrode copper, zi nc, and brass. I t i s an
i rri t ant t o the ski n and eyes. A 7. 5% sol uti on achi eves hi gh-l evel di si nfecti on i n 30
mi nutes. An eff ect ive low-l evel di sinfectant, 3% hydrogen peroxi de i s usef ul f or
work surfaces. Hydrogen peroxide is used for plasma steri l izati on (see bel ow).
Ozone
Ozone steri l izers use oxygen, water, and electrici t y to produce ozone
(121, 122,123). The gas i s humi di f i ed and di spersed into a st eri l i zati on chamber. A
steri l i zat ion cycl e incl udes t hree stages: ai r evacuat ion, f ol l owed by ai r and ozone
mi xture admi ssion; an exposure st age; and a st age of vacuum-dryi ng and ozone
removal . Af ter the cycl e, t he ozone passes through a catal yt ic convert er t hat
changes i t back to oxygen.
Ozone steri l izati on i s good f or most goods that need l ow-temperature st eri l i zati on.
I t i s not approved for f l exi bl e scopes and reacti ve metal s such as copper and brass.
I t i s compat ible wi th most anodi zed al umi num steri li zati on contai ners and al l plasti c
contai ners. It i s unsui tabl e f or devices that contai n natural gum rubber products,
some plasti cs, and some met al s such as brass and copper.
According t o the manuf acturer, ozone can st eri l i ze single stai nl ess steel l umens
wi th an i nsi de di amet er of 2 mm and no l onger than 250 mm, l umens wi t h an i nside
di ameter of 3 mm or l arger and no l onger t han 470 mm, and those wi th an i nsi de
di ameter of 4 mm and no l onger than 600 mm (121,122).
The process i s envi ronmental l y f ri endly and produces no toxic resi duals. It requi res
no vent or drai n and uses onl y oxygen, elect ri ci ty, and a l i t tl e wat er. The st eri l i zer
can be t ransport ed easi l y. No exhaust gas venti l at i on duct is requi red in a room
t hat i s adequat el y venti lat ed. The treated objects are dry. No ri nsing or degassi ng
i s requi red. Whi l e si gni f i cantl y sl ower t han gas pl asma, t hi s process i s l ess
expensive.
Formaldehyde
Formal dehyde i s a hi ghl y t oxi c and f lammabl e gas that has been used as a
di si nf ectant and a steri l ant i n both a water-based soluti on (f ormal in) and the
gaseous state (5). I t i s noncorrosi ve and i s not i nact ivated by organi c matter.
P. 974


Al though f ormali n is a hi gh-l evel disinfectant, i t s uses are l imi ted by i ts pungent
odor and f umes, whi ch i rri tate the ski n, eyes, and respi ratory tract . I ts t oxi ci ty
requi res that di si nfected materi al s be thoroughl y ri nsed before use. NI OSH has
i ndi cated that f ormaldehyde shoul d be handl ed as a potent sensi t i zer and probabl e
carci nogen. Ki ts are avai lable t o absorb and neut ral i ze formal dehyde spi l ls.
St eri l i zati on wi th l ow- temperature steam and f ormal dehyde i s used i n some
count ri es (5,124).
Advantages and Di sadvantages of Chemical Disinfection
and Steril ization
Advantages of l i quid chemical di si nf ecti on include economy, speed, and si mpl ici t y.
Thi s i s especi al l y i mport ant in busy endoscopy sui tes because i t enables equi pment
t o be used several t imes a day. I t i s usef ul f or equi pment that does not requi re
steri l i zat ion but does requi re hi gh-l evel disinf ecti on.
Chemi cal di si nf ect ion cannot be used f or al l t ypes of equipment . Many devi ces
cannot be soaked. Prepackagi ng i s not possibl e, and the equi pment wi l l be wet.
There i s a ri sk of recontami nat i on during subsequent ri nsing, dryi ng, or wrapping.
Wi th most agents, steri li t y cannot be guaranteed. I t is more expensi ve, less
ef fective, and more prone to human error t han steam steri l i zati on. Hi nged
i nst ruments must be opened and those wi t h sl i di ng or mul t i ple parts di sassembl ed.
Some soluti ons are i rri t ati ng to t i ssues and have unpl easant odors. Personnel who
handl e t hem must take precaut i ons to avoi d prolonged skin contact or vapor
i nhal at i on (92). The chemi cal s may be absorbed onto the t reated i tems, causi ng
harm to the pat i ent.
A si gni f i cant di sadvant age of col d steri l i zati on i s the l ack of a good method f or
vali dat i on. The eff icacy can be moni tored onl y i ndi rectl y, through surveyi ng pati ent
outcomes, t o identif y subsequent i nf ecti ons that can be att ri but ed t o exposure t o
t he reusabl e device (125). Most heal th care i nsti tuti ons have an acti ve survei l l ance
program i n whi ch i nfecti on cont rol practi t ioners seek to i denti f y nosocomi al
i nfect ions.
Gas Sterilization
Characteristics of Ethyl ene Oxi de
Et hyl ene oxide (Et O, EO) i s a colorl ess, poi sonous gas wi t h a sweet odor
(126, 127,128,129, 130, 131,132, 133, 134). I t i s avai l abl e in hi gh-pressure tanks and
uni t -dose ampul es and cartri dges. I t i s fl ammable i n concent rat i ons of 3% or
great er. Manuf acturers have deal t wi t h thi s hazard i n two ways. EO may be mi xed
wi th carbon di oxi de or hydrochl orof l uorocarbons (HCFs). Mi xtures contai ni ng up t o
12% EO i n these i nert di l uents are nonf lammable but retai n thei r steri l i zi ng abi l i ty.
A mixture of EO and chlorof luorocarbon (CFC) was used i n the past, but t he use of
CFCs was banned because of damage to t he ozone layer. HCFs are si mil ar t o CFCs
but are l ess damagi ng to t he ozone layer (127,135). Thei r use wi l l be el i mi nated i n
t he Uni ted St ates by 2030.
EO is suppl i ed most l y as 100% i n smal l cyl i nders, cartri dges (Fi g. 34. 11), or
ampules. Equipment i s desi gned for gas contai nment and to mi ni mi ze the risk of
f i re or explosi on (126,127,136). A cartri dge i s punct ured onl y af ter i t i s secured i n a
sealed and l ocked steri l i zat i on chamber. An ampul e is broken onl y af t er i t i s placed
i n a bag wi t h the medical devi ce to be steri l i zed. Expl osi on-proof cabi nets shoul d
be used for stori ng cart ri dges of 100% EO (Fi g. 34.12).
EO ki l l s bacteri a, spores, f ungi , and vi ruses. I t penetrates into crevi ces and through
permeable bags. I t i s not degraded by organic soil but wi l l not penet rate dried
protein mat erial .
Preparation for Ethyl ene Oxide Steri lization
I t i s i mportant to veri f y that a devi ce i s sui tabl e f or steri l i zati on usi ng EO. The
manuf acturer' s i nstruct ions shoul d be consul t ed. Some devi ces need t o be
steri l i zed at a l ower t emperature.
Bef ore packagi ng, i tems must be disassembl ed, cl eaned, dri ed, and wrapped.
Di sassembl y is i mportant t o remove barri ers t o f ree movement of gas. Caps, plugs,
valves, and/or st yl ets must be removed. Hol l ow-bore
P. 975

products such as needl es and t ubes must be open at both ends. The wrapping must
be permeable to EO gas and wat er vapor and al l ow proper aerati on (137).

View Figure

Figure 34.11 Cartridge of EO. The cartridge is punctured
only after the sterilizer door is closed and locked and proper
conditions are met. There are no external tanks, hoses, or
gas source hookups, which are major sources of potential
operator exposure to EO.


View Figure

Figure 34.12 Explosion-proof cabinet for flammable
materials.

Bl ood and other proteinaceous materi al s can act as a barri er t o EO. If sal t and
protein are present in a narrow l umen, st eri l i zat ion wi l l not be achi eved consistentl y
(114). Theref ore, equipment must be thoroughl y cl eansed and ri nsed before
steri l i zat ion.
I tems f or gas steri l i zati on must be f ree of wat er dropl ets. They shoul d be al l owed t o
dry i n ambi ent ai r or t owel dri ed. The use of heated ai r should be avoi ded because
EO steri l i zati on depends on the presence of adequate (but not excessive) moi sture.
A rel at i ve humi di ty between 35% and 70% and a temperature bet ween 18C and
22C throughout t he processi ng and storage f aci l i t y are recommended (23, 128).
Devices should be sort ed according to the steri l i zati on ti me and recommended
t emperat ure. It ems to be steri li zed are pl aced i n wi re baskets, met al steri li zer carts,
or other carri ers that do not absorb EO. The steri l i zer manuf act urer' s i nst ructi ons
f or l oadi ng shoul d be caref ul l y fol l owed. It ems shoul d be l oaded l oosel y to al l ow
gas to penetrate t hroughout t he l oad. Items shoul d be l oaded i n such a fashi on that
packages wi l l not contact t he chamber wal ls or the operator' s hands when the load
i s transf erred to the aerator. Some i nst ruments are st eri l i zed i n ri gid contai ners that
have f i l t ers on the l i d and bot tom to al l ow di ff usi on of steri l ant gas. There may al so
be an addi t i onal l i d at tached to t he upper l id.
The Steril ization Process
Processing Parameters affecting Ethylene Oxide
Sterilization
Gas Concentration
As the EO concentrat ion increases at a given temperature and rel ati ve humi di t y,
t he microbi al inactivati on rate i ncreases up to a cert ai n range when i t begi ns to
pl at eau (126). EO concent rat i ons between 450 and 750 mg/L are commonl y used in
processi ng medi cal products. The sol ubi l i t y of EO i n the product and t he di ff usi on
rate t hrough t he product wi l l i nf l uence t he st eri l ant concentrat ion. The operati ng
pressure of the EO cycle wi l l great l y i nf luence t he gas di f fusion rate. Packaging
may al so be cri ti cal . Devices that perf orm conti nuous EO moni t oring i n the
steri l i zat ion chamber are avai l able.
Temperature
I ncreasi ng t he temperature can decrease the necessary exposure t ime. Many
steri l i zers provide a sel ect ion of temperatures. In heal t h care, processi ng cycl es
are commonl y perf ormed between 38C and 60C. Some conduct steri l i zati on at
room temperature. This i s equal l y ef f i cacious if other factors (exposure ti me and
concentrati on) are adjust ed.
Relative Humidity
Moi st ure hydrates mi crobes, making t hem more suscepti bl e to dest ructi on by EO.
Theref ore, humidi t y must be cont rol l ed in the st orage and cl eaning/processi ng area
and i n the steri l i zer i tsel f . Most EO chambers are held between 40% and 80%
rel ative humi di ty. Desi red humi di ty l evels are usuall y accompl ished by l ow-
t emperat ure st eam i nj ect ion. For t abl etop moni t ors, i t is necessary t o add wat er t o
t he steri l izer.
Exposure Time
The necessary steri li zati on ti me wi l l depend on the f actors menti oned previ ousl y.
The t i me general l y ranges bet ween 1. 5 and 6 hours i n automati c steri l i zers. Up to
12 hours may be requi red.
Sterilizers
EO steri l i zers range i n si ze f rom smal l tabl etop to large f l oor-l oadi ng models (126).
The basi c desi gn i ncl udes a pressure-rated vessel wi t h a port f or admi t t ing ai r, a
vacuum pump t o evacuate t he chamber gas contents, a j acket to heat the vessel , a
steam source t o humi di f y t he chamber and i t s cont ents, and a means to i nj ect the
steri l ant . A recent change has been to i ntegrate comput ers, microprocessors, and
sof t ware i nto the cont rol , moni t ori ng, and documentat i on of steri l i zati on processing.
Anci l l ary equi pment such as reci rcul ati on bl owers t o equi l i brate t he chamber
envi ronment, exhaust systems to mi ni mi ze rel ease of steri l ant i nt o the work
envi ronment on door openi ng, and a steri lant removal /reclamati on system to handl e
steri l ant emissi ons are commonl y used.
P. 976


Most EO steri l i zers are sophi sti cated uni ts wi t h a choi ce of automati c cycl es. A
source of EO gas (cyl inder or cart ri dge) i s provi ded, and a steri l i zati on cycl e i s
selected. Af ter the steri l i zer chamber is t ightl y sealed and the cont rols set, a t ypi cal
cycl e i ncludes the f ol l owi ng: (a) warmi ng t he chamber, (b) evacuat ing ai r, (c)
i ntroduci ng moi sture and mai ntai ni ng i t f or a dwel l period, (d) i ntroducing the EO,
(e) rai si ng t he chamber pressure (i n some st eri l i zers), (f ) rai si ng the temperature (i f
requi red), (g) exposure to EO f or t he ti me requi red, (h) rel easing the pressure i n
t he chamber, and (i ) removi ng t he EO mi xt ure (purge cycl e or phase). Some
steri l i zers provide several successive purge phases. A st eri l i zer wi thout a purge
cycl e can release a cl oud of EO gas when the door i s opened. This necessi t ates an
extract ion hood above the door wi t h a dedi cat ed exhaust system and may expose
t he operat or t o EO gas (138). The last phase is (j ) re-est abl i shi ng at mospheri c
pressure by i nt roduci ng f il tered ai r i nt o the chamber.
Uni ts that carry out st eri l i zati on at room temperature and ambient humi di t y are
avai l able. Special vent i lat i on cabi nets are avai l abl e f or exhaust ing t he EO f rom
t hese uni ts to at mosphere.
Indi cators
Three t ypes of indicat ors are avai l abl e. For maxi mum val ue, they shoul d be used i n
combi nati on.
Physical Indicators
Physi cal moni t ors include st eri l i zer components that measure exposure ti me,
t emperat ure, and humi di t y and/or pressure duri ng each cycl e. They shoul d be
exami ned at the begi nning, mi ddl e, and end of each cycl e.
Chemical Indicators
Chemi cal i ndi cat ors change col or when certai n condi t i ons necessary f or
steri l i zat ion (temperature, gas concentrati on, and humi di t y) have been met (41).
Col or change vari es wi th t he product. They are avai l abl e as tapes, strips, cards,
and sheets. They may be at tached to the packagi ng materi al or encl osed i n the
packages.
I t i s recommended t hat a chemi cal i ndi cator be used wi t h each package t hat
undergoes EO steri l i zati on. In most packages, t he chemi cal indi cator i s placed i n
t he geometric center. I n ri gi d contai neri zed packagi ng systems, t he chemical
i ndi cator i s pl aced i n the corner (128).
Biological Indicators
A bi ologi cal i ndi cator should be pl aced i n the most i naccessi ble l ocati on i n the
steri l i zed l oad (54,139,140,141). The CDC recommends thei r use at least once a
week. They should al ways be used af ter a st eri l i zer is i nstal l ed, af ter any repai rs or
modi f icati ons are made t o the steri l i zer, and any ti me there are changes i n
packagi ng procedures or mat erials or the composi t ion of the l oad. The Associ ati on
f or the Advancement of Medical Inst rumentati on (AAMI) recommends t hat one be
used wi t h every cycle i n EO steri l i zers (30). Problems wi t h t hese indicators have
been report ed (142).
Aerati on
EO not onl y comes i n cont act wi t h the surf aces of arti cl es bei ng steri l i zed but al so
penet rates some i tems, whi ch t hen retain varyi ng amounts. These i tems need
aerat ion (degassing, desorpti on, off gasi ng) t o reduce EO t o a level saf e f or both
personnel and pat i ent use. Aerat ion may be done passi vel y i n ai r (ambi ent
aerat ion) or acti vel y i n a mechanical aerator.
Ambient Aeration
Ambi ent aerati on i s sl ower t han mechani cal aerati on. The necessary t i me i s hi ghl y
vari abl e because of the l ack of temperature and ai r f l ow control . The temperat ure i n
t he aerati on area shoul d be at l east 18C. Items that requi re between 8 and 12
hours of mechanical aerat i on may requi re 7 days of ambi ent aerati on. Some i t ems
t ake bet ween 5 and 6 weeks.
Ambi ent aerati on may i ncrease worker exposure to EO. If ambient aerat ion i s
unavoi dable (for heat -sensi tive i t ems that cannot wi t hstand the el evated
t emperat ures of conventi onal aerator cabinets or when an aerator i s not avai labl e),
measures should be t aken t o minimi ze traf f i c in the aerat ion area and to ensure
t hat personnel who must ent er the area are not exposed to EO at hazardous
concentrati ons.
Mechanical Aeration
I n mechanical aerators, a st ream of f i l tered ai r is di rected over the steri li zed i t ems.
An EO steri l izer may be combined wi t h an aerator so t hat one chamber is used for
both processes.
Factors Affecting Aeration
Device Characteristics
The amount of residual EO and the l ength of t ime needed f or i t to di ssi pate depend
on the devi ce being steri li zed (143). Thicker objects and wraps requi re l onger
aerat ion ti mes than thi n ones. Unwrapped nonporous metal and glass i tems do not
absorb EO and requi re l i tt l e or no aerat ion but must be aerated if wrapped in EO-
absorbent materi al .
Pl ast i cs, rubber, cloth, paper, and musl in may absorb si gni fi cant quanti ti es. It ems
t hat consi st of a combi nat i on of absorbent and nonabsorbent material s (e.g. , a
metal i tem wi th rubber parts) must be t reated as though t hey were made enti rel y of
absorbent materi al . The most common mat eri al t hat retai ns l arge amounts of EO i s
pol yvinyl chl ori de (PVC). Tefl on and nylon absorb l i t tl e EO; however, i t is bound
t i ghtl y and therefore requi res a rel at ivel y l ong peri od of ti me t o el ute. When the
composi ti on of a devi ce i s i n doubt, i t shoul d be t reated as i f i t were PVC.
Package Size and Arrangement i n the Aerator
Arrangi ng i tems l oosel y i n the aerator wi l l al l ow f aster aerat i on.
P. 977


Diluent
Gas mi xt ures wi t h f l uorocarbon requi re a l onger aerat i on ti me than those di l uted
wi th carbon di oxi de.
Wrappings
The packagi ng materi al shoul d al l ow f or easy gas t ransf er.
Temperature
I ncreasi ng t he temperature accel erates desorpt ion. The usual aerati on t emperature
i s bet ween 50C and 60C. If these temperatures would be damagi ng to a devi ce,
aerat ion should be carri ed out at room temperature.
Air Flow
Aerat ion i s af fected by the rate of ai r exchange and the ai r f l ow patt ern. I ncreasing
ai r exchange beyond a certai n poi nt wi l l not f urther enhance aerati on unl ess t he
t emperat ure i s increased.
Characteristics of an Ethylene Oxide Sterilizer
St eri l i zers that subj ect materi al s to hot gases under elevat ed pressure can resul t i n
hi gher level s of EO in the i t ems steri l i zed.
Intended Use of the Device
Whether t he i tem i s to be external to t he body, wi t hi n a body cavi ty, intravascul ar,
or i mpl anted wi l l af f ect the accept able l evel of resi dual EO.
Time
For many years, aerator manuf act urers passed out i nf ormati on detai li ng aerat i on
t i mes f or di f ferent i tems. This has changed, pri mari l y because t he growi ng
mul ti t ude of EO-st eril i zed devices made i t impossi bl e to keep up wi t h al l the
changes requi red. A recommendati on that aerat ion shoul d be performed f or 12
hours at 50C has evol ved (143). Another i s 8 hours at 60C.
Complicati ons of Ethylene Oxi de Sterilizati on
Patient Complications
Compl i cat i ons of EO steri l i zat ion t hat stem f rom f ai l ure to el i mi nate resi dual gas
f rom st eri l i zed i t ems i ncl ude skin reacti ons and l aryngotracheal i nf l ammati on. When
bl ood i s exposed to EO-t reated materials, hemol ysis can occur. Sensi ti zati on and
anaphylaxis f rom exposure to products that are steri l i zed wi t h EO have been
reported. However, the ri sk of pati ents devel opi ng cancer or suf feri ng other adverse
heal th ef fects f rom exposure to resi dual EO i s negl igi bl e (144).
Et hyl ene chlorhydri n i s f ormed when EO comes i nto cont act wi t h chl oride i ons that
may be present i n previousl y -i rradiated PVC i tems. The Ameri can Nat i onal
St andards I nst i tute at one ti me recommended that PVC i t ems that have been -
i rradi at ed never be resteri l i zed wi t h EO but very l ow l evels of by-products i n
i rradi at ed products treated wi th EO have cast doubt on this recommendat ion and
EO steri l i zati on of -i rradi ated PVC i tems may be acceptable i f st ri ct attent ion i s
pai d to aerati on.
Products st eril i zed usi ng EO may i ncrease the ri sk of latex sensi t i zati on (145).
Equipment Alteration
Repeated exposure of some plasti cs t o EO and heat may l each pl ast icizers and
weaken thei r st ructural i nt egri t y. Rubber and some pl asti c tracheal t ubes may
sof t en, kink more easil y, or become sti cky. I n one case, the bal loon on a di sposabl e
esophageal stethoscope that was steri l i zed wi th EO became detached (146).
Damage to the fl exi bl e sheath of a f l exi bl e endoscope has been report ed (147).
Personnel Complications
Possible Ethylene Oxide Exposure Hazards
The presence of gaseous EO in very hi gh concentrati ons is easi l y detected because
i t is i rri tat i ng to t he eyes and mucous membranes, but odor i s not a rel i abl e way t o
detect i ts presence and does not provide adequate warni ng of hazardous
concentrati ons.
Acute exposure t o si gnif i cant level s of EO usual l y provokes an i rri t ant response.
Upper respi ratory compl ai nts, eye i rri t ati on, headache, bl unti ng of taste or smel l , a
metal l i c tast e, and coughi ng f requent l y occur. Wi th hi gher concent rati ons, nausea,
vomi t ing, di arrhea, i ncreased fat i gabi l i t y, memory l oss, drowsi ness, weakness,
di zzi ness, l ack of coordi nati on, chest di scomf ort, shortness of breath, di f f icul t y
swal l owi ng, cramps, and convulsi ons may occur (148). Respi rat ory paral ysis and
peri pheral nerve damage have been report ed af ter massi ve exposure. The onset of
neurol ogic si gns and symptoms may be delayed f or 6 hours or more af ter exposure.
EO gas i s heavier than ai r and can cause asphyxiati on in encl osed, poorl y
venti l at ed, or l ow-l yi ng areas.
Chroni c exposure can af f ect the eyes (corneal burns, cataracts, epi t hel i al kerat i ti s),
t he cent ral and peri pheral nervous system, and ski n (i rri t ant and al lergi c react ions).
Respi rat ory i nf ecti ons, anemi a, and impai red cogni tive funct ion may occur. EO i s a
recogni zed mut agen and carcinogen and may adversel y af f ect the reproduct i ve
system.
Occupational Safety and Health Administration Regulations
OSHA regul at ions l i mi t worker exposure to an 8-hour ti me- wei ghted average (TWA)
of 1 ppm wi th a short -t erm excursi on l i mi t (STEL) of 5 ppm (149,150,151). In
f aci li t ies where worker exposure exceeds these l evels, empl oyers must i nsti t ute
cert ai n measures to meet OSHA regul ati ons. However, a f aci l i ty i s excused f rom
t hese requi rements i f i t can document that the EO steri l i zati on system empl oyed
does not expose workers t o TWA l evels above 0.5 ppm during 8 hours or 5 ppm
duri ng 15 minutes ti me (acti on l evel s). The purpose of acti on l evel s i s t o encourage
EO users to achi eve an even l ower maxi mum exposure level . By demonst rati ng
compl i ance wi t h the acti on l evel , a f aci l i t y is not requi red to conduct routi ne
moni tori ng (other t han af ter an equi pment or f aci l i t y modi fi cat i on or mai ntenance),
schedul ed employee t rai ni ng, or peri odi c empl oyee medi cal examinati ons.
OSHA regul at ions do not i denti f y a speci fi c moni tori ng sampl i ng techni que but do
set f ort h accuracy requi rements f or sampl i ng methods (149). There are
P. 978

t wo basi c approaches t o moni tori ng workpl ace l evel s of EO: personnel and
envi ronmental area moni tori ng. Personnel moni tori ng incl udes devi ces t hat can be
af fi xed to empl oyee l apels to determi ne operator breathi ng-zone exposures. Area
moni tori ng i ncl udes devi ces t hat rapidl y measure EO l evel s present at t he sampli ng
l ocat i on (Fi g. 34.13). They are used t o moni tor EO concent rat i ons around
equipment or i n the workpl ace envi ronment. They are usef ul to evaluate the
ef fectiveness of engineeri ng changes and can help t o est imat e personnel exposure.
Most al so serve as al arm systems for problems such as l eaks or f ai l ures i n the
venti l ati on system.

View Figure

Figure 34.13 Area monitoring device for EO (on ceiling).

