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Abstract: Ethylene oxide (EO) is used to sterilize Oxygenator and Tubing applied to heart
surgery. Residual levels of EO and its derivatives, ethylene chlorohydrin (ECH) and ethylene
glycol (EG), may be hazardous to the patients. Therefore, it must be removed by the aeration
process. This study aimed to estimate the minimum aeration time for these devices to attain
safe limits for use (avoiding excessive aeration time) and to evaluate the Green Fluorescent
Protein (GFP) as a biosensor capable of best indicating the distribution and penetration of EO
gas throughout the sterilization chamber. Sterilization cycles of 2, 4, and 8 h were monitored
by Bacillus atrophaeus ATCC 9372 as a biological indicator (BI) and by the GFP. Residual
levels of EO, ECH, and EG were determined by gas chromatography (GC), and the residual
dissipation was studied. Safe limits were reached right after the sterilization process for
Oxygenator and after 204 h of aeration for Tubing. In the 2 h cycle, the GFP concentration
decreased from 4.8 (63.2)% to 7.5 (62.5)%. For the 4 h cycle, the GFP concentration
decreased from 17.4 (63.0)% to 21.5 (66.8)%, and in the 8 h cycle, it decreased from 22.5
(63.2)% to 23.9 (63.9)%. This finding showed the potentiality for GFP applications as an EO
biosensor. ' 2009 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 91B: 626630, 2009
Keywords:
INTRODUCTION
Ethylene oxide (EO) is the most common sterilizing agent
used to sterilize medical devices, which are sensitive to
heat or gamma irradiation treatment.1,2
However, after the sterilization process (Process),
residual concentration of EO and its derivative products,
ethylene chlorohydrin (ECH) and ethylene glycol (EG),
might remain in the medical devices, depending mainly on
the type and size of polymeric plastic material.3,4
These residues are potentially toxic, mutagenic, and carcinogenic substances.36 Therefore, it is imperative to remove
them from the devices to avoid adverse effects in patients.
Membrane blood oxygenator (Oxygenator) and set of
PVC tubing (Tubing) are medical devices used interconnected in cardiopulmonary bypass (CPB) undergoing
open-heart surgery providing temporary cardiac and pulmonary support.
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After being subjected to EO sterilization, they are commonly maintained in an aeration room to remove the residual excess of EO and its derivatives. After that the devices
are subjected to a simulated-use extraction,7 and the
remaining residues are determined by gas chromatography
(GC) to check the values against the safety limits.8
The Process is monitored by spores of Bacillus
atrophaeus as biological indicator (BI).9 However, the BI
results do not provide enough information about EO
distribution through the Chamber. Still, it is an important
factor to know the process and better adjust the sterilization
parameters. Besides, it enables economy by reducing costs
with EO gas and by reducing the retention time of the
medical devices in the aeration room.
To address this need, a biosensor capable of providing
information about the distribution and penetration of the
EO through the load in the sterilization chamber (Chamber)
should be used.
Enzymes and proteins have been used as biological
indicators to evaluate the efficacy of industrial procedures,
such as blanching, pasteurization, and disinfection treatments10,11 and EO is a reactive alkylating agent by adding
alkyl groups to DNA, RNA, and proteins.3
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Figure 1. Positions (
) of temperature and humidity sensors, BIs
and GFP distributed in the load of medical devices inside the sterilization chamber.
Load
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DIAS ET AL.
After the Process and forced aeration step, each item was
subjected to the simulated-use extraction. One Oxygenator
was withdrawn from the load at intervals of 2 h and 4 h of
aeration. For the Tubing, one set was withdrawn after 72 h
of aeration, and at intervals of 30 h, 50 h, and so on up to
288 h of aeration time. The devices were withdrawn from
the critical points of the load (Figure 1). Each cardboard
box was replaced with a similar product to keep the load
configuration and avoid air flow preference.
Residual Extraction. The simulated-use extraction was
performed under conditions which provide the greatest
challenge for the intended use as described in ISO 109937,8 which was based on a closed circuit, simulating a CPB,
where purified water (\100 CFU/mL and conductivity
\1.3 lS/cm at 258C) in a volume of 4.0 L for the Oxygenator and 2.0 L for the Tubing filled the path from the venous blood inlet in the circuit up to the arterial blood
outlet.
The circuits were connected to a peristaltic pump which
provided continuous circulation (6 L/min) of purified water
kept warm at 378C (corporeal temperature). After 6 h of
CPB simulation, the collected extract was analyzed to measure the EO, ECH, and EG residues by GC.
devices by simulated-use extraction, 1 lL aliquot of the samples of EO, ECH, and EG was automatically injected into the
GC model HP6890 (Hewlett Packard Company, Wilmington,
DE) operationally controlled by the ChemStation for
HP6890 software. A polyethylene glycol capillary column
model HP 19091N-133 (30 m 3 250 lm 3 0.25 lm) for separation using ultrapure nitrogen as carrier gas running at 1.8
mL/min, and a Flame Ionization Detector (FID) at 2508C
supplied with a hydrogen gas flow rate at 35.0 mL/min were
used. The maximum temperature of the automatic injector
was 2608C at 18 psi of pressure. The LOD and LOQ were
estimated respectively, as 0.42 lg/mL and 1.38 lg/mL for
EO. For ECH, they were 0.37 lg/mL and 1.22 lg/mL, and
for EG, they were 16.71 lg/mL and 55.71 lg/mL.
Residual Level Concentration. The residual levels were
determined by GC (given in lg/mL) multiplied by the total
extract volume used in the simulated-use extraction (2.0 L
and 4.0 L for the Tubing and Oxygenator, respectively), and
the results of each sample analyzed, expressed as mg/device,
and were used to construct the linear dissipation curves,
made on the basis of the established limits for Oxygenator
and Tubing which determined their aeration time.
Limits
The maximum limits of residues for Oxygenators and Tubing are 60 mg for EO and 12 mg for ECH. No exposure limits are set for EG, because the risk assessment
indicates that when EO residues are controlled as required,
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CONCLUSIONS
The control of the sterilization process as well as the residues from EO in medical devices is extremely important
for the patients safety.
High amounts of EO adsorbed by PVC articles provide
a longer retention time in an aeration room than polycarbonate materials, becoming a great challenge for sterilization companies that can handle it by improvements in
sterilization cycle parameters and better aeration conditions.
GFP showed its potential for industrial applications as a
biosensor to measure the EO distribution during the sterilization process, reporting the gas action at different points
inside the Chamber.
The interaction of GFP with the EO sterilization process
is in progress and these preliminary results show interesting
perspectives and encourage further studies.
The authors are grateful to Nipro Medical Ltda. for providing
materials and supplies for this research, to Ivan Pereira de Godoi
for his collaboration in the study of the sterilization cycles and
constant support, and to Professor Adalberto Pessoa Junior for his
encouragement and useful suggestions.
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REFERENCES
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Ethylene oxide sterilization of surgical sutures monitored by
Bacillus subtilis. Zent Steriliz 2002;10:2437.
2. Affatato S, Bersaglia G, Emiliani D, Foltran I, Taddei P,
Reggiani M, Ferrieri P, Toni A. The performance of gammaand -sterilised UHMWPE acetabular cups tested under severe
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