OSHA requi res empl oyers to provi de respi ratory protecti on and personal protect ive
equipment f or work such as mai ntenance, repai r, or ot her acti vi ti es where
engineeri ng and work practi ce control s are not feasi bl e.
Ethylene Oxide Exposure Sources
There are ei ght areas where EO is l i kel y to contact personnel : the area in f ront of
t he steri l izer when the door i s opened af ter the cycl e i s compl eted, t he f reshl y
steri l i zed goods themsel ves, t he aerati on cabi net , the steri l i zer, t he f l oor drain,
where the tank and/ or cart ri dge i s changed, the safety valve, and where t he suppl y
t anks or cartri dges are stored.
Recommendations to Reduce Exposure
Unnecessary use of EO shoul d be avoi ded (149). I t shoul d be reserved f or
products that must be steri l i zed and cannot wi thstand other methods of
steri l i zat ion.
There must be st ri ct adherence t o the manuf act urer' s instal l at ion and
operati ng inst ructi ons f or steri l i zers and aerat ors. Each steri l i zer and aerator
must have regul ar prevent ive mai ntenance to ensure that mal f unct i ons,
especi al l y l eaks, are mini mi zed. Records must be kept on al l mal funct ions
and repai rs.
EO cyl i nders must be stored i n a desi gnated area that meets bui l di ng codes
and OSHA regul at i ons and i s out of the way of traf fi c. Cyli nders must be
chained upright t o a sol i d st ructure and t he protect ion cap kept in pl ace when
not i n use. The storage area must be venti lated to prevent bui l dup of a
si gni f icant EO concentrati on i n the event a cont ai ner l eaks.
Cauti on must be exerci sed when changing tanks and f i l ters to avoi d
personnel exposure. Protect ive att i re (e.g. , goggl es or a f ace shi el d, heavy-
dut y gl oves, f ul l -body sui ts) must be worn. There must be check or shutoff
valves in the l i nes close to the connecti on poi nt t o l i mi t t he release of gas
duri ng cyl i nder changes. A l ocal exhaust hood must be instal l ed near the EO
cyl i nder connect i on area t o capture EO rel eased duri ng changeover and
l eaks around li ne connecti ons. It must exhaust the EO t o the outsi de or an
emi ssi on control system.
St eri l i zers and aerators must be locat ed in wel l -vent i l ated areas wi th l imi ted
access. The room(s) i n which the st eri l i zer and aerator are l ocated must be
l arge enough to ensure adequate EO di luti on. The vent i lati on system must be
non-reci rcul ati ng, al low at l east t en ai r changes per hour, and be desi gned
so t hat ai r f l ows over the steri l i zer door openi ng to an exhaust f an, bl ower
system, or emi ssion cont rol system. Signs warni ng that high l evel s of EO are
possi bl e must be posted at t he ent rances. No suppl i es or unnecessary
equipment shoul d be st ored i n the vicini t y of steri l i zat ion/aerati on equipment .
Products t hat are to be steri li zed wi t h EO must be organi zed i nto f ul l l oads,
and those requi ri ng the same steri li zati on ti mes shoul d be grouped t ogether.
EO steri l i zers, steri l i zer reli ef val ves, and aerators must be vented t o the
outsi de, an emi ssi on control system, or a sani tary f l oor drain. Runni ng vent
l i nes in ways that woul d release EO wi t hi n the bui l di ng, al l owi ng re-entry of
EO-contami nated ai r i nto the bui l ding or releasi ng EO near pedest rian t raf f ic,
i s prohibi ted.
An EO steri l izer must be constructed so that t he cycle cannot be ini t iated or
al l owed to cont inue unl ess t he door is cl osed and secured. I t must not be
P. 979

possi bl e t o open the door when the chamber i s under pressure or before the
postevacuat ion cycl e is compl eted. Local exhaust venti l ati on systems must
be i nstal l ed to capture EO as cl ose to the source as possi bl e and exhaust i t
t o t he outsi de at mosphere.
A combi nati on steri l izer/ aerator wi l l reduce EO exposure associ ated wi t h
openi ng the steri l i zer door and transf erri ng goods to an aerator (128).
Exposure to EO can be avoi ded by using a l oading cart and/or wi re baskets
t hat can be moved di rect l y i nto the aerat or. It ems must be loaded i n such a
manner t hat they wi l l not t ouch the operator' s hands when the cart or basket
i s transf erred.
Wi th st eri l i zers wi t hout a purge cycl e, the si ngl e greatest source of EO
exposure occurs when the steri li zer door i s opened af ter the steri l i zat i on
cycl e i s complete. I t ems must not be l ef t in a cl osed steri li zer af ter t he cycle
i s compl et e, as t hi s wi l l al l ow hi gh concent rat i ons of EO t o bui ld up i n the
steri l i zer and be rel eased i nto t he room when the door i s f i rst opened. The
chamber door shoul d be opened 6 inches i mmedi at el y f ol lowi ng a cycl e on
some steri l i zers. A door-openi ng devi ce al l ows the operator to push a but ton
and then walk away whi l e the steri l i zer door slowl y opens. The operat or
shoul d l eave the i mmedi ate st eri l i zer area for a mi ni mum of 15 minutes af ter
openi ng the door.
The purge charact eri sti cs of some newer steri l i zers prevent EO f rom
accumul at ing i nside t he chamber. These steri l i zers shoul d be unl oaded
i mmedi atel y upon opening the door, because this i s when t he EO
concentrati on i n the chamber i s l owest.
St eri l i zed i t ems must be transferred rapi dl y to t he aerator. Goods shoul d
never be handl ed di rectl y. Transf er carts shoul d be used to remove i tems
f rom large steri li zers and gl oves and f orceps f or i t ems i n smal l st eri l i zers.
Carts must be pul l ed, rat her t han pushed, to t he aerator so that personnel
are not upwi nd of the goods. Baskets must be carri ed at t he si de and not at
t he f ront of the person. I tems shoul d be pl aced in t he aerator wi thout del ay.
Unaerated i tems must never be l ef t outsi de t he aerator, where t hey mi ght
contaminate the envi ronment or be used prematurel y.
Portabl e EO steri l i zers must be used onl y i n a wel l -venti l at ed room. If a
steri l i zer does not have a venti ng mechani sm other t han the door or l i d, t he
heal th care faci l i ty must determi ne t hat t he venti l ati on system ef f ecti vel y
mi nimi zes empl oyee exposure t o EO. Possible measures include usi ng l ocal
exhaust venti lati on and addi ng a chemi cal neut ral i zat i on system or EO
absorbent t o the steri li zer.
Al l EO-steri l i zed i t ems must be aerated before handl ing. A mechanical
aerat or i s best . If ambi ent aerati on i s unavoi dabl e, t he aerat ion area must be
segregated f rom general work areas and have l imi ted access. It must have
good venti lat i on and be at a negati ve pressure wi th respect to adjoining
areas. Stori ng suppl ies i n the area where ambi ent aerati on i s practiced
shoul d be prohi bi t ed.
Personnel and envi ronmental moni tori ng must be practi ced to ensure that
recommended l evel s are not exceeded (152, 153,154). Checki ng f or l eaks
must be performed regul arl y. The moni tori ng f requency requi red by OSHA
depends on t he l evel s f ound i n the work envi ronment. Badges t hat can be
worn by empl oyees are avai labl e. Inst ruments to aid i n instant aneous leak
detecti on and t o alert personnel shoul d be i nstal l ed (Fi g. 34. 13).
The seal s on steri l i zer and aerator doors must be i nspect ed for cracks, tears,
and f orei gn substances before each l oad. St eri l i zer and aerator val ves and
f i t ti ngs must be i nspected regul arl y and repl aced as necessary. I ntake ai r
f il ters f or t he restricted access area must be i nspected and cl eaned
regul arl y.
A l i mi ted number of EO cart ri dges can be stored in t he immediate vi ci ni ty of
t he steri l izer, pref erabl y i n a speci al cabi net (Fi g. 34. 12).
Each facil i ty i n which EO i s used must have a wri tt en emergency pl an for
deali ng wi th EO leaks and spi l l s (149). Thi s i ncludes procedures for al ert i ng
personnel , avoi ding EO cont act , evacuati ng unprotected personnel ,
contacti ng appropri ate saf ety personnel , and speci f ying t he cri t eria f or area
re-entry by unauthori zed personnel .
Empl oyees who operate st eri l i zers or aerators must be properl y i nst ructed in
t he hazards of EO and appropri ate safety procedures.
Environmental Problems
Once EO i s emi t ted, i t remains in the ai r wi t hout breaki ng down f or l ong peri ods of
t i me. Peopl e who l ive near f aci l i t ies wi t h steri l i zers or aerators may, theref ore, be
exposed t o si gni fi cant l evel s of ai rborne EO. Some st ate and l ocal areas l i mi t the
amount of EO t hat can be emi tted into t he ai r (135,155). Cat al yti c converters that
break EO down i nto carbon di oxi de and water are avai l able.
Advantages and Di sadvantages of Gas Sterilizati on
EO steri l i zati on i s very rel i abl e because the gas penetrates i nto crevices, narrow
l umens, and regi ons bl ocked by l i quids. I t can be used on a wi de vari et y of i tems,
i ncl udi ng t hose t hat woul d be damaged by heat or moi sture. It i s the onl y rel i abl e
and practi cal means f or steri l i zi ng many devices that are used t oday. Damage to
most equi pment is mi ni mal . Items can be packaged bef ore steri l izati on and stored
steri l e for extended periods. Prepackaging el i minates the danger of
recontami nat i on that can occur duri ng ri nsi ng and packagi ng f ol l owi ng
P. 980

cold steri l i zat ion and al lows i t ems to remai n steri le duri ng long-term storage. A
l arge amount of equipment can be steri li zed at one t i me.
EO has a number of di sadvantages. Fi res and expl osi ons i nvolving steri l i zers have
occurred. A major disadvant age i s the l ong t otal processi ng ti me requi red. Thi s may
make i t necessary t o have mul ti pl e sets of equi pment. EO i s more costl y than most
ot her t ypes of st eri l i zat i on. Personnel need to be highl y t rained and supervised.
Measures to reduce employee exposure and moni tor l evels of EO must be taken.
Equi pment that i s to be steri l i zed needs to be dry. Some mat eri al s deteri orat e af ter
repeated EO steri l i zati on, especi al l y at el evat ed temperatures. It cannot be used to
steri l i ze devi ces that have petrol eum-based l ubri cants i n or on them, because EO
cannot permeate these.
Radiation Sterilization
Gamma-radiati on uses an el ect romagnet i c wave produced during the di si nt egrat ion
of cert ai n radi oact ive elements. If the dosage appl i ed to a product is l arge enough,
al l mi croorgani sms, including bacteri al spores and vi ruses, wi l l be ki l l ed.
There are many advant ages t o -radiat i on. The product can be packaged i n a wi de
vari et y of impermeabl e contai ners bef ore t reatment. The package wi l l not i nterfere
wi th t he st eri l i zati on process. The treated i tems remai n steri l e i ndef i ni tel y unti l the
packagi ng seal i s broken. As there i s vi rtual l y no t emperat ure ri se during t reatment ,
t hermolabi l e materi al s can be steri l i zed and thermol abi l e packagi ng can be used.
I tems may be used i mmedi atel y af t er treatment wi t h no ri sk f rom retai ned
radi oact i vi ty.
Gamma radi ati on i s not practi cal f or everyday use i n heal th care faci l i ti es. It
requi res expensi ve equipment and i s used onl y by large manufacturers to steri l i ze
di sposabl e equi pment . Some heal th care f acil i t i es send thei r own packs to outsi de
f aci li t ies f or t reatment.
Gas Plasma Sterilization
Gas pl asma i s someti mes descri bed as the f ourth state of mat ter, consi sti ng of a
cl oud of react ive i ons, el ect rons, and neut ral at omi c and mol ecul ar part icl es
(109, 156,157,158, 159). I t i s produced by appl yi ng energy to certai n gases.
Hydrogen peroxi de vapor i s most of ten used. The react ive species in the pl asma
i nteract wi th t he molecul es t hat are essent ial for the metabol i sm and reproducti on
of l i vi ng cel l s.
Devices to be st eri l i zed need to be t horoughl y cl eaned and dri ed. They can be
unwrapped or encl osed i n a nonwoven wrap (137). Cell ul osi c materi al s shoul d not
be used for wrappi ng, because they absorb the steri lant vapors, reducing i ts
concentrati on.

View Figure

Figure 34.14 Gas plasma sterilizer. (Picture courtesy of
Sterrad, a division of Johnson & Johnson Company.)

The steri l i zer (Fi g. 34.14) runs on an aut omat ic cycl e that i s cont rol l ed by a
mi croprocessor. The machi ne produces a pri ntout f or each l oad processed. If f or
any reason the process i s outsi de the normal li mi ts, the cycl e is i nterrupted and t he
pri ntout gives the reason.
The hydrogen peroxi de i s contained i n a sealed di sposable cassette (Fi g. 34.15)
t hat i s pl aced i nsi de t he steri l i zer al ong wi th t he i tems to be steri l i zed.
I t i s i mportant to read the i nst ructi ons wi t h the steri l i zer, especi al l y when devi ces
wi th smal l l umens are processed. Earl y model s coul d not steri l i ze devi ces wi th l ong
narrow l umens (160). Lat er models can steri l i ze most of t hese devi ces, al though a
l onger cycle t ime may be requi red.
Af ter the i tems t o be steri l i zed are placed i n t he steri l i zat ion chamber, t he door is
cl osed and the gas i n the chamber i s evacuat ed (Fig. 34.16). Moi sture remai ni ng on
or i n the obj ects in t he chamber wi l l make i t dif f icul t to achieve the recommended
vacuum, and the cycl e wi l l abort (23,159). Fi l t ered ai r i s t hen introduced to rest ore
at mospheric pressure. Thi s is t he prepl asma (vacuum, precondi ti oni ng) phase.
P. 981



View Figure

Figure 34.15 Once the hydrogen peroxide cassette has been
placed in the sterilizer, it is automatically advanced by the
machine.

The chamber is again evacuated, and a smal l vol ume of aqueous hydrogen
peroxide i s injected f rom a cassette. The hydrogen peroxide vapori zes and di f fuses
around the i tems t o be st eri l i zed for a f ixed peri od of t ime. Thi s i s the dif f usi on
phase (Fig. 34.16). Then, a l ow-t emperature pl asma i s generated by appl yi ng radi o
f requency energy. Thi s i s the pl asma phase. Duri ng the plasma phase, the
t emperat ure i ncreases about 5C.
Af ter the radi o f requency i s turned OFF, the f ree radicals l ose t hei r hi gh energy and
recombi ne to form oxygen, wat er vapor, and other nontoxic products. Wi th some
steri l i zer model s, t his process i s repeated wi t h the excepti on of the prepl asma
stage. Af t er t he cycl e(s) has been compl eted, f i l tered ai r is i nt roduced i nto t he
chamber, di spl aci ng t he vapor f rom the chamber and passi ng i t through a devi ce
speci al ly desi gned to decompose t he hydrogen peroxi de. Thi s i s the vent phase.
The t emperature duri ng t he whol e cycl e does not exceed 50C. The cycle t i me
vari es wi th the steri l i zer model . Di ff erent model s have di f f erent si zes, shapes,
numbers of shelves, and number of injecti on st ages. A chemical i ndi cator shoul d be
i ncl uded i n each t ray and a bi ol ogi cal i ndicator used at least once a week (54,159).
Gas pl asma i s an ef fecti ve steri l i zat ion process. It can be used for most heat-l abi l e
and moi st ure-sensi t ive i t ems wi th t he except i on of cel l ul osi c materi als (e. g., cot ton,
l i nens, paper), powders, li qui ds, impl ants, and devices contai ni ng l ong, narrow,
dead-end l umens. It produces l ess eff ect on metal i tems than st eam steri l i zati on. It
i s compati bl e wi t h ceramics, si l ica, gl ass, and a wi de range of pl asti cs i ncl udi ng
pol yethyl ene, polypropyl ene, PVC, si l i cones, and f l uori nated sil icones. I t can be
used wi t h a vari ety of hinged and non-hinged inst ruments, devi ces wi t h l umens (not
dead ended), el ectri c and f i beropt i c cabl es, bat teri es, and ri gi d endoscopes. I t can
steri l i ze stainless steel l umens that are 1 mm or larger and no l onger than 125 mm,
l umens that are 2 mm or larger and no longer than 250 mm, and l umens that are 3
mm or l arger and no l onger than 400 mm (121).
A gas pl asma steri li zer i s si mpl e to operat e. I t uses rel ati vel y low concentrat ions of
t he steri l izi ng agent , does not l eave t oxic resi dual s, and has short processi ng
t i mes. There is no need f or aerati on or cool -down t i me. The steri l i zed products are
dry and i mmedi atel y avai l able f or use or can be stored for l ater use. There i s no
need f or cool i ng or aerat ion. There are no emissi ons or t oxi c by-products. The
pri mary end products of the process are oxygen and water.
Lack of worker exposure and envi ronmental contami nati on are maj or advantages.
No personnel or exhaust moni t oring is needed. Resul ts f rom moni toring around the
steri l i zer have shown an 8-hour TWA concent rati on of 0.005 ppm hydrogen
peroxide (105). The OSHA l i mi t i s 1 ppm. No wat er source, heati ng, or outsi de
venti ng i s requi red. Thus, i t can be l ocat ed i n close proxi mi t y to t he area where t he
i nst ruments wi l l be used. I t can be moved around easi ly.
Al though t hese are l ow-capaci t y steri l izers, the vol ume of products processed per
uni t of ti me may be equi valent to t hat of l arge-capaci t y EO steri li zers. In cost
compari sons wi th other steri l i zat i on technol ogi es, pl asma st eri l i zat ion was l ess
expensive than EO but more expensive than steam (161,162,163).
P. 982



View Figure

Figure 34.16 Gas plasma sterilization cycle. (Redrawn from
a figure in
The future of low-temperature sterilization technology in
healthcare. A roundtable discussion, April 28, 1995
.)

The system has a number of di sadvantages. These i ncl ude the smal l si ze of the
steri l i zi ng chamber. Cell ul ose mat erials, paper, l i nens, powders, li qui ds, and
i mplants cannot be processed. Devi ces wi t h a dead-end or a l umen 400 mL or
l onger cannot be steril i zed wi thout a speci al adaptor. Penetrati on i s not as good as
wi th EO (164). The st eri l i zat ion process i s impai red when prot ei n or sal t i s present
(156, 165,166). Devi ces t hat are t o be steri l i zed must be abl e to wi t hstand a
vacuum. I t ems whose desi gn permi ts the surf aces to col l apse ont o each other (e.g. ,
bags) shoul d not be processed unl ess some means i s used to keep the surfaces
separated. Thi s process requi res speci al suppl i es (e.g. , i ndi cators, t rays, wraps)
t hat are compati bl e wi t h the syst em. I t may al so requi re modif icati on of some
wrappi ng and stacki ng techni ques.
A Program for Anesthesia Equipment
General Considerations
Those who are concerned wi t h anesthesi a equi pment f i nd t hemselves f aced wi th a
di l emma as to how much t i me, ef fort , and money should be expended to prevent
i nfect ion t ransmi ssi on. Wi th i ncreased pressure to hol d down costs, the t emptat ion
t o do l ess may be st rong. Proponents f or more vi gorous measures argue as f ol l ows:
Cases of cross cont ami nat ion caused by anesthesi a and respi ratory
equipment have been report ed (167, 168,169,170,171, 172,173,174).
The risk of cross contaminati on may be great er t han i s generall y bel ieved.
The l ack of document ati on of many nosocomi al inf ecti ons secondary t o
anesthet ic practi ce may refl ect a l ong i ncubat ion peri od, di ff icul ty i n
pi npoi nt i ng the source of i nf ect ion, or i nadequate f ol low-up (175,176,177).
Anesthesi a interf eres wi t h ci l i ary and mucous act ivi t y, and surgery can impai r
t he pat ient' s abi l i t y to cough and breathe deepl y, so pati ents are more l ikel y
t o devel op respi ratory i nf ect ions than the normal populat i on. Anesthesia care
provi ders of ten care f or i mmunocompromised pat ients, and t hese pati ents
may be unabl e to prot ect t hemselves against what were once thought to be
harml ess organi sms or i nsigni f i cant i nocul ums.
Al though t here is general agreement t hat steri l i zat i on or hi gh-level
di si nf ect ion of equi pment i s essenti al af t er use wi t h a pat ient having a
respi ratory or bl oodborne i nfecti on, i t is i mpossible to i denti f y all of t hese
pati ents.
Even if t he i nci dence of i nf ecti ons resul ti ng f rom anesthesi a apparatus i s
l ow, t he cost of a si ngl e such
P. 983

i nfect ion i n terms of mort ali t y, morbi di t y, and resource expendi t ure i s hi gh.
Bl ood contaminati on of anesthesia equi pment surf aces is common (178).
Vi sual inspecti on i s not a rel i able means for detect ing bl ood.
Centers for Disease Control and Prevention Guidelines
The CDC has publ ished gui del i nes on how t o prevent or control nosocomi al
i nfect ions based on a classi f i cati on of i nst ruments and ot her i t ems by the risk of
i nfect ion i nvolved (68).
Critical Items
These incl ude vascul ar and regi onal bl ock needles and catheters. These i tems must
be steri l e, because they bear a high risk of i nfect ion i f t hey are contami nated.
Semicritical Items
Semi cri t i cal i tems do not pierce mucous membranes. Equi pment that f al ls i nto thi s
category i ncl udes endoscopes; laryngoscope bl ades; reusabl e rectal ,
nasopharyngeal , and esophageal temperature probes; f ace masks; oral and nasal
ai rways; resusci t ati on bags; breathi ng t ubes and connectors; oxygen masks;
esophageal stethoscopes; and tracheal and double-l umen tubes. Ideal l y,
semi cri ti cal i tems should be steri le. However, hi gh-l evel di si nf ecti on i s an
acceptabl e standard of care when st eri l i zati on i s not practi cal .
Noncritical Items
Noncri t ical i tems come int o contact wi th i ntact skin. It ems i n thi s cat egory i ncl ude
stet hoscopes (not esophageal ); bl ood pressure cuf fs and t ubi ng; arm boards; pul se
oximet er sensors and cabl es; electrocardi ogram (ECG) cabl es and electrodes;
reusable ski n t emperat ure probes; t emperature moni tor cabl es; head st raps; blood
warmers; carbon dioxide absorber assembli es; adaptors f or oxygen sensors; and
t he exteri ors of the anesthesi a machi ne, vent i lator, humi di f iers, scavengi ng system,
resusci tati on bags, intravenous f luid pumps, moni tors, and equi pment carts. Si nce
i ntact skin normal l y acts as an ef fecti ve barri er to most mi croorganisms, these
i tems need onl y cl eaning f ol l owed by intermedi ate- or l ow-l evel disinf ecti on.
Some experts add anot her category-envi ronmental surf aces (8). These incl ude
surf aces that do not ordi nari l y come i nt o di rect contact wi t h the pat ient, but i f they
do, i t i s onl y wi th i ntact skin. These surfaces may pot enti al l y contri but e to
secondary cross cont ami nat ion by heal th care workers or medical i nst ruments that
subsequentl y come into contact wi th pati ents. These surf aces can be f urt her
di vi ded i nt o medical equi pment surfaces such as adj ustment knobs or handl es and
housekeepi ng surf aces such as f l oors, wal l s, and wi ndowsi l l s.
Factors Influencing Cl eaning Procedures
No si ngl e agent or procedure is adequate f or al l purposes. Factors that should be
consi dered i n the sel ecti on i ncl ude t he degree of mi crobi ol ogi c inact ion requi red for
t he parti cul ar devi ce, the nature and physi cal composi ti on of the device, and the
cost and ease of usi ng a part i cul ar procedure. Costs can be divided into di rect and
i ndi rect costs (179). Di rect costs i ncl ude processing (cl eaning, steri l izati on
packagi ng), purchasi ng (i ni ti al price, i nst al lat i on, shi ppi ng), repai r, repl acement ,
l abor, and disposal . I ndi rect costs incl ude inf ecti on control (empl oyee i mmuni zati on
and educati on), l i abil i ty (compensat i on, i nsurance, and regul atory compl i ance),
admi ni st rati on (procedure wri t i ng), and lost revenue (processi ng di ff i cul ti es,
product f ail ures, and procedure delays).
Responsibi l i t y f or anesthesi a equi pment decont ami nat i on shoul d be vested i n one
i ndi vi dual who devises and admi ni sters a comprehensive program. Thi s person
shoul d be a member of the i nst i tut i on' s inf ecti on control commi t tee. An i nfecti on
control pol i cy that documents procedures to prevent t ransmi ssi on of inf ecti ous
agents t o pat i ents and personnel and that is approved by t he i nf ecti on cont rol
commi t tee shoul d be in place for anest hesia (180,181). It i s i mperati ve that
equipment cl eani ng and di si nf ecti on or steri l i zati on be perf ormed by consci ent ious,
wel l -t rai ned i ndi vi duals who understand standard precaut ions. Another f actor
necessary f or a successf ul decont ami nat i on program i s survei ll ance to check that
t echni ques are adequate. CDC gui del i nes do not recommend rout ine cul t ures.
Cul tures need to be taken onl y if a probl em becomes evi dent.
A tracki ng system should be i n place to enabl e reusabl e i nst ruments to be traced t o
an i ndivi dual pat ient i n the event of a cl i ni cal i nci dent (e. g. , fail ure of the
decontami nat ion process or a devi ce bei ng used on a pat i ent wi th unsuspected
CJD) (181). Furt hermore, some anesthet i c equi pment (e.g. , l aryngeal masks, gum
el ast i c bougies) should onl y be reprocessed a f i ni t e number of t i mes, so t his must
be documented.
Filters
St udi es show t hat an eff ecti ve f i l ter at the pat ient port wi l l protect t he breathing
system and envi ronment f rom contami nati on (182,183,184, 185). An addi t i onal
benef i t i s that i t hel ps to humi dif y the i nspi red gases and l owers t he humi di t y that
reaches si dest ream moni tors. However, t he ef fi cacy of fi l ters i n reduci ng pat ient
cross i nf ecti on is unproven. The Associ ati on of Anaestheti sts of Great Bri tai n and
I rel and and the Austral ian and New Zeal and Coll ege of Anaestheti sts have
recommended t hat a f i l ter i s pl aced at the pat ient port f or al l adul t pat ients
(186, 187,188), whi l e the ASA concluded that t here was i nsuf f i ci ent cl i ni cal outcome
data to recommend routi ne use (2). However, when a pat ient wi th a respi ratory
i nfect ion must be gi ven i nhalat i onal
P. 984

anesthesi a, a f il t er shoul d be used. Fi l ters are di scussed i n Chapter 7. Choosi ng
t he proper f i l ter i s t ricky, because the speci f icati ons are di f f i cul t t o i nterpret. Fi l ters
are more ef f ective at preventi ng bacteri al than vi ral transmissi on.
I t has been suggested that a f i l ter is used wi t h each pati ent and, as a cost -savi ng
measure, the anesthesi a ci rcui t i s reused (189). Thi s does not address out er
surf ace contaminati on t hat may occur wi t h breathi ng ci rcui ts that are not changed
bet ween pati ents (190). The debate about usi ng f i l ters and reusing the breathi ng
system i s not resolved at t hi s t i me (191).
Equipment Choice
Di sposabl e equi pment may be f or si ngl e use or si ngl e pat i ent use
(181, 192,193,194, 195). Si ngl e use i ndi cates that the manufacturer i ntends for t he
i tem t o be used onl y once on an indi vidual pati ent and t hen di scarded. Si ngl e
pati ent use i ndicates that the manuf act urer advises that the i tem may be used more
t han once on the same pat ient.
Most depart ments have st ruck a bal ance bet ween di sposabl e and reusabl e i tems.
Thi s bal ance should be peri odi cal l y reassessed i n l i ght of changi ng t echnol ogi es,
costs, and waste management probl ems. Most departments keep at l east some
di sposabl e i tems avai labl e f or use wi t h known i nf ect ed cases. Disposables ensure
t hat the pat i ent wi l l al ways recei ve a st eril e or cl ean i tem, and t here i s no need f or
decontami nat ion af ter use. Among the di sadvantages is the need to keep a l arge
i nventory and an i ncrease in the waste generated by a f aci l i t y.
FDA regul at ions requi re manuf acturers of new or redesi gned medical devices
l abel ed as reusabl e to provi de wri t ten i nst ruct ions f or cleani ng, decontami nati on,
and, i f appropri ate, di si nfect ion or steri l i zati on. A reusabl e devi ce of ten requi res
di sassembl y, cl eani ng, drying, reassembl y, repackagi ng, and di si nf ect ion or
steri l i zat ion before reuse. Whi l e equi pment i s bei ng cl eaned, i t cannot be used.
Thi s may necessi t ate a l arger i nventory. There is a l imi ted l i fe span for reusabl e
equipment .
The reprocessi ng of di sposabl e equi pment i s a cont roversi al mat ter
(196, 197,198,199, 200, 201,202, 203). I n an eff ort to reduce costs, some heal th care
f aci li t ies have been or have considered reusing single-use devi ces (204,205).
Thi rd-part y reprocessors are avai l abl e. I n some cases, thei r reprocessi ng costs are
l ower t han reprocessi ng at the heal t h care f acil i t y. The FDA requi res i nst i tut i ons
t hat reprocess si ngl e-use devices to meet the same regul atory requi rements as the
ori gi nal manufacturer of the product (206). This shif ts t he l iabi l i ty f or product saf et y
and eff ectiveness f rom the manuf acturer to t he party doing the reprocessing (180).
The ASA Task Force on Infecti on Control does not recommend reuse of disposabl e
equipment (207).
Most of t he cont roversy rel ated t o reuse of single-use devi ces has concerned
expensive i t ems such as cardi ac cathet ers. Pul se oxi meter sensors have been
recycled (208). Successf ul reprocessi ng of Combi t ubes has been report ed (209).
The heal th care faci l i ty must f ormul ate a pol icy to ensure t he cl eanl i ness, physi cal
i ntegri t y, and f uncti onali t y of the devi ce af ter reprocessi ng. I t is recommended t hat
an i nterdiscipli nary commi tt ee wi thi n each insti tuti on be devel oped to assess
requests to reprocess and reuse any device l abel ed si ngl e use or di sposable. Both
t he eff i cacy of the reprocessi ng procedure and the l i kel ihood that the device wi l l
f uncti on as intended af ter reprocessing must be consi dered (197,204,210,211,212).
Intraoperative Considerations
Anesthesi a provi ders should al ways work f rom a cl ean surf ace. At the start of a
case, onl y those art icles that are l i kel y to be used should be pl aced there. Cl ean
and di rty areas need to be establ ished and equipment placed i n the proper l ocati on.
Si nce gl oves are used duri ng parts of the procedure where the ri sk of contact wi t h
bl ood or body f l ui d i s greatest, they can become contami nated, and this
contaminati on can be t ransf erred t o equi pment. Any reusabl e i tem that i s touched
wi th a di rt y gl ove shoul d be placed i n the container f or di rt y equi pment. Thi s may
contai n wat er wi t h detergent to prevent secret ions or bl ood f rom dryi ng (2).
Di rt y equi pment such as laryngoscope bl ades can be i sol at ed by wrappi ng them i n
a gl ove or t he packaging f rom another i tem (213). At t he end of the case, the
receptacle f or di rt y equipment shoul d be taken to t he decontami nat ion area. Used
di sposabl e i tems shoul d be di scarded i n sui t abl e cont ai ners.
Bl ood or other body f l uids on equi pment or envi ronment al surf aces shoul d be
removed wi t h water and det ergent f ol l owed by decont ami nat i on usi ng an
i ntermediate-l evel disinf ectant. A 1: 10 to 1:100 di l ut ion of 5. 25% sodi um
hypochl ori te has been recommended by the CDC f or cl eani ng bl ood spi l ls.
ASA, AANA, and CDC guidel i nes stat e that syri nges are si ngl e-pat i ent i tems (214).
Once a syri nge has been connected to or has been used to enter a pati ent ' s
i ntravenous i nf usi on, the syri nge and needle are considered contami nated, because
bl ood may have backed up i nto t he t ubi ng. Syri nges shoul d not be used to
admi ni ster medicati on to mul ti pl e pati ents even i f t he needle i s changed.
Unf ortunatel y, some anesthesia provi ders reuse syri nges on more than one pati ent
(177, 215,216,217). Mul ti dose sol uti ons represent a potenti al source of
t ransmissi bl e bloodborne i nf ecti ons (174,216, 218,219,220).
The Anesthesi a Work Area
The anesthesi a work area is usual l y the si te where cl eani ng and ot her procedures
are perf ormed unl ess the equipment goes di rectl y to a central reprocessi ng area.
P. 985

Procedures include di sassembl y, cleani ng, di si nf ect i on, and steri li zati on. How much
i s done i n the anesthesia workroom wi l l depend on how much can be carri ed out by
t he operat i ng room or cent ral servi ce depart ment f or t he enti re f aci l i ty. Even i f most
of t he procedures are perf ormed in another area, i t may be desi rable to
di sassembl e di rt y i tems i n the anest hesi a workroom, removi ng gross soil and
renderi ng them safe f or handl ing pri or t o transport .
Soi l ed equi pment shoul d be t ransported on dedicated carts or mechanical
conveyances that are clearl y marked to i ndi cate that t he i tems are cont ami nat ed.
These shoul d be placed i n a desi gnated area for ti mel y transport to t he cent ral
processi ng depart ment or the reprocessi ng area i n t he operat i ng room. A dedi cated
soil ed cart l if t f rom the operati ng room to t he central suppl y depart ment i s
recommended i f they are on dif ferent fl oors.
The reprocessi ng area shoul d have adequate space for the i ntended procedures. It
may be desi rable t o have a machine t o wash contami nated i t ems. Si nks shoul d be
l arge enough that bul ky i tems wi l l f i t i nto t hem and have at tached counters on
whi ch soil ed and cl ean i tems can be pl aced separatel y. There shoul d be enough
si nks to accommodate concurrent soaki ng, washi ng, and ri nsi ng. Racks f or dryi ng
wi l l be needed.
Consideration of Individual Items
The choi ce of decont ami nat i on method wi l l depend on a number of factors,
i ncl udi ng t he nature of the contami nat ion; the ti me requi red for processi ng; the
heat, pressure, moi sture, and chemi cal t ol erance of the i t em; the avai l abi li ty of
processi ng equipment ; and t he ri sks associated wi th t he decontami nati on method
(181). The manufacturer' s instructi ons shoul d be studi ed and f oll owed careful l y.
Anesthesia Carts
Anesthesi a carts are used as a reposi tory for equi pment and drugs. Cont ai ners that
hol d drugs, syringes, needles, and such shoul d be cleanable. Attent i on should be
pai d to how equi pment is pl aced i n the drawers. For i nstance, a bl ood pressure cuf f
t hat i s used on several pat ients wi th no att empt to decontaminate i t bet ween cases
shoul d not be pl aced in the same drawer as ai rways or masks t hat are not kept in
steri l e contai ners, but the cuf f may be pl aced in a drawer containing i t ems such as
sucti on catheters and syri nges that are kept i n di sposabl e wrappers. Equi pment
t hat i s not kept steri le shoul d be placed i n drawers t hat are l ess f requent l y opened,
t hat i s, not i n t he same drawer as f requent ly used drugs. The top surf ace shoul d be
cl eaned of vi si bl e materi al between cases and at t he concl usi on of the workday and
di si nf ected wi th a germicide (8). A clean coveri ng shoul d be pl aced on the top of
t he cart at t he start of each case. Verti cal surfaces shoul d be cl eaned at the end of
t he workday or i f t here is obvi ous contami nati on. At least once a month, al l
equipment shoul d be removed and t he drawers and containers cl eaned, t hen wi ped
or sprayed wi th a germicide.
Gas Cyli nders
Gas cyli nders are transported to the f aci l i t y i n open trucks and are f requentl y
stored outsi de. Before taki ng a t ank i nto the operati ng room sui te, the wrapper, i f
present, should be removed. The cyl i nder shoul d be washed wi t h water and
detergent and wi ped or sprayed wi th a germi cide. Af ter pl aci ng the cyl i nder on the
anesthesi a machine, i t should be consi dered part of the machi ne and treat ed
accordi ngl y.
Anesthesia Machines
The same pri nci pl es appl y t o cl eani ng anesthesia machines as to cart s. The top
surf ace shoul d be suppl i ed wi th a cl ean cover f or each case. The machi ne should
be cl eaned bet ween cases and at t he end of t he workday, then sprayed or wi ped
wi th a germicide. Care should be taken not t o get l iquid i n the vapori zer f il l ing
f unnels. Parti cul ar at tent i on shoul d be pai d to f requentl y used knobs. Equi pment
shoul d be removed f rom drawers and the drawers cl eaned and di si nf ected regul arl y.
Anesthesia Ventilators
The outside of the vent il ator shoul d be treated the same as the outsi de of an
anesthesi a machine. Many bell ows and tubi ngs can be steri l i zed by using EO. An
i mportant feature of t he newer generati on of anesthesia venti l ators i s that most
parts t hat come i nto contact wi t h respi rat ory gases can be easi l y removed and
steam autocl aved (Fi g. 34. 17). The manuf acturer' s recommendati ons shoul d be
f ol l owed.
Unidirecti onal Val ves, the Adjustable Pressure-li miti ng
Valve, and Water Traps
The outside of APL and unidi rect ional val ves shoul d be cleaned and disinf ected
peri odi cal l y. Uni di recti onal valves are usual l y easi l y disassembl ed and cl eaned by
wi pi ng the disc, the inside of the plasti c dome, and the val ve seat wi th al cohol or a
detergent. Some APL val ves may be autoclaved, and some can be past euri zed
(221). Usi ng gl ut araldehyde on APL valves may cause st i cki ness and i ncrease the
openi ng pressure (222). Water traps shoul d be cl eaned and di si nfected peri odical l y
and whenever wat er i s vi si bl e (223).
Absorbers
Carbon di oxide absorbent is a somewhat eff ect i ve f i l ter, and studies suggest t hat
pati ents rarel y contami nate i t wi t h high level s of bacteri a (184,224,225). The
P. 986

manuf acturer' s i nstruct ions shoul d be consul t ed wi th respect t o disassembl y,
cl eaning, and disi nf ect i on. Many of the newer anesthesi a workstati ons have
absorber assembl i es that can be easi l y disassembl ed and steam autocl aved (Fi g.
34.18). Canisters shoul d be cl eaned when the absorbent is changed, wi th part icul ar
at tenti on t o screens, as t hey are suscepti ble t o obst ructi on. Some canisters can be
steam autocl aved, and some can be steri li zed usi ng EO. Others can be di si nfected
by i mmersion i n a l i qui d such as gl utaral dehyde.

View Figure

Figure 34.17 Drager Divan ventilator that is disassembled
for steam autoclaving.

Newer absorbers use one or more disposabl e pl astic receptacl es. These are
smal l er t han those used i n ol der absorbers and are changed more f requent l y. Si nce
t hey are disposabl e, they do not need t o be cl eaned. The user manual shoul d be
checked to determine i f t he connect i ons to the breathi ng system need regular
cl eaning.
Reservoir Bag
I n many insti tuti ons, reservoi r bags are suppl i ed wi t h the disposabl e breathi ng
t ubes as part of a set , so they do not need cleani ng. Reusable reservoi r bags
shoul d be cl eaned and then steri li zed or subjected to hi gh-level disi nf ect i on. Bags
can be cleaned manual l y or i n an automati c washi ng machi ne. EO can be used to
steri l i ze the bag. Aerat i on ti mes shoul d be careful l y observed and the bag f i l led and
empt i ed a few t i mes before use. Some bags may be pasteuri zed, al t hough this wi l l
resul t i n gradual det eri orati on. Chemi cal di si nfecti on can be used. The bag must be
f il l ed wi t h l i qui d to remove ai r pockets.
Breathi ng Tubings
St udi es have shown t hat corrugated t ubi ng i s cont ami nat ed af ter use, especi al l y at
t he end cl osest to the pati ent . Water commonl y condenses i n the expi ratory tubi ng.
I f the t ubi ng i s l i f t ed up, this wat er may run down i nt o the ai rway or t he absorber,
reservoi r bag, or vent i l ator. These tubes shoul d peri odi cal l y be drained away f rom
t he pat ient and the condensate discarded (2).
Di sposabl e tubi ngs are wi dely used today. These t ubi ngs are usual ly suppl ied clean
but not steri le. When i t i s necessary to include the breathi ng t ubes i n the steri l e
f iel d, i t i s i mport ant to make cert ai n that they are steri l e.
The l ow cost of di sposable t ubi ngs makes thei r use at tracti ve, consi deri ng the cost
and dif f i cul t y of cl eaning and di si nfecti ng reusabl e tubi ngs. Reusabl e breathi ng
t ubi ngs shoul d be cl eaned and then steri l i zed or subjected t o hi gh-level disi nf ecti on
(226). They should be rinsed soon af ter use to prevent dryi ng. They may then be
soaked i n a contai ner t hat cont ai ns wat er and detergent. The l ong length and
corrugat i ons precl ude a brush f rom bei ng ef f ect ive i n cl eani ng. Ul t rasonic cl eani ng
can be used to remove debris. A washi ng machine may be used. Af t er washi ng, the
t ubi ngs shoul d be thoroughl y dri ed unless they are to undergo pasteuri zati on.
Speci al t ube dryers are avai lable (Fi g. 34. 2).
Pasteuri zat i on can be used for corrugated tubi ngs. The Y-pi ece shoul d be removed
beforehand; ot herwi se, a l oose f i t may resul t.
Chemi cal di si nf ect ion can be carri ed out by usi ng an automati c washing machi ne or
by i mmersion i n a l i qui d agent. It i s i mport ant that the t ube be i nsert ed vert icall y,
maki ng cert ai n that i t is f i l led on the i nsi de and that there are no ai r pockets. One
study f ound that machi ne-assisted chemi cal disinfecti on wi th gl utaral dehyde was
superior to machine-assi st ed pasteuri zati on f or t ubi ngs (227).
Y-piece
The Y-pi ece i s contami nated i n a hi gh percentage of cases. It has been postul at ed
t hat a contaminated Y-pi ece may have caused pati ent -t o-pat ient t ransmissi on of
hepat i t is C vi rus (HCV) i n one case (169). Disposabl e Y-pi eces that are
permanentl y at tached to di sposabl e tubings are commonl y used.
A reusabl e Y-pi ece shoul d be cleaned and steri l i zed or subj ected t o hi gh-l evel
di si nf ect ion (226). Af ter use,
P. 987

i t shoul d be removed f rom the corrugated t ubi ngs and ri nsed. It shoul d then be
soaked i n a sol uti on of water and detergent, t hen scrubbed manual l y or placed i n a
washi ng machi ne. If chemi cal disinf ecti on or EO steri l izat ion i s to be used, i t shoul d
be thoroughl y dri ed. Y-pi eces may be pasteuri zed, i mmersed i n l i qui d agents, or
steri l i zed by usi ng EO or plasma steri l i zati on.

View Figure

Figure 34.18 A: Absorber assembly that is partly
disassembled. B: The APL and unidirectional valves are
also disassembled. The assembly can now be steam
sterilized.

Mapleson Systems
Af ter use, Mapl eson systems should be disassembl ed and the components cl eaned.
Met al components can undergo autocl avi ng. Rubber and pl astic parts can undergo
gas or pl asma st eril i zat ion or a l i qui d chemi cal agent may be used. I n many cases,
di sposabl e tubi ngs are more cost-ef fective.
The Bai n and Lack coaxi al ci rcui ts present problems wi th cleani ng because of the
central t ubi ng. It i s best to use disposabl e ci rcui ts.
Adaptors
Adaptors that are used near t he pati ent are contami nat ed i n a high percentage of
cases. Af ter use, t hey shoul d be ri nsed and then soaked in a sol uti on of detergent
and water. They may be washed manual l y or i n a washi ng machine. Rubber and
pl ast i c adaptors may be steri l i zed wi t h EO, pl asma steri l i zat i on, or in a l i qui d such
as gl ut aral dehyde. Metal adaptors may be aut ocl aved or pasteuri zed.
Scavenging Equipment
A sat isfactory method of treati ng scavengi ng equipment i s to wash t he devi ce i n a
detergent sol uti on monthl y and to change the hoses that connect the devi ce to t he
breat hi ng system and vent il ator at t he same t i me (221). Li nt may accumul ate i n the
ai r i ntake val ves on closed scavengi ng interfaces. These val ves shoul d be removed
and cl eaned f requent l y.
P. 988


Face Masks
Face masks are among t he most heavil y contami nat ed pi eces of equi pment .
Because of thei r proxi mi t y t o the pat ient, i nf ect i on transmi ssion i s a def ini te
possi bi li ty. For obvi ousl y cont aminated cases, di sposable masks should be used.
Asepsi s shoul d be practi ced when usi ng face masks. A face mask shoul d not be
al l owed to drop onto t he f l oor or be exposed t o obvi ous contami nat ion. Af ter use,
t he mask shoul d be kept near t he pat i ent 's head or wi th t he di rt y equi pment. I t
shoul d not be al l owed t o cont ami nat e cl ean equipment.
Reusabl e face masks shoul d be cl eaned then steri l i zed or subjected t o hi gh-level
di si nf ect ion. I mmedi atel y af t er use, the connector shoul d be removed and the mask
ri nsed, t hen soaked and scrubbed. I t may be cl eaned automat ical l y i n a washi ng
machi ne. Masks should al ways be thoroughl y ri nsed and dri ed.
Wi th gas steri l i zat ion, t he mask can be kept steri le f or l ong peri ods of t i me.
Aerat ion must be adequate; otherwi se, facial burns may resul t . Most automati c EO
steri l i zers empl oy a vacuum at least once duri ng the steri l i zat i on cycl e. Thi s
vacuum may cause the pneumati c cushion on the mask to be damaged. Thi s can be
prevented by removing t he pl ug that seal s the cushi on or by usi ng a steri l i zer that
does not have a vacuum phase.
St eam autocl avi ng i s someti mes used f or f ace masks. As wi t h EO steri l i zati on, i t
i nvol ves a vacuum phase t hat wi l l damage the i nf l ated cushi on, so the pl ug shoul d
be removed bef orehand. Pasteuri zat ion has been used f or f ace masks.
Li qui d chemical agents are of ten used t o disinf ect or steri l i ze f ace masks. Thorough
ri nsing i s i mport ant to remove resi dual agent. Cracks in t he mask cushi on can all ow
l i quid agent t o ent er t he ai rspace. When pl aced on a pati ent ' s f ace, t he l i qui d can
be squeezed out , possi bl y i nto the eyes.
Head Straps
Af ter use, head st raps shoul d be subj ected t o cleani ng wi th a detergent , then
soaked i n a disinf ectant sol ut i on or steri l i zed usi ng EO or pl asma steri l i zat i on.
Airways
Ai rways shoul d be t reated as cl ean obj ects and not al l owed to drop onto the f l oor.
Most ai rways are now di sposable. They shoul d be pl aced i n a sui tabl e cont ai ner.
As soon as possi ble af ter use, reusable ai rways shoul d be ri nsed wi t h col d water,
t hen pl aced i n a sol ut ion of wat er and detergent. They can be washed manual l y or
i n a machi ne. They shoul d be t horoughl y ri nsed t o remove residual detergent.
Pasteuri zat i on, l i qui d chemi cal disinfecti on, and EO and pl asma steri l i zat ion have
been used f or ai rways. Rubber ai rways may be aut ocl aved, but this wi l l shorten
t hei r useful l i fe.
Rigi d Laryngoscopes
Di sposabl e laryngoscopes are di scussed i n Chapter 18. Ei ther t he bl ade or t he
bl ade and handl e may be di sposable (228).
Contami nat i on of ri gi d l aryngoscope bl ades and handl es is common, and there are
reported cases of cross i nfect ion ari si ng f rom contami nated l aryngoscopes
(229, 230,231,232, 233, 234,235, 236, 237,238).
Laryngoscopes shoul d be stored under cl ean condi ti ons. Disposabl e covers that f i t
over the handl e and/or blade are avai labl e (239,240,241) (Fi g. 34.19).
Af ter use, the handl e and bl ade are cont ami nated and shoul d not be placed on a
cl ean surf ace. The gl ove that the operator i s weari ng may be i nverted over the
bl ade and handl e t o prevent spreadi ng contami nat i on (242,243).
There i s no consensus on what consti tutes adequate bl ade or handle processi ng,
and the met hods employed range f rom superf i ci al cl eaning t o steri l i zati on
(24,244,245,246). If pri ons are a l i kel y contami nant, disposabl e bl ades shoul d be
used, i f possi bl e (238).
Af ter use, the outside of the handl e shoul d f i rst be wi ped clean wi t h wat er and
detergent, t hen wi th al cohol . The batteri es (and bulb chamber, i f present) must be
removed pri or t o disi nf ecti on or st eril i zat i on unl ess t he handle i s desi gned to be
wat erproof . The bat teri es must be removed i f the method of steri l i zati on i ncl udes a
vacuum cycle, pressure, or heat. Af t er the bat teri es are removed, t he handle can be
steri l i zed by usi ng steam, pl asma, or gas steri l i zat i on.
As soon as possi ble af ter use, the blade shoul d be ri nsed, then i mmersed i n water
and an enzymati c detergent . I t should be washed gent l y but thoroughl y by usi ng a
sof t brush, wi th part icul ar at tenti on to t he area around t he bul b or l ight bundle.
Cl eani ng i s of t en i nadequate (24,232, 233). Ul trasoni c cleani ng is usual l y not
recommended. Af ter cl eaning, t he bl ade shoul d be ri nsed and dri ed.
Bl ades may be steri l i zed wi t h EO, steam, pl asma, or t reated wi t h l i qui d chemi cals.
There i s one reported case i n which t ongue swel l ing was thought to be caused by a
react i on to gl ut araldehyde t hat was used on the l aryngoscope blade (247). The
St eri s system can be used (248). EO i s appropri ate for most blades, provided a
t emperat ure of 180F and pressure of 8 pounds per square i nch are not exceeded.
No aerat ion i s requi red. Some bl ades can be st eril i zed by using steam. Fl ash
steri l i zat ion i s not recommended.
Aut ocl aving f i ber-opti c bl ades may cause detri mental ef f ects t o the f ibers t hat
t ransfer l i ght (64,249, 250). Fi ber-opti c bl ades shoul d not be i mmersed i n col d water
af ter autocl aving, as the fi ber-opti c bundles may crack.
P. 989



View Figure

Figure 34.19 Disposable laryngoscope covers. A: Covering
for blade only. (Picture courtesy of Blue Ridge Medical,
Inc.) B: Covering for both blade and handle.

Flexi ble Endoscopes
Endoscopes are semi cri t ical devi ces that carry a real ri sk t hat i nf ect i on may be
t ransmi t t ed to pati ents
(88,101,108,251,252,253,254,255,256,257,258,259,260,261,262,263,264,265,266,2
67,268,269,270, 271,272, 273, 274,275, 276, 277,278,279,280, 281,282, 283, 284,285, 28
6, 287,288,289, 290, 291). Pseudoinfecti ons have al so been report ed
(283, 289,292,293, 294, 295,296, 297, 298,299, 300,301,302,303,304).
Onl y endoscopes t hat are submersibl e shoul d be used. Disposabl e sucti on val ves
may help t o reduce the ri sk of cross i nf ect i on (251,266,268). A fi ber-optic
endoscope shoul d be stored i n a clean area wi t h the di stal t i p protected.
A f i berscope is compl ex, f ragi le, and heat-sensi ti ve, whi ch makes i t di ff i cul t to
cl ean and disinf ect or steri l i ze. I t may be best to have i t decont ami nat ed in an
endoscopy uni t . Pressure (i .e., l eak) t esti ng shoul d be perf ormed bef ore i mmersi on
t o avoi d costl y damage t hat can occur duri ng the cleani ng process (253). Speci al
l eakage testers are avai l abl e for thi s purpose. I f a leak is detected, t he endoscope
shoul d be removed f rom servi ce and t he manuf acturer consul ted.
I mmedi ately af ter bei ng removed f rom t he pat ient , the exteri or of the f i berscope
shoul d be wi ped wi t h a disi nfectant. The endoscope should not be squeezed t i ght l y
(257). Al l channel s shoul d be f l ushed wi t h wat er and/or an enzymati c detergent . I t
i s i mport ant t hat t he enzymat i c sol uti on i s properl y di l ut ed; otherwi se, t he
endoscope may be damaged (257).
Af ter leak testi ng, the f iberscope shoul d be i mmersed i n an enzymat i c detergent
solut i on. I t i s i mport ant t o pl ace a wat er-resi stant cap over the vi deo connector
before submersi on (257). Al l channels shoul d be f i l l ed wi th t he sol ut ion and al l owed
t o soak f or t he ti me stated on the l abel (usual ly 2 to 5 mi nutes). The f i berscope
shoul d then be cleaned. Special cl eani ng devi ces that can be inserted i nt o the
channels are avai l abl e. Short strokes should be used to gradual l y i ntroduce the
brush. If si gni fi cant resistance is f el t, one shoul d proceed f rom the other di recti on
rather than f orce t he brush t hrough a bl ocked channel . If a cleani ng devi ce cannot
be passed easi l y t hrough a channel , the scope shoul d be sent f or repai r. The
solut i on should be suct ioned through al l channel s unt i l they are f ree of debri s.
Sucti oni ng f luid and ai r al ternat el y removes more debri s f rom lumens than
sucti oning onl y f luid (101). Speci al ki ts to check f or bl ood resi due i n the channel
are avai l abl e.
Fol l owi ng cl eani ng, the f i berscope and al l of i ts channels shoul d be thoroughl y
ri nsed wi t h steri l e water or ri nsed wi th tap water then alcohol . Tap water ri nsi ng
t hat i s not f ol lowed by al cohol ri nsi ng has been l i nked t o contami nat i on (281).
Endoscopes shoul d be hung vert ical l y to al l ow any remai ni ng f l ui d to drai n out of
t he i nserti on tube (101).
P. 990


Fol l owi ng cl eani ng, f i berscopes shoul d be st eri l i zed or recei ve hi gh-level
di si nf ect ion. Current data suggest that hi gh-l evel disinf ecti on provi des the same
degree of saf et y as st eri l i zati on (88). If the scope i s t otal l y i mmersible, chemi cal
di si nf ect ion can be used. Al l l umens and/or channel s must be f i ll ed.
Gl utaral dehyde, hydrogen peroxi de, and OPA are ef f ect ive disinfectants
(101, 120,305). Af t er di si nf ect ion, the device shoul d be thoroughl y ri nsed wi t h
steri l e wat er, f ol l owed by 70% al cohol (298). The Steris system, using speci al
adapt ors f or t he lumens (Fig. 34.10), consi stentl y st eri l i zes f iberscopes, even wi t h
protein and sal t i n the narrow l umen (110, 113,114,309,310).
Aut omat ed endoscope reprocessors t hat perf orm disi nfecti on and ri nsi ng are
avai l able, but some have been impl i cated i n i nf ect i ons and pseudoi nfecti ons
(267, 269,276,277, 278, 292,293, 294, 295,296, 306,307,308). Al l automat ic
reprocessi ng systems have f i l trat i on syst ems (261). It i s i mport ant that the f i l t ers
are changed regul arl y. The scope shoul d be al l owed t o cool about 5 to 7 minutes
af ter i t has been processed (257).
Gas steri l i zat ion may also be used. It is ef fect ive but wi l l keep t he f i berscope out of
servi ce f or a l ong period of ti me. Some sucti on val ves can be autocl aved (266).
Most f i berscopes have lumens that are too narrow and t oo long for plasma
steri l i zat ion.
Styl ets
Many bel i eve t hat st ylets shoul d be kept steri l e because they are pl aced insi de a
steri l e tracheal tube. Reusabl e gum elast ic bougi es are f requentl y contami nat ed
(311, 312,313,314). Steri l e disposabl e styl et s are avai labl e (315), but they may not
work as wel l as mul ti pl e-use ones (316).
As soon as possi ble af ter use, the stylet shoul d be ri nsed and t hen i mmersed in
wat er and disi nfectant. Styl ets, dependi ng on thei r const ruct ion, may be
autocl aved, gas or pl asma steri li zed, or t reated wi t h l i qui d chemi cals. Of the l i qui d
chemical agents, al cohol and glutaral dehyde are used most f requent l y. Peracet i c
acid and hydrogen peroxi de can al so be used. If EO i s used for steri l i zati on, no
aerat ion ti me i s requi red unl ess the stylet is i n a package.
Tracheal and Double-lumen Tubes and Connectors
A tracheal or doubl e-l umen tube is pl aced into an area of t he body that is normal l y
steri l e. I t shoul d be kept f ree of contaminati on unt i l used. Di sposabl e steri l e tubes
are avai l abl e at such a l ow cost that i t usual l y i s not cost -eff ect ive to use reusabl e
ones. The t ube shoul d be kept in i ts package unt il j ust bef ore use, and the pat ient
end shoul d not be touched. Studi es indicate t hat tracheal t ubes can be used f or up
t o 28 days af ter bei ng opened but not removed f rom the package (317,318, 319).
Lubri cants, st yl ets, and suction catheters f or use wi t h t hese tubes should be f ree
f rom contami nat i on. I f possi bl e, t he tube shoul d not touch any part of the mouth or
pharynx during i nsert i on.
A hi gh percent age of tracheal t ubes show contami nati on wi th bl ood af ter use (320).
I f the t ube i s reusable, secret ions should be prevented f rom drying by ri nsi ng and
t hen soaki ng i n a detergent sol ut ion. Bef ore i mmersi on, t he i nfl ati ng tube shoul d be
pl ugged. The connector and any tape should be removed. The t ube shoul d then be
washed i nsi de and out, t aki ng care not to catch the cuff on any sharp obj ect .
Tracheal tubes may also be cleaned i n a washi ng machine.
The t ube shoul d be ri nsed thoroughl y, making cert ai n to f lush the l umen. Thorough
dryi ng is i mportant bef ore chemi cal di si nfect i on or gas steri l i zat ion. Unl ess the tube
i s to be steam aut ocl aved or pasteuri zed, the connect or shoul d be rei nserted af ter
cl eaning.
EO is a popul ar method f or steri l izing t racheal t ubes. The end of the i nf lati ng t ube
shoul d be open. Wi th repeated gas steri l i zat i on, rubber and some pl asti c tracheal
t ubes sof t en and ki nk more easi l y. Spi ral l atex tracheal tubes should not be gas
steri l i zed wi th a vacuum appl i ed during the steri l i zi ng cycle, as thi s can cause the
l atex layers to separate.
St eam st eri l i zati on has been used in t he past for certai n tracheal t ubes. Repeat ed
autocl aving makes them more l ikel y to ki nk and causes a decrease i n the el asti ci t y
of t he cuff s. Spi ral embedded tubes are especi al l y suscepti bl e to damage f rom
autocl aving. Most of t he newer tracheal t ubes t hat are made of pl ast ic wi l l not
wi thstand the hi gh temperat ures invol ved i n autocl avi ng.
Li qui d chemical di si nf ect ion has been used f or tracheal t ubes. The i nf l ati ng t ube
shoul d be cl osed duri ng immersi on to prevent t he solut i on f rom enteri ng t he cuf f .
The t ube wi l l f requent l y f loat and needs to be hel d down wi th an obj ect that does
not di stort i t or prevent t he solut i on f rom reachi ng al l surf aces. Thorough ri nsi ng is
necessary af t er use of al l chemical agents except al cohol . Pseudomembranous
l aryngi ti s has been li nked to di si nf ecti on of t racheal tubes wi t h gl ut araldehyde.
Sucti on Catheters
Sucti on catheters are disposable devi ces that are di scarded af ter use unl ess used
i n a closed sucti on system (Chapter 3). A contaminated suct ion catheter that may
st i l l be needed f or a pati ent should be ri nsed wi th steri l e wat er and t hen returned t o
i ts packaging af t er use, not pl aced under t he mat tress of the operati ng room tabl e
or draped over the carbon di oxi de absorber. At the end of the case, i t shoul d be
di scarded.
Supraglottic Airway Devi ces
Up to 76% of laryngeal mask ai rways (LMAs) have been f ound to have occul t bl ood
on them af t er use (320, 321, 322,323).
P. 991

There have been no cases of di sease t ransf erred between pat ients by reuse of a
steri l i zed LMA reported (324).
Di sposabl e supragl ot tic ai rway devi ces are avai lable (325). They may be more
economi cal to use than reusabl e devi ces when the costs of cl eani ng and
steri l i zat ion are f actored al ong wi t h the number of reuses that a devi ce wi l l t ol erate.
The manufacturer' s di recti ons wi th regard to cleani ng and steri l i zi ng supragl ot ti c
ai rway devi ces shoul d be consul ted. Soaki ng the reusabl e supraglot t ic ai rway i n a
di l ute (8% t o 10%) soluti on of bi carbonate bef ore cleani ng wi l l hel p to dissol ve
secreti ons (326). The i nf l ati on val ve shoul d not be exposed to any fl ui d (327). The
supraglott ic ai rway shoul d be cl eaned i n di lut e bi carbonate or mi l d detergent
solut i on unt i l al l vi si bl e f orei gn materi al i s removed. A pi pe-cl eaner t ype brush
shoul d be inserted through the di stal apert ure(s). Studi es show that compl et e
removal of protei ns f rom an LMA i s of ten not achi eved (235, 321,328,329, 330,331).
Ul trasonic cleani ng may be more eff ective than other met hods of cl eani ng t o
remove protei naceous materi al f rom the most inaccessi bl e areas of the mask (321).
Suppl ementary cl eani ng wi t h potassium permanganate wi l l signi f i cantl y reduce t he
amount of prot ei n deposi ts (331). The LMA shoul d be ri nsed wi t h water and then
dri ed.
Aut ocl aving i s the onl y recommended method of steri l i zat ion f or a reusable LMA.
Temperatures up t o 134C (273F) may be used (326, 327). Hi gher temperatures
can cause t he tube to become bri t t l e and f ragment . I t may be preferable t o use a
steri l i zer wi thout a vacuum phase (332). As much ai r as possi bl e shoul d be
removed f rom t he cuf f short l y before autoclaving (333,334). Resi dual ai r wi l l
expand i n the heat and may damage the cuf f , val ve, or pi lot bal l oon (335). Af ter
steri l i zat ion, t he devi ce shoul d be lef t i n i ts package unti l j ust pri or t o use (336).
Li qui d chemical agents shoul d not be used on an LMA, as they are adsorbed onto
t he si l i cone and can cause pharyngi ti s and l aryngi t is as wel l as shorten the l if e of
t he LMA (326,337). Gas steri l i zati on must not be used.
The manufacturer' s i nstruct i ons shoul d be consul ted f or i nst ruct ions on cl eani ng
and steri l i zi ng ot her reusabl e supragl ot ti c devices.
Spray Appli cators
Mul ti dose spray appl i cat ors are f requent l y contami nated (275,338). Consi derati on
shoul d be given to using disposabl e devi ces. If a mul t idose appl i cator i s used, t he
nozzl e should be cl eaned and di si nf ected af ter use.
Resuscitation Bags
Resusci t ati on bags have been i mpl i cated as t he source of cross i nf ect ion (339).
Thei r rel at ivel y l ow cost probabl y makes the disposable ones cost-ef fecti ve. The
pri mary source of contami nat i on is the val ve. Thi s shoul d be disassembled and
cl eaned and, if possibl e, disinf ected or steri l i zed af t er each use or on a regular
basis i f dedi cated to a si ngl e pat ient . The manufacturer' s i nstructi ons shoul d be
f ol l owed.
Blood Pressure Cuffs, Tubing, and Stethoscopes
Bl ood pressure cuff s are f requentl y contami nated wi th bl ood and can be a reservoi r
of bacteri a (178, 340). Spraying cuff s wi th a topical di si nf ect ant wi l l reduce thei r
bacteri al l oad (340). Protect ive covers for cuf fs are avail abl e (341). The arm can be
wrapped wi t h sof t cot ton bef ore the cuf f i s appl i ed to prevent skin contact.
Reusabl e cuf f s shoul d be cl eaned wi t h a det ergent at the end of the day and when
vi si bl y cont ami nat ed (2). Peri odi c di si nf ection or st eri l i zati on i s advi sable. Most
cuff s can be washed af ter the bl adder i s removed. Af ter dryi ng, the cuff may be
subject ed to gas steri l i zat i on or chemical di si nf ect i on. Nonfabri c cuf f s can be
steri l i zed by usi ng plasma steri l i zati on.
The stethoscope i s a pot ent ial source f or t ransmi tt i ng bacteria
(342, 343,344,345, 346, 347,348). Si ngl e-use covers are avai l abl e (342).
St ethoscopes can be washed wi t h wat er and wi ped wi th al cohol . Earpl ugs can be
cl eaned wi t h an al cohol -saturated appl i cator.
Pulse Oxi meter Probes and Cables
Pul se oxi meter probes and cabl es are f requentl y contami nated wi th bl ood and
organisms (178,349,350). Disposabl e probes may be reprocessed f or reuse by
pulse oxi meter manuf acturers and heal th care i nsti tut i ons. Reprocessi ng may be
cost-ef fecti ve (349,351). Reusabl e probes and cables shoul d be cl eaned at the end
of t he day or when vi si bl y contami nated by wi pi ng wi t h al cohol or t he cl eaning
solut i on recommended by the manuf act urer (2). Cabl es can be steri l i zed by using
pl asma steri l i zat ion.
Temperature Monitors
Temperature sensors shoul d be cl eaned wi t h a di si nfectant af ter use (2). Speci al
soak st ati ons f or rectal probes are avai l abl e. The maj ori t y of temperat ure sensors
are disposabl e.
Transesophageal Echocardiography Probes
Transesophageal echocardi ography probes are easi l y damaged (352). They shoul d
be cl eaned caref ul l y and t hen soaked i n di si nf ectant . A soak stat i on shown i n
Fi gure 34. 20. One cont ai ner i s f or the di si nf ect ant , and the second one is used f or
t he i ni t i al ri nse. Fumes are drawn away f rom t he operator and i nto a special f i l t er,
where they are neut ral i zed.
An automat ed reprocessor f or ul t rasound probes that complet es the di si nf ecti on
and rinse cycles in l ess than 8 mi nutes i s avail able. It uses a f resh bott l e of a
P. 992

gl ut araldehyde-based di si nf ectant for each cycl e. This i s pierced inside t he
reprocessor, avoiding spl ashes and spi l l s. A vapor management system adsorbs
chemical vapors.

View Figure

Figure 34.20 Soak station for transesophageal
echocardiography probes.

A chemi cal burn secondary to a probe t hat may not have been properl y processed
has been reported (102).
Other
Obj ects that do not contact the pati ent but are contacted by the anest hesia
provi der' s f i ngers (t he pen used to record dat a, the computer keyboard, t el ephone,
nerve st i mul ators, i nf usi on devi ces, etc.) shoul d be consi dered sources of
contaminati on. A simpl e device f or a pen has been descri bed (353). Computer
keyboards can be covered wi t h a pl asti c cover that can be changed or cleaned.
Adequate level s of saf et y for medi cal equi pment surfaces may be achi eved by
t horough cl eani ng f ol l owed by appl i cati on of an i ntermedi ate- or l ow-l evel germi ci de
(8). Adequate safety l evel s f or surfaces can be achi eved by mai ntaining t hem in a
stat e of cl eanl i ness by usi ng wat er and a detergent or a hospi tal -grade
di si nf ectant /detergent t hat i s designed f or general housekeepi ng purposes. Onl y
when t here has been a signi f i cant spi l l of bl ood or other potenti al l y i nf ect ious body
f lui d shoul d the added use of an intermedi ate-l evel chemical di si nf ectant be
necessary.
Preventing Occupational Infection
I n 1991, OSHA mandat ed uni versal precauti ons. These are now part of st andard
precauti ons. These precauti ons requi re t hat gloves and other barri er prot ecti on are
used when heal th care personnel perf orm tasks that may resul t in exposure to
bl ood and other body f l ui ds, secreti ons, excreti ons, non-i ntact ski n, or mucous
membranes (2, 12, 354). For pat ients wi t h specif ic i nf ecti ons, addi ti onal
t ransmissi on-based precaut i ons are appl i ed. These are desi gned to reduce t he ri sk
of ai rborne, droplet, or contact transmi ssion of pat hogens. Annual educat ional
programs on the use of precauti ons are requi red f or empl oyees. Unf ortunat el y,
noncompl i ance wi t h t hese procedures i s common.
Barriers
Appropri at e barri er precauti ons i ncl uding gl oves, f l uid-resi st ant masks, face
shiel ds, eye protect i on, and gowns or l ab coats must be used when contact wi th
body f l ui ds, mucous membranes, or broken ski n i s possi ble (2,355, 356). I t i s
i mportant to remove or change these barri ers i mmediat el y af ter use and before
t ouchi ng uncontami nat ed i tems or goi ng to another pati ent (178,216,357). The use
of gl oves can reduce needlesti cks, percutaneous i nj uries, and surf ace
contaminati on i n the anesthesi a workpl ace (358). I t shoul d be noted that gl ove
protect ion i s compromi sed wi t h each acti vi ty perf ormed and especi al l y when
adhesive tape i s torn, unl ess adhesi ve-spari ng moi sturi zi ng cream is used (359).
Theref ore, i t i s i mport ant that hand di si nf ecti on be perf ormed immediatel y af ter
removi ng gl oves. A f ul l -f ace disposable pl asti c shi el d is best f or eye protect i on.
Goggles or prescri pti on gl asses are l ess adequat e. I t shoul d be noted that the edge
of t he f ace shiel d could be a source of injury t o t he pat i ent (360).
Hand Hygiene
Anesthesi a personnel can harbor hi gh bacteri al counts on thei r hands
(361, 362,363). Hand hygiene should be perf ormed af t er t ouching bl ood or other
body f l ui ds, secreti ons, excreti ons, mucous membranes, broken skin, wound
dressi ngs, or cont ami nat ed i tems; pri or t o and between pat i ent contacts; and at any
ot her t i me when microorganisms might be transferred to ot her pati ents, staff , or
envi ronments. The use of gl oves does not precl ude t he need f or proper hand
t reatment. I f the hands
P. 993

are vi si bl y soi l ed, hand washi ng shoul d be perf ormed. If t here i s no vi si bl e soi l i ng,
rubbi ng wi th an al cohol -based gel or solut i on wi t h persi stent acti vi t y i s more
conveni ent and ef f ect ive (103,364, 365, 366). Some hand sol ut i on manuf acturers
recommend a soap-and-wat er hand wash aft er ei ght to ten consecuti ve appl i cat i ons
t o remove resi dual and organi c contami nants. A di sadvantage of al cohol -based
products i s that they are f l ammabl e (367). However, a study publ i shed i n 2003
f ound no f i res at tri butabl e to hand sani t i zers, and the Nati onal Fi re Prot ecti on
Associ at ion now al l ows alcohol -based hand sani t i zer di spensers i n corri dors and
ot her publ ic areas, provi ded cert ai n restricti ons are observed (368). If a di spenser
i s mounted i n a hal l way, the corri dor must be at l east 6 f eet wi de. The di spenser
can proj ect up to 6 i nches f rom the wal l and must be i nst al led above handrai l
hei ght.
Hand washi ng shoul d be perf ormed by fi rst wet t i ng t he ski n, then addi ng the soap
or cl eansi ng agent . Tepi d wat er shoul d be used. The hands shoul d be vigorousl y
rubbed together f or at l east 15 seconds, coveri ng and generat ing f ri cti on on al l
surf aces, then thoroughl y dried. When using an alcohol -based rub, rubbi ng shoul d
be conti nued unti l the hands are dry. If the hands dry i n l ess than a minute, more of
t he wat erl ess rub shoul d be used. It i s i mportant to make cert ai n that the rub i s
appli ed to al l parts of the hand. Studi es show that this i s f requentl y not done (369).
Preventing Needlesticks
Percutaneous i nj ury, especi al l y a needl est ick wi t h a hol low needl e, i s associ ated
wi th t he ri sk of t ransmi tt i ng bl oodborne i nf ect i on (370,371,372,373). Used needl es
shoul d not be recapped, bent , or broken by hand or ot herwi se manipul ated by usi ng
any t echni que that i nvolves di recti ng the poi nt t oward any part of the body. I f i t is
necessary to recap needles, a si ngl e-handed techni que i n whi ch the needl e i s not
di rected toward an unprotected hand or a mechani cal protective devi ce should be
used (2,374). Puncture-resi stant sharps containers must be avail abl e in al l work
l ocat i ons and shoul d be l ocated as cl ose as possible t o where sharps are used
(375).
Routi nel y weari ng gloves resul ts i n a si gni f i cant reduct i on in needl est i ck and
percutaneous i nj uries (358). Doubl e gloving off ers increased protect ion (376,377).
Double-gl ove systems that use a col ored i nner gl ove make i t easi er t o detect gl ove
perf orati ons (378).
Ef f orts t o reduce needl est i cks have resul ted i n a variety of new products (371,379).
Protect ive devi ces such as shiel ded needl es, protecti ve l ancets, and needl el ess
i ntravenous l i ne connectors can pl ay an i mportant rol e i n prevent ing needl esti cks.
St rai ght needl es that are used to suture central venous access (CVA) and
pul monary art ery (PA) catheters are associated wi t h f requent injuri es. The CDC
recommends usi ng curved, i nst rument -held suture needl es (380).
Emergency Ventilation Devices
When resusci tat i on is perf ormed, mouthpi eces, resusci tati on bags, or other
venti l ati on devi ces shoul d be used as an al ternat ive t o mouth-to-mouth venti lati on.
Personnel with Cutaneous Lesions
Heal th care workers wi th breaks in t he ski n or exudat i ve lesi ons shoul d ref rain f rom
di rect pati ent cont act and f rom handl i ng pati ent care equi pment unless the open
area can be protected by a barri er t hat is i mpermeabl e to bl ood and body f l uids
(381). One i nvesti gat i on suggest ed that t wo pati ents became i nfected wi t h HBV
f rom a heal t h care worker wi t h severe exudati ve dermat i t is on t he hands (382).
Specific Disease States
Tuberculosis
Out breaks of mul t i drug-resi st ant TB have heightened concern about nosocomi al
t ransmissi on (175,380, 383,384, 385, 386,387). M. tubercul osi s is spread pri mari l y
vi a dropl et nuclei . Because of t hei r smal l size, dropl et nucl ei remai n suspended i n
ai r currents and can spread over great di stances. TB i s l ess i nf ecti ve af ter therapy
has begun.
Consi derati on shoul d be given to desi gni ng one operati ng room to handle pati ents
wi th TB. To prevent suspended i nf ecti ous dropl ets f rom l eaving the operati ng room,
t he i deal operati ng room woul d have an anteroom that has a negat ive pressure
bet ween t he corri dor and operati ng room (383).
An i sol at ion room is desi rable. It should have negati ve pressure t o the surrounding
rooms, outside ai r exhaust , an ant eroom to act as an ai rl ock, and ul t raviolet l i ghts
t o ki l l M. tubercul osis i n inf ecti ous droplets (383). The caregiver i n t hi s area wi l l
need to have adequat e suppl i es readi l y avai l able so t hat i t wi l l not be necessary to
make many trips i nt o the main recovery area.
The CDC has publ ished gui del i nes f or preventi ng M. t uberculosis t ransmi ssi on i n
heal th care faci l i ti es, includi ng the operati ng room sui te (383,385,388). Respi ratory
i sol at ion i s requi red f or al l persons suspected or known t o have acti ve pulmonary
TB unt i l the diagnosis has been ruled out or t herapy has been i ni ti at ed and i t can
be demonst rated that t he i ndi vi dual is no l onger i nfecti ous. The pati ent wi t h TB
shoul d be pl aced i n a room that has negat ive ai r pressure, 12 or more ai r changes
per hour, and discharges ai r di rect l y to the outside or high-eff iciency part i cul ate
(HEPA) f i l trat i on of ai r pri or t o reci rculat i on. Ul t raviolet l i ght can be used as an
adj unct
P. 994

t o vent il ati on (385,387). A heal th care f aci l i t y wi t h an obstet ri cal uni t shoul d have a
TB i sol ati on room that i s properl y equipped for obstet ri cal care.
El ect i ve procedures shoul d be del ayed unti l the pati ent i s no l onger i nfecti ous. A
pati ent wi t h TB who i s undergoi ng surgery should be t ransport ed to the operat i ng
room weari ng a surgi cal mask (383). I ndi vi dual s cari ng f or the i nf ect ed pati ent ,
i ncl udi ng t hose t ransport i ng the pati ent , shoul d wear respi ratory protect ion devi ces
t hat meet CDC cri teri a for f i l t rati on and f i t (385,387). Radi ostethoscopes can be
used for auscul tat i on (389). Standard surgical masks are general l y not sui t abl e.
The operati ng room shoul d have an anteroom t hat provi des some i sol at i on f rom
outsi de hal l ways and negati ve ai r pressure rel ative to t he corri dor and ot her
operati ng rooms (390). Traf f ic i n the room and openi ng and cl osi ng doors duri ng
surgery shoul d be li mi ted. The pat i ent shoul d be the l ast case of the day or shoul d
have the procedure perf ormed at a t ime when mi ni mal personnel are present (214).
Si gns shoul d be pl aced on t he operati ng room doors t o mini mi ze traf f i c.
Unnecessary or overstocked equipment shoul d be removed f rom the room. A HEPA
f il ter should be placed bet ween the breathi ng system and the pat i ent (383). Duri ng
postanest hesi a recovery, t he pat ient shoul d be placed i n a pri vate room that meets
t he recommended standards f or TB isol ati on rooms. Since most i nsti tuti ons do not
have such an i sol ati on room i n the surgical sui te, an al ternati ve i s to ut i l i ze
postanest hesi a care uni t (PACU) personnel to provide post operat ive care i n the
operati ng room or i n the pat ient' s i sol ati on room.
Equi pment that has been used f or a pat ient wi th TB shoul d be steri l i zed or undergo
hi gh-l evel disi nfecti on. In general , cul turi ng anesthesi a equi pment f or the presence
of t ubercle baci l l i i s not i ndi cated.
Through thei r part i cipati on i n procedures that mi ght induce coughi ng, anesthesi a
provi ders are at ri sk of acqui ri ng TB. The CDC recommends peri odic tubercul i n
screeni ng of al l heal t h care workers, wi th retest ing on a regul ar basi s (385). If a
posi t i ve test i s recorded, a chest radi ograph shoul d be obt ai ned and
chemoprophyl axi s i nsti tuted, i f needed.
Bloodborne Pathogens
Hepati t is B vi rus (HBV), hepati t is C vi rus (HCV), an human i mmunodefi ci ency vi rus
(HIV) can be transmi t ted t hrough bl ood and ot her body fl ui ds. Anesthesi ologi sts
have an increased risk of death f rom HIV and vi ral hepat i ti s (391). The great est ri sk
of exposure i s a needlesti ck i nj ury. Large-gauge, holl ow-bore needles wi t h visible
bl ood and deep penet rat i on i ncrease the ri sk (380). The risk of infecti on af ter a
percutaneous exposure t o blood carryi ng HBV, HCV, and HI V is 10% to 30%, 2% to
4%, and 0.3%, respect i vel y (175). Contami nat ed mul ti dose vials have been
i mpl i cated i n nosocomi al i nf ect i ons wi th HBV, HCV, and HI V (381,392). A breach i n
procedure by any one person can pl ace mul t i pl e pat i ents at ri sk.
Devices contami nated wi th bl ood f rom pati ents inf ected wi t h a hepati t i s vi rus or HIV
shoul d be steri li zed or undergo high-l evel di si nf ect ion (68).
HBV can survive f or a l ong t ime on i nani mate obj ects (7). Fi f ty percent of surf aces
f rom whi ch hepati t is B anti gen can be recovered do not have vi si bl e bl ood
contaminati on. Mul t i ple studies have shown that anesthesi a provi ders are at ri sk for
acqui ri ng HBV. The pri mary strategy f or preventi ng HBV i nfecti on i s immuni zati on
wi th hepat i ti s B vacci ne, which is recommended f or al l anesthesi a personnel who
do not have i mmuni ty. OSHA regul ati ons requi re empl oyers to provide t he hepati t is
B vacci ne at no cost i f occupat i onal exposure i s expected.
HCV is t ransmi tt ed by respi ratory secreti ons as wel l as blood (167). Transf er of
HCV f rom anesthesi a personnel to pati ents and pati ents to anest hesi a providers
has occurred (172,392,393). Transmi t tal has been att ri buted t o reusi ng needles and
syri nges (215,381).
HCV inf ecti on i s a maj or cause of chroni c l iver di sease and hepatocel l ul ar cancer
and poses a consi derabl e ri sk f or anest hesi a personnel . It is more common i n
heal th care workers than the general populati on. At present, there is no vacci ne
avai l able t o prevent i nf ect i on, nei ther i s t here eff ecti ve postexposure prophylaxi s.
Current recommendati ons f rom t he CDC do not suggest that HCV-i nf ected heal th
care personnel be restricted f rom pat i ent care duti es as l ong as they f ol low st ri ct
aseptic t echniques and standard precaut i ons (394, 395).
HI V i s relat i vel y unstable i n the envi ronment and i s rapi dly i nacti vated by a wi de
range of chemi cal germi ci des, even those that are cl assi f ied as l ow l evel . There i s
a case where HI V was transmi t ted f rom a pati ent to an anesthesi ol ogi st (396).
Creutzfeldt-J akob Disease
CJD i s one of a group of neurodegenerat ive disorders caused by pri ons
(111, 397,398,399, 400, 401,402). It i s one of a class of di seases known as
t ransmissi bl e spongi f orm encephal opathi es because of the pathol ogi c changes i n
t he cent ral nervous system. These diseases are characteri zed by i ncubat ion
peri ods rangi ng f rom mont hs to years and fol l owed by a rapi dl y progressi ve
dementi a. The di sease is i nvari abl y fat al once cl i ni cal symptoms have appeared.
Currentl y, t here are no known t reatments t o i nhibi t i ts progressi on or outcome.
There i s no evi dence that heal th care workers are at i ncreased occupat i onal ri sk for
CJD.
The discovery that pri ons can l urk i n body organs l ong bef ore people exhibi t signs
of disease has the al armi ng i mpl i cat ion t hat mul t i pl e-use devi ces used on
P. 995

i nfect ed individual s can t ransmi t the di sease. The extensive l ymphoreti cular
i nvol vement that i s present i n CJD rai ses the possi bi l i ty that devi ces that come in
contact wi th l ymphoreti cul ar t issues such as the tonsi l s coul d become contami nated
(398). I t has been recommended that laryngoscopes and supraglot t ic devi ces used
on pati ents wi t h suspected CJD shoul d be dest royed (235,244,399).
TABLE 34.3 Methods of Inactivation of Prionsa
Effective Methods I neffective Methods
Incineration
Prolonged steam sterilization (132C, 1 to 4 hours)
Others: 270F for 18 minutes in a prevacuum
sterilizer or at 250F for 60 minutes in a gravity
sterilizer (402)
Sodium hydroxide (1N, 1 hour)
Sodium hypochlorite (1:10 solution)
Proprietary phenolics
Peracetic acid in Steris system (possibly)
Glutaraldehyde
Formaldehyde
Hydrogen peroxide
Chlorine dioxide
Phenolics
Iodophores
Alcohols
Dry heat
Boiling
Desiccation
Freezing
Ultraviolet, ionizing, and
microwave radiation
Normally recommended
autoclave cycles
Ethylene oxide
Gas plasma
a
No method has currently been shown to be 100% effective against prions. From
Antloga K, Meszaros J, Malchesky PS, et al. Prion disease and medical devices.
ASAIO J 2000;46:S69S72.

Pri ons are notori ousl y hardy and demonstrat e resi stance to routi ne met hods of
steri l i zat ion. Standard washi ng techni ques reduce the concent rati on of prions i n an
exponenti al f ashion, but 10 to 20 cycl es are requi red t o produce negl i gi bl e level s
(181). Ef f ecti ve and i neff ect ive methods of i nacti vat i on are summari zed i n Table
34.3. Devi ces that are di ff i cul t or i mpossi ble t o cl ean shoul d be discarded (403).
The Creut zf el dt-Jakob prion requi res a uni que decontami nati on procedure. The
pref erred treat ment of contaminated i nst ruments af t er cleani ng is steam
steri l i zat ion f or at least 30 mi nutes at a temperat ure of 132C (121C is
i nef f ecti ve). When a prevacuum steri l i zer i s used, 18 mi nut es at between 134C and
138C has been found to be eff ect ive. Al ternati vel y, i tems can be i mmersed i n a 1N
sodium hydroxi de sol ut ion f or 1 hour at room temperature and then steam steri l i zed
at 121C f or 30 mi nutes (5). Noncri t i cal pati ent care i tems or surf aces may be
di si nf ected wi th ei ther bl each (up to 1:10 di l ut ion) or 1N sodi um hydroxi de at room
t emperat ure f or 15 mi nutes. I t may be necessary to sacri f i ce some equi pment af ter
use on a pati ent at ri sk of transmi t ti ng t his disease (404,405).
Severe Acute Respiratory Syndrome
Severe acute respi ratory syndrome (SARS) i s a vi ral di sease that i s transmi t ted by
respi ratory dropl ets or contact (406,407,408,409,410,411). Anest hesi a provi ders
are at hi gh ri sk because of f requent exposure t o pat i ents' respi ratory secreti ons.
Tradi ti onal precauti ons may not af ford adequate protection when handl i ng SARS
pati ents.
Whenever possibl e, pati ents shoul d have a private, negati ve-pressure room wi th at
l east 6 to 12 exchanges per hour. If t hi s is unavail abl e, they shoul d have a room
wi th a HEPA f i l ter.
A NIOSH approved, f i t-tested N-95 or greater respi rat or shoul d be used when
contact wi th pati ents is necessary. Goggl es or a face shi el d, a di sposable gown and
cap, and doubl e gl oves shoul d be worn by the anest hesia provi der and di scarded
when l eaving the pati ent ' s room.
When surgery i s requi red, eff orts shoul d be made t o l i mi t exposure t o personnel
and other pat ients. In addi ti on t o observi ng standard precauti ons, the anesthesi a
provi der should use a respi rator. Doubl e gl oves are recommended. The outer pai r
shoul d be removed af ter di rect pat ient contact and before t ouching equi pment or
f urni ture i n other areas of the room. Hands shoul d be washed immedi atel y af ter
gl oves are removed.
References
1. Gl aser ZR. A di cti onary f or cent ral steri l e. I nfect ion Control and Steri li zat i on
Technol ogy 1998;4: 1424, 46.
2. Ameri can Soci ety of Anesthesi ol ogi sts Commi t tee on Occupati onal Heal th of
Operat ing Room Personnel . Recommendat ions for i nfecti on control f or t he pract ice
of anest hesi ol ogy. 2nd ed. 1998.
P. 996


3. Sharbaugh RJ. Decontaminati on: pri ncipl es of disinfecti on. In: Rei chert M, Young
JH, eds. Steri li zat i on Technol ogy f or t he Heal th Care Facil i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc, 1997:2128.
4. Graham GS. Decontami nat i on: scienti f ic pri nci pl es. I n: Reichert M, Young JH,
eds. Steri l i zati on Technology f or t he Heal th Care Faci l i t y. 2nd ed. Gai thersburg,
MD: Aspen Publ i shers, I nc., 1997:19.
5. Rutal a W. APIC guidel i ne f or selecti on and use of di si nf ectants. Am J Infect
Control 1996;24(suppl ):313342.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
6. McCormi ck RD. Singl e-use versus reusabl e devi ces. Biomed Inst Tech
1996; 30:407410.
7. Mayworm D. What you need to know about vi ruses. Outpati ent Surgery Magazi ne
2002; 3:7578.
8. Favero MS, Bond WW. Chemical di si nf ect i on of medi cal and surgi cal materi al s.
I n: Bl ock SS, ed. Di si nf ect ion, Steri l izati on, and Preservati on. 4th ed. Phi ladel phi a:
Lea & Febiger, 1991:617641.
9. Koch FA. Resources and professi onal associ at ions. I n: Rei chert M, Young JH,
eds. Steri l i zati on Technology f or t he Heal th Care Faci l i t y. 2nd ed. Gai thersburg,
MD: Aspen Publ i shers, I nc., 1997:257261.
9A. Chamberl ai n VC. Regul atory requi rements f or reusable devi ce reprocessing. In:
Rei chert M, Young JH, eds. Steri l i zat i on Technol ogy f or t he Heal th Care Faci l i ty.
2nd ed. Gai thersburg, MD: Aspen Publi shers, Inc., 1997:262267.
10. Ameri can Associati on of Nurse Anest heti sts. Infecti on control guide. Park
Ri dge, IL: Author, 1997.
11. Anonymous. Proposed recommended practi ces f or cl eani ng and processi ng
anesthesi a equipment. AORN J 1994;60: 487489.
[CrossRef ]
[Medli ne Li nk]
12. Mayworm D. 5 steps to better, saf er decontami nati on. Out pat i ent Surgery
Magazi ne 2000;1:5156.
13. Schul t z JK. Decont ami nati on: recommended pract i ces. I n: Reichert M, Young
JH, eds. Steri li zat i on Technol ogy f or t he Heal th Care Facil i t y. 2nd ed.
Gai thersburg, MD: 8, 1997:1020.
14. Mayworm D. How to prevent i nfecti on f rom surgi cal instruments. Outpati ent
Surgery Magazine 2002; Speci al edi ti on:3844.
15. Seavey R. Breaki ng down enzymati c cl eaners. Advi ce f or choosi ng t he f ormul a
t hat f i ts your faci l i ty's needs. Outpat ient Surgery Magazi ne 2006; 7:6263.
16. Mayworm D. How to handl e 3 employee hazards. Outpat i ent Surgery Magazi ne
2001; 2:6266.
17. Gei ss HK. Reprocessing of anaesthetic and vent i l at ory equi pment . J Hosp
I nfect Suppl 1995;4: 414420.
[CrossRef ]
[Medli ne Li nk]
18. Chobi n N. Cl eani ng and steri li zi ng cannul at ed inst ruments. Si x steps to help
your reprocessi ng staf f meet the chal l enge. Out pat ient Surgery Magazi ne
2005; 6:92.
19. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steam steri l i zat ion and steri l i t y assurance i n heal th care
f aci li t ies (ANSI /AAMI ST-462002). Arl i ngt on, VA: Aut hor, 2002.
20. Johnson S. Quali t y assurance in steri l e processi ng. Veri f ying t hat your
equipment i s worki ng properl y beats assumi ng that i t i s. Out pat i ent Surgery
Magazi ne 2006;7:99100.
21. Ryan P. Concepts of cleani ng technologi es and processes. J Heal thc Mater
Manage 1987;5:2027.
[Medli ne Li nk]
22. Li qui d chemi cal germi ci de resi due causes burns. FDA Pati ent Safet y News,
August 2002. Retri eved November, 2002 f rom
ht tp:/ /www.f da.gov/cdrh/ psn/show7. ht ml .
23. Rei chert M. Preparat ion of suppl i es f or t ermi nal steri l i zati on. In: Rei chert M,
Young JH, eds. Steri l i zat ion Technology f or the Heal th Care Faci l i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc., 1997: 3649.
24. Bucz MJ, Dankert J, Beenhakker MM, et al . Decontami nati on of l aryngoscopes
i n the Netherl ands. Br J Anaesth 2001;86: 99102.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
25. Thaete R. Steam steri l i zati on. Bi omed Inst Tech 1996;30:538540.
26. Mayworm D. A pri mer on steam steri l i zat i on. Outpati ent Surgery Magazine
2001; 2:6772.
27. Young JH. Steam steri l i zati on: sci ent if i c pri nci pl es. In: Rei chert M, Young JH,
eds. Steri l i zati on Technology f or t he Heal th Care Faci l i t y. 2nd ed. Gai thersburg,
MD: Aspen Publ i shers, I nc., 1997:124133.
28. Hancock CO. Steam steri l izati on: st eri l izer operat i on. In: Rei chert M, Young JH,
eds. Steri l i zati on Technology f or t he Heal th Care Faci l i t y. 2nd ed. Gai thersburg,
MD: Aspen Publ i shers, I nc., 1997:134145.
29. Schul t z JK. St eam st eri l i zat i on: recommended practices. I n: Reichert M, Young
JH, eds. Steri li zat i on Technol ogy f or t he Heal th Care Facil i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc., 1997: 146154.
30. Lee J. If you' re thinki ng of buyinga steri l i zer. Outpati ent Surgery Magazi ne
2003; 4:7279.
31. Mayworm D. A steam steri l i zer. Pi cki ng t he ri ght chamber si ze and t ype of
steri l i zer f or your f aci l i t y. Out pat i ent Surgery Magazine 2005;6:7479.
32. Mel t zer B. A st ep-by-step instrument steri l i zati on gui de. Outpat ient Surgery
Magazi ne 2003; Special edi t ion:3642.
33. Farri s S. What I saw at t he AORN. The tabl es, l i ghts, and other capi tal
equipment that stood out i n the AORN exhi bi t hal l . Outpati ent Surgery Magazi ne
2002; 3:2939.
34. Farri s S. Steri l i zers. Outpat i ent Surgery Magazine 2004;5:7478.
35. Koch FA. Steam steri l i zati on: recommended pract i ces f or f lash steri l i zati on. I n:
Rei chert M, Young JH, eds. Steri l i zat i on technology for the heal th care faci li ty. 2nd
ed. Gai thersburg, MD: Aspen Publ i shers, I nc. , 1997: 167172.
36. Mayworm D. Ti ps for eff ect i ve f l ash steri l i zat i on. Outpati ent Surgery Magazi ne
2000; 1:7375.
37. Schnei er ML. St eri l i zat ion process moni t ori ng: mechani cal i ndi cators. I n:
Rei chert M, Young JH, ed. Gai thersburg, MD: Aspen Publ i shers, Inc. , 1997:114
123.
38. Harmer BA. Are you surgi cal l y precise in your i nst rument reprocessi ng
pract i ces? Out pat i ent Surgery Magazi ne 2003; Special edi t ion:2635.
39. Schul l tz JK. Insi de tabletop steam steri l i zers. Outpat i ent Surgery Magazi ne
2002; 3:7576.
40. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Flash steri li zati onsteam steri l i zati on of pat ient-care
i tems f or i mmedi at e use (ANSI/AAMI ST-3796). Arl i ngt on, VA: Author, 1996.
41. Gurevi ch I, Jacobsen E, Cunha BA. Unrel i abi li t y of chemical i nt egrators
compared to spore t ests for steri li zer moni tori ng. Am J Inf ect Cont rol 1996;24: 405
406.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
42. Proi et t i RM. Steri l i zati on process moni tori ng: chemi cal i ndicators. In: Rei chert
M, Young JH, eds. St eri l i zat ion Technology for the Heal th Care Faci l i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc., 1997: 104109.
43. Rutala WA, Jones SM, Weber DJ. Comparison of a rapi d readout bi ol ogical
i ndi cator f or steam steri l i zat ion wi t h f our conventi onal biol ogical i ndi cat ors and f i ve
chemical i ndi cat ors. I nf ect Control Hosp Epi demi ol 1996;17:423428.
[Medli ne Li nk]
44. Mayworm D. The true val ue of chemi cal i ndi cators. Out pat ient Surgery
Magazi ne 2003;4:7173.
45. Associ ati on f or t he Advancement of Medical Inst rumentati on. Chemi cal
i ndi catorsgui dance for the sel ecti on, use, and i nterpretat ion of resul ts (AAMI TI R-
25). Arl i ngton, VA: Author, 1999.
46. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal th care productschemical i ndi cators.
Part 1: general requi rements (ANSI/AAMI ST-60). Arl i ngton, VA: Author, 1996.
47. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal thcare productschemi cal indicators.
Part 2: class 2 i ndicators f or ai r removal test (ANSI/AAMI ST-66). Arl i ngton, VA:
Aut hor, 1999.
48. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Gui dance f or sel ecti on, use and i nterpretat ion of resul ts (ISO
15882). Geneva, Swi t zerl and: Author, 2000.
49. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Part 1: general requi rements (ISO 111401). Geneva,
Swi tzerl and: Aut hor, 1995.
50. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Part 2: test equipment and methods (ISO 11402). Geneva,
Swi tzerl and: Aut hor, 1998.
51. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Part 3: cl ass 2 indi cators f or steam penet rati on test sheets
(ISO 111403). Geneva, Swi t zerl and: Author, 2000.
52. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Part 4: cl ass 2 indi cators f or steam penet rati on test packs (ISO
111404). Geneva, Swi tzerl and: Aut hor, 2001.
53. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
chemical i ndi cat ors. Part 5: cl ass 2 indi cators f or ai r removal test sheets and packs
(ISO 111405). Geneva, Swi t zerl and: Author, 2000.
54. Berube R, Oxborrow GS. St eri l i zati on process moni tori ng: biological i ndi cat ors.
I n: Rei chert M, Young JH, eds. Steri l i zati on Technol ogy f or t he Heal th Care
Faci l i ty. 2nd ed. Gai thersburg, MD: Aspen Publ i shers, Inc. , 1997:110115.
55. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal th care productsbi ol ogi cal i ndicators.
Part 3: biological i ndi cators for moist heat st eri l i zati on (ANSI/AAMI ST-19).
Arl i ngton, VA: Aut hor, 1999.
56. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal th care productsbi ol ogi cal i ndicators.
Part 2: biological i ndi cators for ethylene oxi de steri l i zati on (ANSI /AAMI ST-21).
Arl i ngton, VA: Aut hor, 1999.
57. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Guideli nes f or t he use of ethyl ene oxi de and steam
bi ol ogi cal indicat ors i n indust ri al steri l i zati on processes (ANSI/AAMI ST-34).
Arl i ngton, VA: Aut hor, 1991.
58. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal th care productsbi ol ogi cal i ndicator.
Part 1: general requi rements (ANSI/AAMI ST-59). Arl i ngton, VA: Author, 1999.
59. Int ernati onal Standards Organi zat ion. Gui del i nes f or the use of ethyl ene oxi de
and steam bi ol ogi cal indi cators i n indust ri al steri l i zati on processes (ISO 14161).
Geneva, Swi t zerl and: Author, 2000.
60. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
bi ol ogi cal indicat ors. Part 1: general requi rements (I SO 111381). Geneva,
Swi tzerl and: Aut hor, 1994.
61. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
bi ol ogi cal indicat ors. Part 2: bi ol ogi cal i ndi cat ors f or et hyl ene oxi de steri l izati on
(ISO 111382). Geneva, Swi t zerl and: Author, 2006.
62. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
bi ol ogi cal indicat ors. Part 3: bi ol ogi cal i ndi cat ors f or moi st heat steri li zati on
processes (ISO 111383). Geneva, Swi tzerl and: Aut hor, 2006.
63. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
bi ol ogi cal indicat ors. Gui dance for t he selecti on, use and i nterpretat i on of resul ts
(ISO 14161). Geneva, Swi tzerl and: Aut hor, 2000.
64. Bucx MJL, Vel dman DJ, Beenhakker MM, et al . The eff ect of steam steri l isati on
at 134C on l i ght i nt ensi t y provided by f i berl i ght Maci ntosh l aryngoscopes.
Anaesthesia 1999;54: 875878.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
65. Mayworm D. A pri mer on dry heat steri li zati on. Outpati ent Surgery Magazi ne
2002; 3:5355.
66. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Tabl e-t op dry heat (heated ai r) st eri l i zat ion and steri l i ty
assurance i n dent al and medi cal f aci l i ti es (ANSI/AAMI ST-40). Arl i ngt on, VA:
Aut hor, 1998.
67. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Dry heat (heated ai r) st eri l i zers (ANSI /AAMI ST-50).
Arl i ngton, VA: Aut hor, 1995.
68. Rutala WA. Di si nf ect ion and st eri l i zat ion of pat i ent-care i t ems. Inf ect Cont rol
Hosp Epidemiol 1996;17:377384.
[Medli ne Li nk]
69. Int ernati onal Standards Organi zat ion. St eri l i zati on of heal th care products
bi ol ogi cal indicat ors. Part 6: bi ol ogi cal i ndi cat ors f or dry heat steri l i zati on
processes (ISO 111386). Geneva, Swi tzerl and: Aut hor, 1994.
70. Associ ati on f or t he Advancement of Medical Inst rumentati on. Chemi cal
steri l ants and steri l i zati on methods: a gui de to sel ecti on and use (AAMI TIR-7).
Arl i ngton, VA: Aut hor, 1990.
71. Babb JR, Bradl ey CR, Barnes AR. Review of microbici dal act ivi ty of
gl ut araldehyde wi t h progressi ve di luti on i n an aut omated system (quest i on &
answer). J Hosp Inf ect 1992;20:5154.
[CrossRef ]
[Medli ne Li nk]
P. 997


72. Bond WW, Ott BJ, Franke KA, et al . Ef fect ive use of l i quid chemi cal germi ci des
on medi cal devices: i nstrument desi gn probl ems. In: Bl ock SS, ed. Disi nf ecti on,
St eri l i zati on and Preservat ion. 4t h ed. Phi l adel phi a: Lea & Febi ger, 1991:1097
1106.
73. Ameri can Nati onal Standards Inst i tut e/Associ ati on f or t he Advancement of
Medi cal Inst rumentat i on. Safe use and handl i ng of glutaral dehyde-based products
i n heal th care f aci li t ies (ANSI AAMI ST-58). Arl i ngton, VA: Author, 1996.
74. Lei nst er P, Baum JM, Baxter PJ. An assessment of exposure to gl ut araldehyde
i n hospi t al s: t ypi cal exposure l evel s and recommended control measures. Br J
I ndust Med 1993;50:107111.
[Medli ne Li nk]
75. Notari anni GL. Control li ng gl ut aral dehyde exposure: Part I I. I nf ect Control Ster
Technol 1995;1:1625.
76. Jachuck SJ, Bound CL, Steel J, et al . Occupati onal hazard i n hospi tal staf f
exposed t o 2 per cent gl ut araldehyde in an endoscopy uni t . J Soc Occup Med
1989; 39:6971.
[Medli ne Li nk]
77. Swi ndol l S, Langer C. Creati on of i ndividual soaki ng compart ments wi thi n a
gl ut araldehyde f ume hood. Anesth Anal g 2001;92:1073.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
78. Kruger D. Gl utaraldehyde can be used saf el y. Surgi cal Products
1998, 17(13):20.
79. Newman MA, Kachuba JB. Gl utaral dehyde: a potent i al heal th ri sk to nurses.
Gastroenterol Nurs 1992;15:296300.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
80. Notari anni GL. Gl ut araldehyde overexposure: myt h or real i t y? One hospi tal wi de
study. J Heal thc Mater Manage 1992; 10:2034.
[Medli ne Li nk]
81. Schul t z JK. Usi ng glut aral dehyde saf el y. Out pat i ent Surgery Magazi ne
2002; 3:7475.
82. Notari anni GL. Gl ut araldehyde overexposure: myt h or real i t y? One hospi tal -
wi de study. JHMM 1992;10:2034.
83. Russel l AD. Gl utaral dehyde: current stat us and uses. Inf ect Control Hosp
Epi demi ol 1994;15:724733.
[Medli ne Li nk]
84. Rutala WA, Gergen MF, Weber DJ. Spori cidal acti vi ty of chemi cal steri l ants
used i n hospi tals. Inf ect Cont rol Hosp Epidemiol 1993;14:713718.
[Medli ne Li nk]
85. Capori no P. Ti mes and t emperatures. Sort i ng out confl icti ng advice on
di si nf ect ion procedures. Mater Manage 1996: 3435.
86. Hanson PJV, Chadwi ck MV, Gaya H, et al . A st udy of gl utaral dehyde
di si nf ect ion of f i beropti c bronchoscopes experi mental l y contami nated wi th
Mycobacteri um t ubercul osi s. J Hosp I nf ect 1992; 2:137142.
[CrossRef ]
[Medli ne Li nk]
87. Best M, Satt ar SA, Spri ngthorpe VS, et al . Ef fi caci es of sel ected disinfectants
against Mycobacteri um t ubercul osi s. J Cl ini c Mi crobiol 1990;28:22342239.
88. Rutala WA, Weber DJ. Di si nf ect i on of endoscopes: revi ew of new chemical
steri l ants used f or high-l evel di si nf ecti on. Infect Control Hosp Epi demi ol
1999; 20:6976.
[CrossRef ]
[Medli ne Li nk]
89. Mbi t hi JN, Spri ngt horpe SV, Sat tar SA, et al . Bactericidal , vi ruci dal and
mycobacteri ci dal acti vi ti es of reused al kal i ne gl utaral dehyde i n an endoscopy uni t.
J Cl in Mi crobi ol 1993; 31:29882995.
[Medli ne Li nk]
90. Anonymous. Advanced steri l i zat i on productsCi dex pl us test stri ps: may not
accuratel y detect mi nimum ef fect ive concent rat i on. Heal t h Devi ces Al erts
2004; 28:4.
91. Gannon PFG, Bri ght P, Campbel l M, et al . Occupati onal ast hma due t o
gl ut araldehyde and formal dehyde i n endoscopy and x ray departments. Thorax
1995; 50:156159.
[Full text Li nk]
[Medli ne Li nk]
92. Chan-Yeung M, McMurren T, Catoni o-Begl ey, et al . Occupati onal asthma i n a
t echnol ogi st exposed to gl utaraldehyde. J Al l ergy Cl i n Immunol 1993;91:974978.
[CrossRef ]
[Medli ne Li nk]
93. Fowl er JF. Al l ergi c cont act dermati t is f rom gl utaraldehyde exposure. J Occup
Med 1989; 31:852853.
[Medli ne Li nk]
94. Wi ggins P, McCurdy SA, Zei denberg W. Epi staxi s due to gl utaral dehyde
exposure. J Occup Med 1989; 31:584586.
95. Bhavani -Shankar K. Sal i vary gland enl argement caused by chemical agents.
Anesth Anal g 1999;89:804.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
96. Oi e S, Kami ya A. Assessment of and i nterventi on for the mi suse of al dehyde
di si nf ectants i n Japan. Inf ect Cont rol Hosp Epidemiol 2002;23:9899.
97. Alf a MJ, Si tt er DL. In-hospi tal evaluati on of ort hophthal al dehyde as a hi gh l evel
di si nf ectant f or f l exi bl e endoscopes. J Hosp Inf ect 1994;26:1526.
[CrossRef ]
[Medli ne Li nk]
98. Rutala WA, Weber DJ. New disi nf ecti on and steri l i zat ion methods. In: Emergi ng
I nfecti ous Diseases. ht tp:/ /www.cdc.gov.nci dod/eid/vol7no2/ rutal a.htm.
99. Wasek S. Endoscope di si nf ect i on product update. Outpati ent Surgery Magazi ne
2004; 5:8485.
100. Mayworm D. How shoul d we reprocess our endoscopes? Out pat ient Surgery
Magazi ne 2003;4:74.
101. Taylor D. Bui lding toward consensus i n GI endoscope reprocessi ng. Outpati ent
Surgery Magazine 2004;5:2633.
102. Vent i ci nque SG, Kashyap VS, O' Connel l RJ. Chemical burn i nj ury secondary t o
i ntraoperati ve t ransesophageal echocardiography. Anesth Anal g 2003; 97:1260
1261.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
103. Smartschan A. The undeni abl e connect i on between hand hygi ene and i nf ect i on
rates. Outpat i ent Surgery Magazi ne 2004;5:1017.
104. Wal der B, Lauber R, Zbi nden AM. Accuracy and cross-sensi ti vi t y of 10
di ff erent anestheti c gas moni tors. J Cl i n Moni t 1993; 9:364373.
[CrossRef ]
[Medli ne Li nk]
105. Young JH. New st eri l i zat i on technol ogi es. In: Rei chert M, Young JH, eds.
St eri l i zati on Technology for the Heal t h Care Faci l i t y. 2nd ed. Gai thersburg, MD:
Aspen Publ i shers, Inc., 1997:228235.
106. Crow S. Peracet ic aci d steri li zati on: a t i mel y devel opment f or a busy
heal thcare i ndustry. I nf ect Control Hosp Epi demi ol 1992;13:111113.
[Medli ne Li nk]
107. Mal chesky PS. Peracet ic acid and i ts appl i cat ion t o medi cal i nstrument
steri l i zat ion. Arti f Organs 1993;17: 147152.
[Medli ne Li nk]
108. McKee K. Update on endoscope reprocessing products. Out pat i ent Surgery
Magazi ne 2002;3:4852.
109. Rutal a WA, Gergen MF, Weber DJ. Comparat ive evaluati on of t he spori ci dal
acti vi ty of new l ow-t emperat ure steri l i zati on technol ogies: ethyl ene oxi de, 2 pl asma
steri l i zat ion systems, and l i qui d peraceti c aci d. Am J Infect Control 1998; 26:393
398.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
110. Seball os RJ, Walsh AL, Meht a AC. Cl inical evaluati on of a l i qui d chemi cal
steri l i zat ion system for the f l exi ble bronchoscope. J Bronchology 1995;2:192199.
111. Ant l oga K, Meszaros J, Mal chesky PS, et al . Prion disease and medi cal
devices. ASAIO J 2000;46:S69S72.
112. Shet t y N, Sri ni vasan S, Hol t on J, et al . Eval uati on of microbicidal acti vi ty of a
new di si nf ect ant : St eri l ox 2500 agai nst Clostri di um di f fi ci le spores, Hel i cobacter
pylori , vancomycin resi st ant Enterococcus species, candi da al bi cans and several
Mycobacteri um speci es. J Hosp I nfect 1999; 41:101105.
[CrossRef ]
[Medli ne Li nk]
113. Wal lace CG, Agee PM, Demicco DD. Li qui d chemi cal steri l i zat ion using
peraceti c aci d: an al t ernative approach to endoscope processi ng. ASAIO J
1995; 41:151154.
114. Al fa MJ, DeGagne P, Ol son N, et al . Compari son of l i qui d chemical
steri l i zat ion wi t h peracetic aci d and ethyl ene oxide steri l i zat i on f or l ong narrow
l umens. Am J Inf ect Control 1998; 26:469477.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
115. Bradl ey CR, Babb JR, Ayl i ff e GAJ. Eval uat ion of the St eris syst em 1 peracet ic
acid endoscope processor. J Hosp Inf ect 1995;29: 143151.
[CrossRef ]
[Medli ne Li nk]
116. Rutal a WA, Col e EC, Thomann CA, et al . St abi l i t y and bacteri ci dal act ivi t y of
chlori ne sol ut ions. I nf ect Control Hosp Epi demi ol 1998;19: 323327.
[Medli ne Li nk]
117. du Moul i n GC, Hedl ey-Whyte J. Hospi tal -associ ated vi ral i nf ecti on and the
anesthesi ol ogi st . Anesthesi ol ogy 1983;59: 5165.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
118. Morri ssey RF. Changes i n the science of steri li zat i on and di si nf ect ion. Bi omed
I nst rum Technol 1996;30:404406.
[Medli ne Li nk]
119. Rutal a WA, Weber DJ. Low-temperature st eri l i zati on technol ogi es: do we need
t o redef i ne steri l i zat i on? Inf ect Cont r Hosp Epi demiol 1996;17:17871791.
120. Sat tar SA, Taylor YE, Paquet te M, et al . In-hospi tal eval uati on of 7.5%
hydrogen peroxi de as a di si nf ect ant f or f l exi bl e endoscopes. Can J I nf ect Control
1996; 11:5154.
[Medli ne Li nk]
121. Krivda MS. The newest al t ernati ves to steam. Outpati ent Surgery Magazi ne
2004; 5:1825.
122. Robi tai ll e S. Set ti ng the record strai ght on ozone. Out pat ient Surgery
Magazi ne 2004;5:12.
123. Mayworm D. Expandi ng opt i ons f or l ow-t emperature steri l i zati on. Outpati ent
Surgery Magazine 2004;5:8284.
124. Nystrom B. New technol ogy f or steri l i zat i on and di si nf ecti on. Am J Med
1991; 91:264S266S.
[Medli ne Li nk]
125. Rhi nehart E. Rol e of i nf ecti on cont rol i n st eril i zat ion and disinfecti on. In:
Rei chert M, Young JH, eds. Steri l i zat i on Technol ogy f or t he Heal th Care Faci l i ty.
2nd ed. Gai thersburg, MD: Aspen Publi shers, Inc., 1997:251256.
126. Burgess DJ, Rei ch RR. Et hyl ene oxi de steri l i zati on: sci ent i f i c pri nci pl es. In:
Rei chert M, Young JH, eds. Steri l i zat i on Technol ogy f or t he Heal th Care Faci l i ty.
2nd ed. Gai thersburg, MD: Aspen Publi shers, Inc., 1997:178186.
127. Conviser SA, Wal t z C. Ethyl ene oxi de steri l i zat ion: st eri l ant al t ernat ives. In:
Rei chert M, Young JH, eds. Steri l i zat i on Technol ogy f or t he Heal th Care Faci l i ty.
2nd ed. Gai thersburg, MD: Aspen Publi shers, Inc., 1997:187199.
128. Young ML. Ethyl ene oxide steri l i zat i on: recommended practi ces. In: Rei chert
M, Young JH, eds. St eri l i zat ion Technology for the Heal th Care Faci l i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc., 1997: 209219.
129. Associ at ion f or t he Advancement of Medi cal I nst rument ati on. Et hyl ene oxide
steri l i zat ion equi pment , process consi derati ons and perti nent cal culat i ons (AAMI
TI R-15). Arl ington, VA: Author, 1997.
130. Associ at ion f or t he Advancement of Medi cal I nst rument ati on. Process
devel opment and perf ormance qual i fi cati on f or et hyl ene oxide steri li zati on
mi crobi ologi cal aspects (AAMI TI R-26). Arl ington, VA: Author, 2000.
131. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on. Automati c, general -purpose et hyl ene oxide steri li zers and
et hyl ene oxi de steri l ant sources i ntended f or use i n heal th care (ANSI /AAMI ST-24).
Arl i ngton, VA: Aut hor, 1999.
132. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on. Guideli nes f or t he sel ecti on and use of reusable rigid
contai ner systems f or ethylene oxi de st eri l izat ion and steam steri li zat i on in heal th
care faci li ti es (ANSI /AAMI ST-33). Arl i ngton, VA: Author, 1996.
133. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on. Ethylene oxi de steri l i zati on i n heal th care f aci l i ti es. Safet y
and eff ectiveness (ANSI / AAMI ST-41). Arl i ngt on, VA: Author, 1999.
134. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on/ Internat i onal Standards Organi zat ion. Medical devices
vali dat i on and routi ne cont rol of ethyl ene oxi de steri l i zati on (ANSI/AAMI /ISO 1135).
Arl i ngton, VA: Aut hor, 1994.
135. Anonymous. Ethyl ene oxide steri l i zat i on: how hospi tal s can adapt to t he
changes. Heal th Devi ces 1994; 23:485492.
[Medli ne Li nk]
136. American Nat i onal Standards Insti tute/Nat ional Fi re Prot ecti on Associ at ion.
St orage, handl i ng and use of ethyl ene oxi de f or st eri l i zat ion and fumi gati on
(ANSI/ NFPA 5602002). Quincy, MA: Aut hor, 2002.
137. Mayworm D. How to select t he proper packagi ng f or l ow t emperature
steri l i zat ion. Outpat ient Surgery Magazine 2000;1: 7577.
138. Rendel l -Baker L. Mai ntenance, cleani ng, and st eri l i zati on of anesthesia
equipment . In: Ehrenwerth J, Eisenkraf t JB, eds. Anest hesi a equi pment , pri nci pl es
and appl icati ons. St . Louis: CV Mosby, 1992:492511.
139. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on. Steri l i zat ion of heal th care products-Bi ol ogi cal i ndi cators-
Part 2, Bi ol ogical i ndi cators f or ethylene oxi de steri l i zati on (ANSI /AAMI ST-21).
Arl i ngton, VA: 1999.
140. American Nat i onal Standards Insti tute/Associ at ion f or t he Advancement of
Medi cal Inst rumentat i on. Guideli nes f or t he use of ethyl ene oxi de and steam
bi ol ogi cal indicat ors i n indust ri al steri l i zati on processes (ANSI/AAMI ST-34).
Arl i ngton, VA: Aut hor, 1991.
141. Associ at ion f or t he Advancement of Medi cal I nst rument ati on. St eri l i zati on of
heal th care productsbi ol ogi cal indi cat ors. Part 2: bi ol ogi cal i ndi cators f or
et hyl ene oxi de steri l i zati on (AAMI 11138). Arl i ngt on, VA: Aut hor, ????.
142. Anonymous. 3MAt test 1264/1264P bi ol ogi cal indicat ors: possibi l i ty of f al se-
negat ive resul ts. Heal th Devi ces 2004;28:7.
143. Whi tbourne J, Page BFJ, Centol a DT. Et hyl ene oxi de st eri l i zati on: ethyl ene
oxide resi dues. In: Rei chert M, Young JH, eds. Steri li zati on Technol ogy f or t he
Heal th Care Faci l i ty. 2nd ed. Gai thersburg, MD: Aspen Publ i shers, I nc., 1997:200
208.
144. Anonymous. Heal th ri sk due t o EtO resi due on st eri l i zed devices is
negli gi bl eHIMA. Bi omed Saf e Stand 1988;18:138139.
145. Moneret -Vaut ri n DA, Laxenai re MC, Bavoux F. Al lergi c shock to l ate and
et hyl ene oxi de duri ng surgery f or spina bif ida. Anest hesi ol ogy 1990; 73:556558.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
146. Bryson TK, Sai dman LJ, Nel son W. A pot ent ial hazard connected wi t h t he
resteri l izati on and reuse of di sposabl e equipment. Anesthesi ol ogy 1979;50:370.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
147. Dj ogovic D, Bri ndl ey PG, Schroeder DG, et al . Care of f lexible bronchoscopes.
Chest 2004; 126: 658.
[CrossRef ]
[Medli ne Li nk]
148. Anonymous. Hospi tal empl oyees t reat ed af ter ethylene oxi de l eak. Biomed
Saf e Stand 1992;22:145, 147.
P. 998


149. Schnei der PM. Ethylene oxi de steri l i zat i on: empl oyee moni tori ng. In: Rei chert
M, Young JH, eds. St eri l i zat ion Technology for the Heal th Care Faci l i t y. 2nd ed.
Gai thersburg, MD: Aspen Publ i shers, Inc., 1997: 220227.
150. American Soci et y for Testi ng and Materi al s. St andard t est method for
determinati on of ethyl ene oxi de i n workpl ace atmospheres (charcoal t ube
methodology) (ASTM D-441398e1). West Conshohocken, PA: Aut hor, 2003.
151. American Soci et y for Testi ng and Materi al s. St andard t est method for
determinati on of ethyl ene oxi de i n workpl ace atmospheres (HBr deri vati zati on
method) (ASTM D-557894e1). West Conshohocken, PA: Author, 1999.
152. Anonymous. Passive di ff usi on moni t or detects et hyl ene oxi de. Bi omed Saf e
St and 1988; 18:101.
153. Anonymous. Personal chemical exposure moni tor badges devel oped. Bi omed
Saf e Stand 1989;19:29.
154. Anonymous. Et O moni tori ng anal yzer based on crystal growt h. Bi omed Saf e
St and 1990; 20:126.
155. Anonymous. Hospi tal s wei gh opt ions and costs i n Et O steri l i zat ion. Technol
Anesth 1995; 15,9: 14.
156. Al fa MJ, DeGagne P, Ol son N, et al . Compari son of ion plasma, vapori zed
hydrogen peroxi de, and 100% ethylene oxi de st eri l i zers to the 12/88 ethylene oxi de
gas steri li zer. I nf ect Control Hosp Epi demi ol 1996;17:92100.
[Medli ne Li nk]
157. Rutal a WA, Gergen MF, Weber DJ. Spori ci dal acti vi t y of a new l ow
t emperat ure st eri l i zat ion technol ogy: t he Sterrad 50 steri l i zer. I nf ect Cont rol Hosp
Epi demi ol 1999;20:514516.
[CrossRef ]
[Medli ne Li nk]
158. Rutal a WA. Cl i ni cal eff ect i veness of l ow-temperature st eri l i zati on
t echnol ogi es. I nf ect Cont rol Hosp Epi demi ol 1998; 19:798804.
[Medli ne Li nk]
159. Kyi MS, Hol ton J, Ridgway GL. Assessment of the eff i cacy of a low
t emperat ure hydrogen peroxide gas pl asma steri l i zati on system. J Hosp Inf ect
1995; 31:275284.
[CrossRef ]
[Medli ne Li nk]
160. Al fa MJ. Plasma-based steri l i zat i on: t he chal l enge of narrow l umens. I nfect
Control Steri l i z Technol 1996; 2:1924.
161. Adl er S, Scherrer M, Daschner FD. Costs of l ow- temperature pl asma
steri l i zat ion compared wi th other steri l i zat i on methods. J Hosp Infect 1998;40:125
134.
[CrossRef ]
[Medli ne Li nk]
162. Evans K. Sel ect i ng and i mpl ement ing new steri l i zati on t echnol ogy. Surgi cal
Servi ces Management 1997;3:4748.
163. Chobin NG. Cost anal ysi s of t hree l ow- temperature st eri l i zat ion syst ems at
Sai nt Barnabas Medical Cent er. J Heal t hc Mater Manage 1994;12:3234.
164. Mayworm D. Di si nf ecti on vs. steri l ization: how t o handl e bot h. Out pati ent
Surgery Magazine 2000;1:65.
165. Al fa MJ. Changes i n hospi tal pract ice. Bi omed Inst rum Technol 1996;30:400
404.
[Medli ne Li nk]
166. Hol l er C, Marti ny H, Chri st iansen B, et al . The ef f i cacy of l ow temperature
pl asma (LTP) steri l i zat i on, a new steri l i zat ion techni que. Zbl Hyg 1993;194:380
391.
167. Hei nsen A, Bendtsen F, Fomsgaard A. A phyl ogenet ic anal ysi s el uci dati ng a
case of pati ent -t o-pat ient t ransmissi on of hepat i ti s C vi rus during surgery. J Hosp
I nfect 2000;46:309313.
[CrossRef ]
[Medli ne Li nk]
168. Ol ds JW, Ki sch AL, Eberl e BJ, et al . Pseudomonas aeruginosa respi ratory
t ract infecti on acqui red f rom a contami nated anesthesi a machine. Am Rev Respi r
Di s 1972;105:628632.
169. Anonymous. Investi gati on of possi bl e pati ent-to-pat i ent t ransmi ssi on of
hepat i t is C i n a hospi tal . NSW Pub Heal th Bul l 1994;5:4749.
170. Hospi tal Inf ecti on Cont rol Practi ces Advi sory Commi tt ee. Gui deli nes f or
preventi on of nosocomi al pneumoni a. Respi r Care 1994;39:11911236.
171. Lessard M, Trepani er C. Use and mi suse of syri nges i n anaesthesi a. Can J
Anaesth 1997;44:793797.
[Medli ne Li nk]
172. Bosch X. Hepati t is C outbreak astounds Spai n. Lancet 1998;351: 1415.
[CrossRef ]
173. Chant K, Kociuba K, Munro R. Investi gat i on of possi bl e pati ent-to-pati ent
t ransmissi on of hepat i ti s C i n a hospi tal . NSW Publi c Heal t h Bull 1994;5:4751.
[CrossRef ]
174. Herwal dt LA, Potti nger JM, Cof f i n SA. Nosocomi al inf ecti ons associ ated wi th
anesthesi a. I n: Mayhal l CG, ed. Hospi tal Epi demi ol ogy and Inf ect ion Control .
Phi l adel phi a: Wi l l i ams & Wi l ki ns, 1999: 847874.
175. Berry AJ. Recent i nfect ion cont rol issues: an update. ASA Newsl et t 1995;59:5
9.
176. Kempen PM. Avoi di ng nosocomi al inf ecti on in anaesthesi a. Can J Anaesth
1989; 36:254255.
[Medli ne Li nk]
177. Tai t AR, Tutt l e DB. Prevent i ng peri operati ve t ransmi ssi on of i nf ecti on: a
survey of anesthesi ol ogy practi ce. Anest h Anal g 1995;80:764769.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
178. Hal l JR. Blood cont ami nat i on of anesthesi a equipment and moni tori ng
equipment . Anesth Analg 1994;78:11361139.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
179. Lord EV. Cost benef i t anal ysi s: i ts appl icati on i n a heal th care f aci l i t y. In:
Rei chert M, Young JH, eds. Steri l i zat i on Technol ogy f or t he Heal th Care Faci l i ty.
2nd ed. Gai thersburg, MD: Aspen Publi shers, Inc., 1997:268279.
180. Berry AJ. Infecti on control i n anesthesi a. Anesth Cl i n Nort h Am 1989; 7:967
981.
181. Ki ng TA, Cooke RPD. Devel opi ng an i nfecti on cont rol pol icy f or anaestheti c
equipment . J Hosp I nfect 2001;47:257261.
[CrossRef ]
[Medli ne Li nk]
182. Lei j ten DTM, Rej ger VS, Mouton RP. Bact erial contami nati on and the ef fect of
f il ters i n anaestheti c ci rcui ts i n a simul at ed pati ent model . J Hosp I nfect
1992; 21:5160.
[CrossRef ]
[Medli ne Li nk]
183. Gal lagher J, St rangeways JEM, Al l t -Graham J. Contami nati on cont rol in l ong-
t erm venti l ati on. A cl i ni cal study usi ng a heat-and-moi sture-exchanger f i l ter.
Anaesthesia 1987;42: 476481.
[CrossRef ]
[Medli ne Li nk]
184. Lei j ten DTM, Rej ger VS, Mouton RP. Bact erial contami nati on and the ef fect of
f il ters i n anaestheti c ci rcui ts i n a simul at ed pati ent model . J Hosp I nfect
1992; 21:5160.
[CrossRef ]
[Medli ne Li nk]
185. Wi l kes AR. Reducing t he risk of prior transmi ssi on i n anaesthesi a.
Anaesthesia 2005;60: 527529.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
186. Grange C. Hepat i t is C and anaest heti c breathing systems. Anaesth Intens
Care 1996;24:514.
[Medli ne Li nk]
187. Knoblanche GK. Revi si on of t he anaest hetic aspects of an i nf ect i on control
pol i cy f oll owi ng reporti ng of hepati ti s C nosocomi al i nfect ion. Anaest h Intens Care
1996; 24:169172.
[Medli ne Li nk]
188. Knoblanche G. Inf ecti on cont rol . A repl y to Arnol d J Berry. Anaesth Intens
Care 1997;25:87.
189. Berry AJ, Nol te FS. An al t ernative strat egy f or i nfecti on cont rol of anesthesi a
breat hi ng ci rcui ts: a l aboratory assessment of t he Pal l HME f i l ter. Anesth Anal g
1991; 72:651655.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
190. Greene E. Hepati t is C nosocomi al i nf ecti on. Anaesth Intens Care 1997;25: 86
87.
[Medli ne Li nk]
191. Lawes EG. Hi dden hazards and dangers associ ated wi t h the use of HME/ fi l ters
i n breathing ci rcui ts. Thei r eff ect on t oxic met abol i te producti on, pul se oxi met ry and
ai rway resistance. Br J Anaesth 2003;91: 249264.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
192. Lees DE. To reuse or not to reuse, that i s the quest i on. ASA Newsl ett
1992; 56:1315.
193. Wal ton JR. A new cont roversy i n respi rat ory equi pment management .
Reusabl es versus di sposed di sposabl es versus reused di sposabl es. Respi r Care
1986; 31:213217.
[Medli ne Li nk]
194. Canadi an Heal thcare Associati on. The reuse of si ngle-use medi cal devi ces.
Ot towa: Canadi an Heal thcare Associ ati on, 1996.
195. Gi bson N. Debate on reuse of di sposabl e medi cal equipment f uel ed by FDA.
APSF Newslett 1997;12:910.
196. Campbel l S. The reuse of si ngl e-use devices: the story cont inues. Bi omed
I nst rum Tech 2001;35:307311.
197. Sol omon RP. ECRI expert reviews reuse of single-use medi cal devi ces. J
Cl in Moni t Comput 1998; 14:203205.
[Medli ne Li nk]
198. Rei chert M. Reuse of singl e-use devi ces. I n: Rei chert M, Young JH, eds.
St eri l i zati on Technology for the Heal t h Care Faci l i t y. 2nd ed. Gai thersburg, MD:
Aspen Publ i shers, Inc., 1997:236250.
199. Weeni g C. The pros and cons of reusi ng disposabl es. APSF Newsl et t 1997
1998; 11:34.
200. Berry A. Expert wei ghs f act ors on reuse of di sposabl es, urges saf ety cri t eria
and new studi es. APSF Newsl ett 1997;12:11.
201. Mayworm D. When can you reuse si ngl e-use devices? Outpati ent Surgery
Magazi ne 2003;4:8485.
202. Wasek S. 5 i nf ecti on control controversies. Out pat ient Surgery Magazine
2004; 5:5255.
203. Dunn D. A guide t o recycl i ng si ngl e-use devices. Outpati ent Surgery Magazi ne
2004; (suppl ): 2629.
204. Anonymous. Expert s cauti ous about devi ce reuse. Biomed Safe St and
1997; 27:14.
205. Chudley P. Second ti me around. Nurs Ti mes 1988; 28:18.
[Medli ne Li nk]
206. Anonymous. FDA issues revised gui dance on reuse of si ngle-use devi ces:
what i t means t o i n-house reprocessors. Heal th Devi ces Al erts 2004;28: 13.
207. Berry AJ. Ameri can Soci et y of Anesthesi ol ogi sts i nfecti on control poli cy.
Anaesth Intens Care 1996;24:618.
[Medli ne Li nk]
208. Anonymous. GAP f i nds l i tt le evidence of danger f rom SUD reuse. Bi omed Saf e
St and 2000; 30:133135.
209. Li pp M, Jachni chen G, Gol ecki N, et al . Mi crobi ol ogi cal mi crost ruct ure, and
materi al sci ence exami nati ons of reprocessed Combi tube af t er mul ti pl e reuse.
Anesth Anal g 2000;91:693697.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
210. Anonymous. FDA cl arif ies opened-but-unused SUD reuse quest ion. Bi omed
Saf e Stand 2002;32:128129.
211. Greene VW. Reuse of di sposable medi cal devices: historical and current
aspects. Inf ect Cont rol 1986;7:508513.
[Medli ne Li nk]
212. Hyman WA. Reuse revi si ted. Bi omed Saf e Stand 2000;30:1820.
213. Gadall a F, Fong J. I mproved i nf ecti on cont rol i n the operati ng room.
Anesthesi ol ogy 1990; 73:1295.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
214. Berry AJ. Infecti on control i n the practi ce of anesthesiology (ASA Ref resher
Course #162). Atl anta, GA: ASA, 1995.
215. Anonymous. The not-so hi dden dangers of reusing needl es and syri nges.
Out pat i ent Surgery Magazi ne 2002;3: 5.
216. Ryan AJ, Webster CS, Merry Af , et al . A nat ional survey of i nf ecti on cont rol
pract i ce by New Zeal and anaestheti sts. Anaest h Intens Care 2006;34: 6874.
[Medli ne Li nk]
217. El Mi kat ti N, Di l l on P, Heal y TEJ. Hygienic pract i ce of consul tant
anaestheti stsa survey in the North West regi on of the UK. Anaesthesi a
1999; 54:1318.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
218. Druce JD, Locarni ni SA, Bi rch CJ. Isolati on of HIV-1 f rom experi mental l y
contaminated mul ti dose l ocal anaesthetic vi al s. Med J Aust 1995;162:513515.
[Medli ne Li nk]
219. Perry J. A hepat i ti s-i nf ected surgeon speaks out on OR safety. Outpat ient
Surgery Magazine 2003;4:6871.
220. Anonymous. Transmi ssion of hepati ti s B and C vi ruses in outpati ent set ti ngs
New York, Oklahoma, and Nebraska 20002002. MMWR Morb Mort al Wkl y Rep
2003; 52:901906.
221. Browne RA. I nf ect ious di seases and t he anaest het ist. Can J Anaesth
1988; 35:655665.
[Medli ne Li nk]
222. Mostaf a SM. Adverse eff ects of buff ered glutaral dehyde on the Hei dbrink
expi ratory valve. Br J Anaesth 1980;52:223227.
[CrossRef ]
[Medli ne Li nk]
223. Body SC, Phi l i p JH. Gram-negat i ve rod contami nati on of an Ohmeda
anesthesi a machine. Anesthesi ol ogy 2000;92: 911.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
224. Murphy PM, Fi t zgeorge RB, Barret t RF. Vi abi l i t y and di st ri but i on of bacteri a
af ter passage through a ci rcle anaesthet i c system. Br J Anaesth 1991;66:300
304.
[CrossRef ]
[Medli ne Li nk]
225. Langevi n PB, Rand KH, Layon AJ. The potent ial f or di ssemi nat i on of
Mycobacteri um t ubercul osi s t hrough t he anesthesi a breathing syst em. Chest
1999; 115: 11071114.
[CrossRef ]
[Medli ne Li nk]
226. Tablan OC, Anderson, LJ, Arden NH, et al . Gui del i nes f or preventi on of
nosocomial pneumoni a. Part I . Issues on preventi on of nosocomi al pneumoni a.
AJI C 1994;22:247292.
[Medli ne Li nk]
227. Gurevi ch I , Taf uro P, Ristucci a P, et al . Di si nf ecti on of respi rator t ubi ng: a
compari son of chemical versus hot wat er machi ne-assisted processi ng. J Hosp
I nfect 1983;4:199208.
[CrossRef ]
[Medli ne Li nk]
228. Yee KF. Decontami nat i on issues and perceived rel i abil i ty of the
l aryngoscopea cl i ni ci an' s perspecti ve. Anaesth Int ens Care 2003;31:658662.
[Medli ne Li nk]
229. Morel l RC, Ri ri e D, RL, Crews DA, et al . A survey of l aryngoscope
contaminati on of a universi t y and a communi t y hospi tal . Anesthesi ol ogy
1994; 80:960.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
230. Neal TJ, Hughes CR, Rothburn MM, et al . The neonatal l aryngoscope as a
potenti al source of cross-i nf ect ion. J Hosp Inf ect 1995;30:315317.
[CrossRef ]
[Medli ne Li nk]
231. Foweraker JE. The laryngoscope as a potenti al source of cross-i nf ect i on. J
Hosp Inf ect 1995;29:315316.
[CrossRef ]
[Medli ne Li nk]
232. Beamer JER, Cox RA. MRSA cont ami nat i on of a l aryngoscope bl ade: a
potenti al vector f or cross i nf ecti on. Anaest hesi a 1999; 54:10101011.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
233. Bal l in MS, McCl usky A, Maxwel l S, et al . Contaminati on of l aryngoscopes.
Anaesthesia 1999;54: 115116.
234. Phi l ips RA, Monaghan WP. Inci dence of vi si bl e and occul t bl ood on
l aryngoscope blades and handl es. JAANA 1997;65:241246.
235. Mi l l er DM, Youkhana I, Karunaratne WU, et al . Presence of protein deposi ts on
cl eaned re-usabl e anaesthet ic equi pment . Anaesthesi a 2001;56: 10691072.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
236. Chrisco JA, DeVane GA. A descri pti ve study of blood in the mouth f ol l owi ng
rout ine oral endot racheal i ntubat ion. AANA J 1992;60:379383.
[Medli ne Li nk]
P. 999


237. Si mmons SA. Laryngoscope handl es: a potenti al f or i nf ecti on. J Am Assoc
Nurs Anesth 2000; 68: 233236.
238. Hi rsch N, Becket t A, Col l i nge J, et al . Lymphocyte contami nat ion of
l aryngoscope bladesa possi bl e vector f or t ransmissi on of vari ant Creut zf el dt -
Jakob di sease. Anaest hesi a 2005;60:664667.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
239. Tobin MJ, Stevenson GW, Hal l SC. A si mple, cost-eff ective met hod of
preventi ng l aryngoscope handl e contami nati on. Anest hesiol ogy 1995;82:790.
[Full text Li nk]
[Medli ne Li nk]
240. Conroy TF. Laryngoscope handle contami nati on. Anesthesi ology
1995; 83:428.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
241. So EC. Use of a condom as a bl ade cover for l aryngoscope. Anest hesi ol ogy
2000; 93:906.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
242. Barnet te RE, Pietrzak WT, Bi anRosa JJ. On prevent ing t ransmi ssion of vi ral
i nfect ions. Anest hesi ol ogy 1985;62:845.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
243. Ben-David B, Gai t ini L. Gl oves, l aryngoscopes and l aryngeal masks. J Cl in
Anesth 1997; 9:345346.
[CrossRef ]
[Medli ne Li nk]
244. Esl er MD, Baines LC, Wi lkinson DJ, et al . Decontaminati on of l aryngoscopes:
a survey of nat ional practi ce. Anaesthesi a 1999;54:587592.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
245. Esl er MD, Wi lkinson DJ, Langford RM. Degradati on of l aryngoscopes.
Anaesthesia 2000;55: 300301.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
246. Ski l ton RWH. Ri sks of cross i nf ecti on associated wi t h anaesthesi a: cl eani ng
procedures for l aryngoscopesa need for Associ ati on gui deli nes? Anaesthesi a
1996; 51:512513.
247. Gri gsby EJ, Lennon RL, Didier EP, et al . Massi ve t ongue swel l i ng af ter
uncompl i cated general anesthesi a. Canad J Anaesth 1990;37: 825826.
248. Sacks MD. St eri l isati on of l aryngoscopes. Anaesthesi a 2000;55:700.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
249. Bucx MJL, de Gart HM, Vel dhui s J, et al . The eff ect of mechani cal cl eani ng
and thermal di si nf ecti on on l i ght intensi ty provi ded by f i breli ght Maci ntosh
l aryngoscopes. Anaesthesia 2003; 58:461465.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
250. Ski l ton RWH, Parry D, Art hurs GJ, et al . A study of the bri ghtness of
l arygnoscope l i ght . Anaesthesi a 1996;51:667672.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
251. Mehta AC, Mi nai OA. Inf ect i on control i n the bronchoscopy sui te. A revi ew.
Cl in Chest Med 1999;20: 1932.
[CrossRef ]
[Medli ne Li nk]
252. McKee K. Tips for preventi ng equi pment cross-contami nat i on. Outpati ent
Surgery Magazine 2002;3:4146.
253. Anonymous. Recommended practi ces f or use and care of endoscopes. AORN J
1998; 67:256262.
[CrossRef ]
254. Mayworm D. What you need to know about endoscope reprocessi ng.
Out pat i ent Surgery Magazi ne 2003;4: 6063.
255. Emergency Care Research Inst i tut e. Evaluati on update: l iquid disi nf ecti ng and
steri l i zi ng reprocessors used f or f l exi bl e endoscopes. Heal th Devices 1994;23:477
481.
256. Pi ll a L. Can you successful l y channel your f lexi bl e endoscope reprocessi ng
t echni que? Outpati ent Surgery Magazine 2003; Speci al edi ti on:1824.
257. Wasek S. 11 common endoscope handl i ng mi stakes. Outpat i ent Surgery
Magazi ne 2003;4:5259.
258. Reeves DS, Brown NM. Mycobacteri al contaminati on of a f ibreopti c
bronchoscopes. J Hosp I nf ect 1995; 30(suppl ): 631636.
259. Ayl i ff e G, Mi ni mal Access Therapy Decontami nati on Worki ng Group.
Decont aminat ion of mi ni mal l y i nvasi ve surgi cal endoscopes and accessories. J
Hosp Inf ect 2000;45:263277.
[CrossRef ]
[Medli ne Li nk]
260. Sl oan TB, Ovassapi an A. The pri nci pl es of f i beropti c endoscopes. In:
Ovassapian A, ed. Fi beropti c endoscopy and t he dif f icul t ai rway. Phi ladel phi a:
Li ppi ncott -Raven, 1996:116.
261. Wasek S. Eight st eps to bet ter scope reprocessi ng. Outpati ent Surgery
Magazi ne 2004;5:5458.
262. Yi gl a M, Oren I , Bentur L, et al . I nci dence of bacteraemia f ol l owi ng f ibreopti c
bronchoscopy. Eur Respi r J 1999; 14:789791.
[CrossRef ]
[Medli ne Li nk]
263. Pat i l A, Barker GL, Woodall N, et al . Pyrexia and ri gors f ol l owi ng f i breopt ic
i ntubat ion i n a del egate at tendi ng an awake f i breoptic i nt ubati on trai ni ng course.
Anaesthesia 2004;59: 10451046.
[Full text Li nk]
264. Takigawa K, Fuj i ta J, Negayama K, et al . Eradi cati on of contaminati ng
Mycobacteri um chel onae f rom bronchof i brescopes and an automated bronchoscope
di si nf ect ion machi ne. Respi r Med 1995; 89:423427.
[CrossRef ]
[Medli ne Li nk]
265. Ut tl ey AHC, Si mpson RA. Audi t of bronchoscope disi nfecti on : a survey of
procedures in England and Wal es and i nci dents of mycobacteri al contami nat ion. J
Hosp Inf ect 1994;26:301308.
[CrossRef ]
[Medli ne Li nk]
266. Wheel er PW, Lancast er D, Kai ser AB. Bronchopulmonary cross-col oni zati on
and i nf ect i on rel at ed to mycobacteri al cont aminati on of sucti on val ves of
bronchoscopes. J Infect Di s 1989; 159:954958.
[Medli ne Li nk]
267. Fraser VJ, Jones M, Murray PR, et al . Contami nat i on of f lexi ble f iberoptic
bronchoscopes wi t h mycobacteri um chel onae l i nked to an aut omat ed bronchoscope
di si nf ect ion machi ne. Am Rev Respi r Di s 1992;145:853855.
[Medli ne Li nk]
268. Bryce EA, Wal ker M, Bevan C, et al . Contami nati on of bronchoscopes wi t h
Mycobacteri um t ubercul osi s. Can J I nfect Control 1993; 8:3536.
[Medli ne Li nk]
269. Cent ers for Disease Control . Nosocomi al i nf ect ion and pseudoi nf ect i on f rom
contaminated endoscopes and bronchoscopesWi sconsi n and Missouri . MMWR
Morb Mort al Wkl y Rep 1991;40:675678.
[Medli ne Li nk]
270. Anonymous. Hazard report. Cont aminat i on of the modi f i ed Olympus EW-10
and EW-20 aut omat i c f l exi bl e endoscope reprocessors. Heal th Devices
1994; 23:143145.
[Medli ne Li nk]
271. Anonymous. Can device lubri cants harbor microbes and prevent adequate
di si nf ect ion? Biomed Saf e Stand 1995; 25:139140.
272. Mickel e TM, Croni n WA, Graham NMH, et al . Transmi ssion of Mycobactei um
t ubercul osis by a f i beropti c bronchoscope. JAMA 1997;278:10931095.
273. Anonymous. Nosocomi al i nf ect i on and pseudoi nf ecti on f rom contami nated
endoscopes and bronchoscopes. JAMA 1991; 266:21972198.
[CrossRef ]
[Medli ne Li nk]
274. Anonymous. Improperl y cl eaned endoscopes may have spread tubercul osi s.
Bi omed Saf e Stand 1997;19:145146.
275. Cox R, deBorja K, Bach MC. A pseudo-outbreak of Mycobacteri um chel onae
i nfect ions rel at ed to bronchoscopy. Infect Cont rol Hosp Epi demi ol 1997;18:136
137.
[Medli ne Li nk]
276. Al varado CJ, Stol z SM. Nosocomi al inf ecti ons f rom contaminated endoscopes:
a fl awed automated endoscope washer. An i nvesti gati on usi ng mol ecular
epi demiol ogy. Am J Med 1991; 91[Suppl 3B]: 272S280S.
277. Anonymous. The FDA and CDC warn hospi tal s of i nf ect ions stemming f rom the
use of automated endoscope reprocessors. Bi omed Saf e Stand 1999;29:137139.
278. El ston RA, Hay AJ. Aci d-f ast baci l lus contami nati on of a bronchoscope
washi ng machi ne. J Hosp Infect 1991;19: 7273.
[CrossRef ]
[Medli ne Li nk]
279. Hanson PJV, Gor D, Cl arke JR, et al . Recovery of the human
i mmunodef i ci ency vi rus f rom f iberopti c bronchoscopes. Thorax 1991;46:410412.
[Medli ne Li nk]
280. Spach DH, Si lverstei n FE, Stamm WE. Transmi ssi on of i nf ect i on by
gastroi nt esti nal endoscopy and bronchoscopy. Ann I nt Med 1993;118:117128.
[Medli ne Li nk]
281. Ki el y JL, Sheehan S, Cryan B, et al . Isol at ion of Mycobacteri um cheol nae i n a
bronchoscopy uni t and i ts subsequent eradi cati on. Tuber Lung Di s 1995;76:163
167.
[CrossRef ]
[Medli ne Li nk]
282. Kaczmarek RG, Moore RM, McCrohan J, et al . Mul ti -state i nvesti gat i on of t he
actual di si nf ecti on/steri l i zat i on of endoscopes i n heal th care f aci l i ti es. Am J Med
1992; 92:257261.
[CrossRef ]
[Medli ne Li nk]
283. Hof f mann KK, Weber DJ, Rut al a WA. Pseudoepi demic of Rhodotorul a rubra i n
pati ents undergoing f i beropt ic bronchoscopy. Infect Cont rol Hosp Epidemiol
1989; 10:511514.
[Medli ne Li nk]
284. Fraser VJ, Zuckerman G, Cl ouse RE, et al . A prospecti ve randomi zed tri al
compari ng manual and automated endoscope di sinf ecti on methods. I nfect Cont
Hosp Epidemiol 1993;14:383389.
[Medli ne Li nk]
285. Perry PA. Bronchoscope blues. Mat er Manage 1999;8:17.
286. Anonymous. Ol ympus bronchoscope recal l update. Bi omed Safe Stand
2002; 32:8485.
287. Anonymous. Bronchoscopes. Technol Anesth 2002;22:67.
288. Vandenbroucke-Grauls CMJE, Baars ACM, Vi sser MR, et al . An outbreak of
Serat ia marcescens t raced t o a contaminated bronchoscope. J Hosp Inf ect
1993; 23:263270.
[CrossRef ]
[Medli ne Li nk]
289. Cent ers for Disease Control . Nosocomi al i nf ect ion and pseudoi nf ect i on f rom
contaminated endoscopes and bronchoscopesWi sconsi n and Missouri . MMWR
Morb Mort al Wkl y Rep 1991;40:675682.
[Medli ne Li nk]
290. Agert on T, Val way S, Gore B, et al . Transmi ssi on of a hi ghly drug-resi stant
st rai n of Mycobacteri um tubercul osi s. JAMA 1997; 278:10731077.
[CrossRef ]
[Medli ne Li nk]
291. Anonymous. Hospi tal steri li zer manuf acturer debate responsi bi l i t y for deadly
bacteri a outbreak. Outpati ent Surgery Magazi ne 2003;4:8.
292. Bel l egui c C, Bri ens E, Lena H, et al . Mycobacteri um chel onae pseudoepi demi c
due to contami nat i on of f lexi bl e bronchoscopes. J Bronchol 1998; 5:2024.
293. Campagnaro RL, Teichtahl H, Dwyer B. A pseudoepi demi c on Mycobacteri um
chelonae: contami nat ion of a bronchoscope and autocleaner. Aust NZ Med
1994; 24:693695.
294. Gubl er JGH, Sal f i nger M, von Graeveni tz A. Pseudoepi demi c of
nontubercul ous mycobacteri a due to a contami nated bronchoscope cleani ng
machi ne. Report of an out break and revi ew of t he l i terature. Chest 1992;101:1245
1249.
[CrossRef ]
[Medli ne Li nk]
295. Kressel AB, Ki dd F. Pseudo-outbreak of Mycobact erium chel onae and
Methyl obact eri um mesophi l i cum caused by cont aminati on of an automated
endoscopy washer. Infect Cont rol Hosp Epidemiol 2001;22:414418.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
296. Mal oney S, Welbel , Daves B, et al . Mycobacterium abscessus pseudoi nfecti on
t raced to an automated endoscope washer: ut i l i ty of epi demi ol ogi c and laborat ory
i nvesti gat i on. J Inf ectious Dis 1994;169:11661169.
297. Ni col le LE, McLeod J, Romance L, et al . Pseudo-outbreak of bl astomycosi s
associ ated wi th contami nated bronchoscopes. Inf ect Con Hosp Epi demi ol
1992; 13:324.
298. Wang H-C, Li aw Y-S, Yang S-H, et al . A pseudoepidemic of Mycobacterium
chelonae i nf ecti on caused by contami nati on of a f i beropt i c bronchoscope sucti on
channel . Eur Resp J 1995; 8:12591262.
[CrossRef ]
[Medli ne Li nk]
299. Prakash UBS. Does t he bronchoscope propagate i nf ect ion? Chest
1993; 104: 552559.
300. Gubl er JGH, Sal f i nger M, von Graeveni tz A. Pseudoepi demi c of
nontubercul ous mycobacteri a due to a contami nated bronchoscope cleani ng
machi ne: report on an outbreak and review of t he l i terature. Chest 1992;101:1245
1249.
[CrossRef ]
[Medli ne Li nk]
301. Bl anc DS, Parret T, Jani n B, et al . Nosocomi al i nfecti ons and pseudoi nf ecti on
f rom contami nated bronchoscopes: t wo-year f ol l ow up using molecul ar markers.
I nfect Control Hosp Epi demi ol 1997;18: 134136.
[Medli ne Li nk]
302. Brown NM, Hel l yar EA, Harvey JE, et al . Mycobacteri al contami nat ion of
f iberopti c bronchoscopes. Thorax 1993;48: 12831295.
[Medli ne Li nk]
303. Certain Ol ympus bronchoscopes recal l ed. FDA Pati ent Saf et y News, Apri l
2002. Ret ri eved Apri l , 2002 f rom http: // www. f da.gov/cdrh/recal l s/ recal l -
032002.ht ml .
304. Anonymous. Endoscopes. Heal th Devices Al ert s 2004;28:7.
305. Vesley D, Norl i en KG, Nel son B, et al . Si gni f i cant factors i n the disi nf ecti on
and steri l i zat i on of f lexi bl e endoscopes. Am J Inf ect Cont rol 1992;20:291300.
[CrossRef ]
[Medli ne Li nk]
306. El ston RA, Hay AJ. Aci d-f ast baci l lus contami nati on of a bronchoscope
washi ng machi ne. J Hosp Infect 1991;19: 7273.
[CrossRef ]
[Medli ne Li nk]
307. Bradl ey CR, Babb JR. endoscope decont ami nat ion: aut omated vs manual . J
Hosp Inf ect 1995;30:537542.
[CrossRef ]
[Medli ne Li nk]
308. Lynch DAF, Murphy PL, Axon ATR. Evaluati on of f our commerci al automat i c
endoscope washi ng machi nes. Endoscopy 1992;24:766770.
[Medli ne Li nk]
309. Mannion PT. The use of peraceti c aci d f or the reprocessi ng of f l exi ble
endoscopes and ri gi d cystoscopes and laparoscopes. J Hosp I nfect 1995; 29:313
315.
[CrossRef ]
[Medli ne Li nk]
310. Murdock D. The fundamental s of t he automat i c endoscope reprocessor.
Bi omed I nst rum Technol 2001;35:421424.
[Medli ne Li nk]
311. Cupi t t JM. Mi crobi al contami nati on of gum elasti c bougi es. Anaesthesia
2000; 55:466468.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
312. Shah N, Grei g JR, Stephenson JR, et al . Mi crobi al cont ami nat ion of gum-
el ast i c bougies. Anaesthesi a 2000;55:1225.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
313. Jerwood DC, Mort i boy D. Di si nfect ion of gum elastic bougi es. Anaesthesi a
1995; 50:376.
[CrossRef ]
[Medli ne Li nk]
314. Letheren MJR. Steri l i zat i on of gum el ast i c bougi es. Anaesthesi a
1994; 49:921.
[CrossRef ]
[Medli ne Li nk]
315. Jackson S. Ti me to swi tch to di sposabl e bougies. Anaest hesi a 2003;58:392.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
316. Annamaneni R, Hodzovi c I , Wi l kes AR, et al . A compari son of simulat ed
di ff i cul t i ntubat ion wi t h mul t i ple-use and si ngl e-use bougi es in a maniki n.
Anaesthesia 2003;58: 4549.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
317. Moor MW, Bowe EA, Turner JF, et al . Opened endot racheal tubes can be
saved. Anest hesi ol ogy 1992;77:A1059.
[Full text Li nk]
[CrossRef ]
318. Scharf SM, Nol an RL, Luci a HL, et al . Are previ ousl y opened endotracheal
t ubes (ETTs) saf e for use at a l ater ti me? Anesthesi ol ogy 1995; 83:A1032.
319. Rasic NF, Fri esen RM, Anderson B, et al . Prepared endotracheal t ubes: are
t hey a potent i al source f or pathogenic mi croorgani sms? Anest h Anal g
2003; 97:11331136.
320. Parker MRJ, Day CJE. Visible and occul t bl ood contami nati on of laryngeal
mask ai rways and tracheal tubes used i n adul t anaest hesi a. Anaesthesi a
2000; 55:388390.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
P. 1000


321. Coet zee GJ. El i mi nat ing protei n f rom reusabl e l aryngeal mask ai rways. A
study comparing routi nel y cl eaned masks wi th t hree al ternative cl eani ng methods.
Anaesthesia 2003;58: 346352.
[Ful l text Li nk]
[CrossRef ]
[Medli ne Li nk]
322. Wal sh EM. Reduci ng the risk of pri on transmi ssi on i n anaesthesi a.
Anaesthesia 2006;61: 6465.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
323. Tordof f SG, Scott S. Bl ood contami nati on of l aryngeal mask ai rways and
l aryngoscopeswhat do we t el l our pat ients. Anaesthesi a 2002;57: 505506.
[Full text Li nk]
[Medli ne Li nk]
324. Cook TM, Lee G, Nol an JP. The ProSeal l aryngeal mask ai rway: a review of
t he l i terat ure. Can J Anesth 2005; 52:739760.
325. Wal sh EM. Ti me t o di spose of nondi sposabl e LMAs. Anest h Anal g
2005; 100: 896897.
[Full text Li nk]
[Medli ne Li nk]
326. Asai T, Morri s S. The l aryngeal mask ai r way: i t s features, ef f ects and rol e.
Can J Anaesth 1994;41:930960.
[Medli ne Li nk]
327. Brain AIJ, Denman WT, Goudsouzi an NG. LMA Classi c and LMA Fl exi bl e
I nst ructi on Manual , LMA Nort h Ameri ca, San Di ego, CA.
328. Cl ery G, Bri macombe J, Stone T, et al . Rout ine cleani ng and autoclaving does
not remove protei n deposi ts f rom reusabl e l aryngeal mask devi ces. Anesth Anal g
2003; 97:11891191.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
329. Bri macombe J, St one T, Kel l er C. Supplementary cl eaning does not remove
protein deposi ts f rom re-usabl e l aryngeal mask devi ces. Can J Anesth
2004; 51:254257.
330. St one T, Bri macombe J, Kel l er C, et al . Residual prot ei n cont ami nat i on or
ProSeal laryngeal mask ai rways af ter two washing protocol s. Anaesth Intens Care
2004; 32:390393.
[Medli ne Li nk]
331. Laupu W, Bri macombe J. Potassi um permanganate reduces protein
contaminati on of reusabl e arl yngeal mask ai rways. Anesth Anal g 2004;99:614
616.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
332. Bri macombe JR. Laryngeal mask resi dual vol ume and damage duri ng
steri l i zat ion. Anesth Anal g 1994; 79: 391.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
333. Brain AIJ. Autoclavi ng laryngeal masks. Anesth Anal g 1994;79:199.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
334. Bri macombe J. Spont aneous rei nf l ati on characteri st i cs of the l aryngeal mask
ai rway. Can Anaesth Soc J 1993;40:873.
335. Bi ro P. Damage to l aryngeal masks duri ng steri l i zat i on. Anesth Anal g
1993; 77:1079.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
336. Khan KZ, West M, Vi ckers RJ. An evaluati on of safety of storage practi ces of
l aryngeal mask ai rways and t racheal t ubes. Anaesthesi a 2003;58:10381040.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
337. Shannon PE, Steel D. Pot ent i al hazard f rom i ncorrect cleani ng of l aryngeal
mask ai rway. Anaesthesi a 1996; 51:603604.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
338. Wi l l iams OA, Wi l con MH, Ni col CD, et al . Li gnocai ne spray appl icators are a
potenti al source of cross-i nf ect ion i n anaestheti c room. Anaesthesi a 1993;48:61
62.
[Medli ne Li nk]
339. Weber DJ, Wi l son MB, Rutala WA, et al . Manual venti lati on bags as a source
f or bacteri al coloni zat ion of intubated pati ents. Am Rev Resp Di s 1990; 142:892
894.
[Medli ne Li nk]
340. St ernl i cht AL, Van Poznak A. Si gnif i cant bacteri al col oni zati on occurs on t he
surf ace of non-di sposabl e sphygmomanomet er cuf f s and re-used disposabl e cuf fs.
Anesth Anal g 1990;70:S391.
341. Anonymous. Bl ood pressure cuff s designed to protect agai nst i nf ect i ous
agents. Bi omed Saf e Stand 1996;26:142.
342. Assadi an O, Assadi an A, Aspock C, et al . The st ethoscope as a potenti al
source of transmissi on of bacteri a. Inf ect Control Hosp Epi demi ol 1998; 19:298
299.
[Medli ne Li nk]
343. Smi th MA, Mat hewson JA, Ul ert I A, et al . Contami nated stet hoscopes
revi si ted. Arch Intern Med 1996;156:8284.
[CrossRef ]
[Medli ne Li nk]
344. Thof ern UA. Bacteri al contami nati on of hospi t al physi ci ans' stet hoscopes.
I nfect Control Hosp Epi demi ol 2000;21: 558559.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
345. Bernard L, Kereveur A, Dureand D, et al . Bacteri al cont aminati on of hospi tal
physi ci ans' stethoscopes. Infect Cont rol Hosp Epi demiol 1999;29:626628.
[CrossRef ]
[Medli ne Li nk]
346. Lange CG, Morri ssey AB, Donskey CJ. Poi nt-prevalence of contaminati on of
heal thcare workers' stethoscopes wi th vancomyci n-resi stant ent erococci at t wo
t eachi ng hospi tals i n Clevel and, Ohi o. I nfect Control Hosp Epi demi ol 2000;21:756.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
347. Brook I. The stet hoscope as a potent i al source of t ransmissi on of bacteri a.
I nfect Control Hosp Epi demi ol 1997;18: 608.
[Medli ne Li nk]
348. Marinel l a MA, Pi erson C, Chenowet h C. The stethoscope. A potent ial source of
nosocomial infecti on? Arch Intern Med 1997;57:786790.
349. Sal yer JW, Burton K, Lynch J, et al . Adventures i n recycl ing: t he reuse of
disposabl e pul se oxi meter probes. Respi r Care 1993;38:10721076.
[Medli ne Li nk]
350. Wi l ki ns MC. Residual bacteri al contami nati on on reusabl e pul se oximet ry
sensors. Respi r Care 1993; 38:11551160.
[Medli ne Li nk]
351. Sal yer JW. Cl ean em or t oss emdoes i t matter? Respi r Care 1993;38:1141
1142.
352. Raf fert y TD, Wol k SR, Raf fert y DK, et al . EPA, FDA and OSHA regul ati on of
t ransesophageal echocardi ography probe cl eaning. Anesth Anal g 2004; 98:A25.
353. Mi l l er KF, Spi ekermann BF. A si mpl e way to keep your pen germ-f ree. Anesth
Anal g 1998;86:495.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
354. Tai t AR, Tutt l e DB. Universal precauti ons are not universal l y practi ced by
anesthesi ol ogi sts. In response. Anesth Anal g 1995;81:205.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
355. Si debotham D, Anderson B, Featherstone D, et al . Transfer of adenovi rus
i nfect ion f rom pati ent t o anaesthet ist during emergency t racheal i ntubati on.
Anaesth Intens Care 1997;25:8385.
[Medli ne Li nk]
356. Perry J. Prot ecti ng your eyes f rom sprayed, spl ashed blood. Outpati ent
Surgery Magazine 2003;4:8283.
357. Cul l en BF. Yes, put on gloves, but also t ake them of f . Anesthesiol ogy
1995; 80:1066.
358. Ben-David B, Gai t ini L. The rout i ne weari ng of gl oves: i mpact on the f requency
of needl esti ck and percutaneous i nj ury and on surf ace contaminati on i n the
operati ng room. Anesth Anal g 1991;83: 623628.
[Medli ne Li nk]
359. Cork RC, Wood D, Evans B, et al . Leak rate of l atex gloves af ter teari ng
adhesive tape. Am J Anesth 1995;22:133137.
360. Ho AM-H, Lam GCS, Karmaker MK. Pot enti al eye i nj ury due to protect ive f ace
shiel ds. Anesthesi ol ogy 2004; 100: 201.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
361. Babb JR, Bradl ey CR. The mechani cs of endoscope disinfecti on. J Hosp Inf ect
1991; 18[Suppl A]:130135.
362. Bj erke NB. Test your hand hygi ene IQ. Outpati ent Surgery Magazi ne
2003; 4:3844.
363. Tessl er MJ, Gri l l as N, Gi osef f i ni S. Bacteri al counts on the hands of
anesthet ists and anesthesia t echni ci ans. Anest h Anal g 1994;78:10301031.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
364. Anonymous. CDC backs hand rubs over soap and wat er. Outpati ent Surgery
Magazi ne 2002;3:6.
365. Anonymous. Integrati ng the new CDC hand hygi ene gui del i nes wi th OSHA' s
BBP st andard. Heal th Devices Al ert s 2002;26:12.
366. Kat z JD. CDC gui del i ne urges physi ci ans t o wash thei r hands of a di rt y
probl em. ASA Newsl ett 2003; 67:21.
367. Mayworm D. Do al cohol -based hand sani ti zers pose a f i re hazard? Outpati ent
Surgery Magazine 2003;4:9495.
368. Barl as S. TIA cleans up hand-sani ti zer cont roversy. NFPA J 2004;98:36.
369. Widmer AF, Dangel M. Alcohol -based handrub: eval uat i on of technique and
mi crobi ologi cal eff icacy wi th i nternati onal i nfect ion cont rol professi onal s. I nf ect
Control Hosp Epi demi ol 2004;25:207209.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
370. Rosenberg AD, Bernstei n DB, Bernstei n RL, et al . Acci dental needl esticks: do
anesthesi ol ogi sts pract ice proper i nf ect ion cont rol precauti ons? Am J Anesth
1995; 22:125132.
371. Orenstei n R, Reynolds L, Karabaic M, et al . Do protect i ve devices prevent
needl est ick inj uri es among heal th care workers? Am J Inf ect Control 1995; 23: 344
351.
372. Perry J. Improvi ng your sharps saf ety program. Outpati ent Surgery Magazi ne
2003; 4:9496.
373. Anonymous. Needlesti ck prevent ion: a bri ef review. Technol Anest h
2003; 24:15.
374. Tai t AR, Tutt l e DB. Prevent i on of occupati onal transmissi on of human
i mmunodef i ci ency vi rus and hepat i ti s B vi rus among anesthesi ol ogi sts: a survey of
anesthesi ol ogy practi ce. Anesth Anal g 1994;79:623628.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
375. Anonymous. Saf e di sposal of medi cal wast e sharps. Technol Anesth
1993; 14:112.
376. Anonymous. Double-gl oving. Technol Anesth 2002(12); 22: 35.
377. Edl i ch RF, Wi nd TC, Hi l l LG, et al . Resi stance of doubl e-gl ove hol e punct ure
i ndi cat i on systems to surgical needl e puncture. J Long Term Ef f Med I mplants
2003; 13:8590.
[Medli ne Li nk]
378. Lee J. How to prevent i nfecti on f rom heal t h care workers. Outpat ient Surgery
Magazi ne 2002; Special edi t ion:2124.
379. Hughes SC, Marti n DE. Tradi t ional I .V. cat heters: to be or not to be, that is the
questi on! ASA Newsl et t 2005; 69:1417.
380. Hughes S. HIV and ot her occupati onal exposures: ri sk management (ASA
Ref resher Course #531). Park Ri dge, IL: Aut hor, 1998.
381. Greene E. Hepati t is C out break: more t han 50 i nf ected by reused needl es and
syri nges. ASA Newslet t 2002;66:2224.
382. Snydman DR, Hi ndman SH, Wi nel and MD, et al . Nosocomi al vi ral hepat i t i s B.
A cl uster among staff wi t h subsequent t ransmissi on to pati ents. Ann I ntern Med
1976; 85:573577.
[Medli ne Li nk]
383. Pet erson GN. CDC sets gui del i nes f or preventi ng TB t ransmissi on in heal th
care faci li ti es. ASA Newsl et t 1995;59: 2426.
384. Greene ES, Berry AJ, Jagger J, et al . Mul t icenter st udy of contami nated
percutaneous i nj uries i n anesthesi a personnel . Anesthesi ology 1998;89:1362
1372.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
385. Tai t AR. Occupati onal transmissi on of t ubercul osis: impl i cat i ons f or
anesthesi ol ogi sts. Anesth Anal g 1997;85:444451.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
386. Decker MD. OSHA enf orcement poli cy f or occupat i onal exposure to
t ubercul osis. Inf ect Cont rol Hosp Epidemiol 1993;14:689693.
[Medli ne Li nk]
387. Davis YM, McCray E, Simone PM. Hospi tal i nf ect ion cont rol pract ices for
t ubercul osis. Cl i n Chest Med 1997;18:1933.
[CrossRef ]
[Medli ne Li nk]
388. Cent ers for Disease Control and Prevent ion. Gui del i nes f or preventi ng t he
t ransmissi on of Mycobacteri um t uberculosi s i n heal th care f aci l i ti es. MMWR Morb
Mortal Wkl y Rep 1994; 43(RR-13):132.
389. Candiott i K, Sal t zman B, Rodri guez YF. Radiostethoscopes: a sol uti on f or the
probl em of auscul tati on whi l e weari ng protect ive gear. Anesthesi ol ogy
2005; 103:A811.
390. Anonymous. Negati vel y pressuri zed operati ng rooms. Technol Anesth
2003; 23:1.
391. Al exander BH, Checkoway H, Nagahama SI , et al . Cause-speci f ic mortali ty
ri sks of anesthesi ol ogi sts. Anesthesiology 2000;93:922930.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
392. Ross RS, Vi azov S, Gross T, et al . Transmi ssion of hepati tis C vi rus f rom a
pati ent t o an anesthesi ol ogy assi stant to fi ve pat i ents. N Engl J Med
2000; 343: 18511854.
[CrossRef ]
[Medli ne Li nk]
393. Cody SH, Nai nan OV, Garfein RS, et al . Hepati ti s C vi rus t ransmi ssi on f rom an
anesthesi ol ogi st to a pati ent. Arch I ntern Med 2002;162:345350.
[CrossRef ]
[Medli ne Li nk]
394. Berry AJ. Infecti on control recommendat i ons; thei r i mportance to t he pract i ce
of anest hesi ol ogy. ASA Newsl ett 2001; 65:15.
395. Berry AJ. Spreadi ng the word on i nf ecti on cont rol . ASA Newsl et t
2002; 66:4546.
396. Busby J. Through the val l ey of many shadows. HIV i nfected physicians. Tex
Med 1991; 87:3646.
[Medli ne Li nk]
397. Hal ti a M. Human pri on di seases. Ann Med 2000; 32:493500.
[Medli ne Li nk]
398. Col l i nge J. Vari ant Creut zf eldt-Jakob di sease. Lancet 1999;354:317323.
[CrossRef ]
[Medli ne Li nk]
399. Bl unt MC, Burchet t KR. Vari ant Creut zf el dt-Jakob di sease and di sposabl e
anaestheti c equi pmentbal anci ng the risks. Br J Anaesth 2003;90:13.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
400. Lowe PR, Engel hardt T. Pri on-related diseases and anaest hesi a. Anaesthesi a
2001; 56:485.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
401. Farl i ng P, Smi t h G. Anaesthesi a f or pat i ents wi th Creut zf el dt-Jakob di sease. A
pract i cal guide. Anaesthesia 2003; 58:627629.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
402. Hernandez-Pal azon J, Marti nez-Lage JF, Tort osa JA, et al . Anaesthet i c
management in pati ents suspected of , or at ri sk of havi ng, Creutzfel t -Jakob
di sease. Br J Anaesth 1998;80:516518.
[Medli ne Li nk]
403. Rei chert M, Schul tz JK. CJD: how to process inst ruments. OR Manager
2001; 17:2122.
[Medli ne Li nk]
404. Dombrovski A, Popat M, Farmery A. Fibreopti c equi pment and pri on di sease.
Anaesthesia 2003;58: 9091.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
405. Anonymous. Fi breopt ic equi pment and pri on di sease. Anaesthesi a
2003; 58:482483.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
406. Peng PWH, Wong DT, Bevan D, et al . Inf ecti on cont rol and anesthesia:
l essons l earned f rom the Toronto SARS outbreak. Can J Anesth 2003;50: 989
997.
407. Chang K-A, Luk H-N, Jawan B, et al . Modi f i ed protect ive sui ts f or
anesthesi ol ogi sts performi ng tracheal i ntubati on for severe acut e respi rat ory
syndrome pat ients i n Tai wan. Anesthesiology 2004;100:16301631.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
408. Anonymous. Inf ected: an anesthesiol ogist ' s personal bat t le wi th SARS. ASA
Newslett 2003;67: 2325.
409. St ackhouse RA. SARS: i ts hi story, i ts chal lenges. ASA Newsl et t 2003;67:19
22, 5.
410. Kammi ng D, Gardam M, Chung F. Anaesthesi a and SARS. Br J Anaesth
2003; 90:715718.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
411. Caputo KM, Byri ck R, Chapman MG, et al . I ntubati on of SARS pati ents:
i nfect ion and perspecti ves of heal thcare workers. Can J Anesth 2006;53: 122129.
P. 1001


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
1. Concerning the three levels of di sinfecti on recognized by the CDC,
A. Hi gh-l evel di sinf ecti on means that bacteri al spores are ki l led
B. Semicri ti cal i t ems can be t reated wi t h i ntermedi ate-l evel di si nf ecti on
C. The Creut zf el dt -Jakob vi rus is kil led wi t h high-l evel di si nf ect ion
D. I nt ermediate-l evel disi nfecti on means that M. tubercul osi s i s ki l l ed
Vi ew Answer2. Advantages of steam autoclaving i nclude
A. I t i s hi ghl y eff ect i ve
B. I tems can be packaged bef orehand
C. I t i s i nexpensi ve
D. Absence of toxi c resi dues
Vi ew Answer3. Factors that affect the effectiveness of chemical
di si nfecti on include
A. Temperature
B. Use pattern
C. pH
D. Characteri st ics of the i t em t o be di si nf ect ed
Vi ew Answer4. EO
A. Is fl ammabl e i n concent rati ons exceedi ng 5%
B. Is not usef ul f or i tems contai ning pet rol eum-based lubri cant
C. I s odorl ess
D. Shoul d not be used on i tems t hat are wet
Vi ew Answer5. Cleaning i s important as the fi rst step because
A. Retai ned sal ts and organic soi l can i nacti vate chemi cal germici des
B. Even af ter steri li zati on resi dues can cause a pati ent reacti on
C. Soi l can protect mi croorgani sms duri ng di sinfecti on and steri l i zat i on
D. Residues may i nt erf ere wi t h the devi ce function even af ter steri l i zati on
Vi ew Answer6. Concerni ng the cl assification of i tems according to the
CDC,
A. Semicri ti cal i t ems i ncl ude t racheal tubes
B. Bl ood pressure cuf fs are noncri ti cal i tems
C. Hi gh-l evel disi nfecti on i s acceptabl e f or semicri ti cal i tems
D. Phenol s are usef ul f or semicri ti cal i tems
Vi ew Answer7. Which of the foll owing statements are correct?
A. An anti septi c can be safel y appl i ed t o li vi ng ti ssue
B. A di si nf ectant i s a germicide to be used sol el y on i nanimate obj ects
C. A sani t i zer i s a l ow-l evel disinf ectant wi t h no cl ai m f or t ubercul oci dal acti vi ty
D. A steri l ant /disi nfectant is a germi ci de that i s capabl e of steri l i zati on or hi gh-l evel
di si nf ect ion
Vi ew Answer8. The rol e of the FDA i s to
A. Requi re new germi ci des to demonstrate 10
6
steri l i t y
B. Regul ate medical devi ces
C. Requi re test ing of formul ati ons for mi crobi ci dal pot ency, stabi l i t y, and toxici t y
D. Regul ate l i qui d chemi cal germici des t hat are used to reprocess medi cal
i nst ruments
Vi ew Answer9. The functi ons of the CDC incl ude
A. Approvi ng germici des
B. Regul ati ng germi ci des
C. Testi ng germi ci des
D. Recommending broad strat egi es to prevent t ransmi ssi on of i nf ect i ons i n the
heal th care envi ronment
Vi ew Answer10. Practi ces and procedures to reprocess reusabl e devi ces
have been publ ished by which organizations?
A. Ameri can Society of Anest hesi ol ogists
B. Associat i on of Operati ng Room Nurses
C. Ameri can Associ at ion of Nurse Anestheti sts
D. Centers f or Di sease Cont rol and Preventi on
Vi ew Answer11. Advantages of pasteurization i ncl ude
A. No t oxi c resi dues or f i lms
B. Can be used f or prepackaged i t ems
C. Can be used f or tracheal tubes and breathi ng tubes
D. Hi gh temperatures can be used
Vi ew Answer12. Disadvantage(s) of steam steri lization i ncl ude
A. Adequate penet rat i on into a pack may not occur wi t h l arge packs
B. Al l spores may not be kil l ed
C. Danger t o processi ng personnel
D. I nst rument damage
Vi ew Answer13. Glutaral dehyde i s effecti ve against which cl asses of
organi sms?
A. Spores
B. Vi ruses
C. Fungi
D. Bacteri a
Vi ew Answer14. Hazards of gl utaraldehyde exposure include
A. Skin i rri t at ion
B. Headaches
C. Asthmal i ke symptoms
D. Gastroi ntest inal upset
Vi ew Answer15. Which agent(s) is(are) sporicidal?
A. Quats
B. Al cohol s
C. Phenol i cs
D. OPA
Vi ew Answer16. Disadvantages of l iqui d chemical disinfection i ncl ude
A. Prepackaging i s not possible
B. Lack of good met hod f or val i dat ion
C. No guarantee of steri l i t y
D. Not eff ecti ve against HIV
Vi ew Answer17. Which of the foll owi ng are ki lled by EO?
A. Vi ruses
B. Fungi
C. Bacteri a
D. Spores
Vi ew AnswerP. 1002


18. Which factors are important for proper EO steri li zation?
A. Exposure t ime
B. Relat i ve humi di ty
C. Gas concentrati on
D. Temperature
Vi ew Answer19. Patient compl icati ons associated with contact wi th EO-
steri l ized i tems i nclude
A. Laryngot racheal i nfl ammati on
B. Anaphylaxi s
C. Hemol ysi s when EO i s exposed to bl ood
D. Cancer
Vi ew Answer20. Advantages of EO steri li zation i ncl ude
A. I tems can be prepackaged
B. A l arge amount of equipment can be steri l i zed at one t ime
C. I t can be used f or i tems that heat or moisture coul d damage
D. Short processing t i me
Vi ew Answer21. Disadvantages of EO steri li zation i nclude
A. Not useful for equi pment wi t h smal l l umens
B. Danger of f i res and explosi ons i n steri l i zers
C. Damage to some very smal l equi pment
D. More costl y than other types of steri li zati on
Vi ew Answer22. Advantage to -radiation i ncl ude
A. Product may be prepackaged
B. Thermol abil e equi pment can be steri l i zed
C. No temperature rise duri ng steri l i zat ion
D. I t i s usef ul f or t he average hospi t al
Vi ew Answer23. Advantages of pl asma steri li zati on include
A. No worker exposure or envi ronmental contami nat i on
B. Lack of t oxi c resi dues
C. Compati bl e wi th cerami cs, sil i ca, gl ass, and many pl ast i cs
D. Steri l i zed products are immediatel y avai l abl e f or use
Vi ew Answer24. Appropri ate barrier precautions i ncl ude
A. Eye protecti on
B. Face shi el ds
C. Fl ui d-resistant masks
D. Gl oves
Vi ew Answer25. Techniques that are designed to prevent needlesti cks
i ncl ude
A. Weari ng gl oves when start i ng an i ntravenous i nfusi on
B. Di sposi ng of used needl es in a central l ocati on
C. Using protect ive devices over the needl e
D. Recapping needl es as soon as they are used by using both hands
Vi ew Answer26. Which of the foll owi ng are part of the CDC guideli nes for
care of a patient with TB?
A. The pat ient shoul d be i n a room wi th posi ti ve-pressure venti l at ion
B. Respi ratory isol ati on i s requi red unti l TB i s rul ed out
C. Ul traviol et l i ght i s not hel pful
D. Personnel should wear special protect ion devi ces that are approved by the CDC
f or f i l trat ion and f i t
Vi ew Answer27. Which statements are true of HI V?
A. The ri sk of HIV inf ecti on af ter a holl ow-bore needle st i ck i s 0.3%
B. The vi rus i s rel at ivel y stabl e i n the envi ronment
C. HI V is relati vel y unstabl e i n the envi ronment and is rapi dl y inactivated by a wi de
range of chemi cal germi ci des
D. HI V-cont ami nated devices need onl y i ntermediate-l evel decont aminati on
Vi ew Answer28. Which statements are true of HBV?
A. The ri sk of cont racti ng HBV af ter a needl est i ck i s 10% to 30%
B. Mul ti dose vi al s have not been f ound to faci l i tate nosocomial i nfecti ons
C. Devices contami nated wi th blood wi t h pat i ents f rom HBV requi re hi gh-l evel
decontami nat ion
D. HBV survi ves onl y a short ti me on envi ronmental surfaces
Vi ew Answer29. Which statements concerni ng CJD are true?
A. St eri l i zati on requi res steam at 134C t o 138C
B. Laryngoscopes and LMAs t hat are exposed to an infected pati ent shoul d be
di scarded
C. The i ncubat i on period can be months to years
D. Gl utaraldehyde, f ormal dehyde, and phenol i cs are not ef fecti ve agai nst pri ons
Vi ew Answer