PerioperativeNursing

Introduction
The term perioperative nursing refersto all activities before, during and after a surgical procedure, which ensure thebest
possible care of an animal. Both the international and theGerman regulations considerit a responsibility of the research or
teaching institution to ensure that all personnel,regardless of academic degrees, are qualified and trained to conduct
surgical procedures. Personnel who perform surgery, as well as staff members who manage the operating rooms,must be
qualified and trained forthe assigned procedures orfunctions. In this chapter a brief description of the fundamental concepts
of perioperative nursing is given,to facilitate the training ofthe MPIKpersonnel. Firstly, the topics of surgical
asepsis,sterilization and disinfection, attire, and tools, are discussed; and secondly the MPIK operating roomand the protocol
ofsurgerypreparation is described in some detail. Finally, abrief description is given of premedication and of the
factorsthatmay greatly influence the presurgicalstate oftheanimal.
SurgicalAsepsisAt MPIK allsurvivalsurgical procedures are performed under aseptic conditions. Itistherefore imperative that
allpersonnel isfamiliar with the principles of asepsis.
Terms and Definitions
Micro-organisms or microbes: Bacteria, viruses,fungi, algae, protozoa, and spores,thatis, allthose
organismsthat are generally considered too smallto be seen clearly with the naked eye, are known asmicrobes ormicro
organisms. The study ofsuch organismsis known as Microbiology. Mostmicrobes are unicellular,thatis,theyconsist of only
one cell which carries out allthe functions necessary forlife. Microbes are named according to thebinomialsystem. The first
partisthe generic name, indicating the genusto which the organismbelongs, and thesecond isthe specific name indicating the
species.
Parasites: A parasite is an organismwhich lives on orin anotherliving organism(the host) and derives
nourishmentfromit.
Pathogen: Pathogen is a parasite that harmsthe host by causing disease.
Bacteria: Bacteria are singlecelled organisms. Three basic shapes are generally recognized: cylindrical or rodshaped called
bacilli (singular bacillus),spherical cellsthat are called cocci (singular coccus), and spiral or helical cells called spirilla
(singularspirillum)ifthey have rigid cell wall spirochaetes(singularspirochaeti) ifthe cell wall is flexible. Some cocci existsingly
while othersremain togetherin pairs after division and are called diplococci. Forour purposesimportantisthe classification of
bacteria on the basis oftheirreaction to a combination ofstainsdeveloped byGram. Gramsmethod enables usto divide
bacteria into two groups:(a)Grampositive, which stain purple, and (b)Gramnegative, which stain red.
Spores: Some species of bacteria (most common in the genera Bacillus and Clostridium) produce dormantformscalled
spores(or endospores)that can survive in unfavorable conditions. Such sporeforming bacteria exist almost everywhere,
including dust, and are extremely resistant structures,remaining viable formany years. They can survive extremes of heat,
pH, desiccation, ultravioletradiation, and exposure to toxic chemicalssuch assomedisinfectants.
Viruses: Viruses aremuch smaller and simplerthan bacteria. They are all obligate parasites depending on
hostcellsforreproduction (replication), and for carrying out other vital processes. Once a virus beginsto replicate,thehost
cells do not usually continue to function normally. Sometimes cells are damaged and killed, othertimesinfected cellsshow no
visible change but do notfunction properly. Viral infections are usually difficultto control and2 treat because any drug
thatinterferes with viralreplication is almost certain to also have a harmful effect on thehost cells.
Fungi: Fungirange in size frommicroscopic, unicellularformsto largemulticellular organisms which can easily beseen with the
naked eye. Some fungi are pathogenic. They can be classified in (a) yeaststhat are unicellularfungiusually round or ovoid
reproduced by a process called budding, and (b) moldsthat aremulticellular organismscomposed by long filaments called
hyphae (singular hypha).
Toxins: Toxins are poisonoussubstancesthat have a damaging effect on the cells ofthe host. Because thetoxincan be
transported through the tissuesthe effects ofthe toxin are felt not only in the affected cells and tissues butalso elsewhere in
the body. Two types oftoxins are recognized: (a) exotoxinsthat aremanufactured by livingmicroorganisms and released into
the surroundingmedium, and (b) endotoxins which are retained within themicroorganismand only liberated when it dies.
Endotoxins are part ofthe cell wall of certainGramnegative bacteria andreleased only when the cells die and disintegrate.
Bloodborne endotoxins are responsible for a range of nonspecific reactionsin the body,such a fever. They alsomake the
walls of blood capillariesmore permeable, causing
blood to leak into the intercellularspaces, which in turn can resultin a serious drop in blood pressure.
Epidemic Disease: Epidemic diseases are those diseases whose incidence increasessharply and involveslargenumbers
ofindividualsin an area.
Zoonoses: Zoonoses are diseasesthat can be transmitted directly to humans by animals. Examples ofzoonoticagentsthat are
known to be transmitted frommonkeysto humans, and which presentserious health hazards, arerabies, bvirus,filovirus,Q
fever,tuberculosis,toxoplasmosis, and others.
Inflammation: In general inflammation isthe reaction of normaltissuesto an irritant. More specifically
inflammation isthe process which beginsfollowing injury to a tissue and ends with healing orthe eventual death ofthe tissue.
The signsthat characterize inflammation (called the cardinalsigns) are:(1) Redness,(2) Swelling, (3)Heat,(4) Pain, and (5) Loss
of normalfunction. The pain is associated with inflammation is due to increased pressureon the nerve endings because ofthe
swelling. Loss offunctionsresultsfrompaininduced inhibition ofmuscleactivity;themechanical effects ofswelling and tissue
distraction. Inflammationsmay be acute or chronic. Chronicinflammationsmay occurin the laboratory because ofthe
recording hardware implanted on the animalsskull. The treatment ofsuch inflammationsis discussed below.
Resolution: Resolution isthe return of a tissue to itsstate priorto the onset of an inflammation.
Regeneration: Regeneration isthe replacement oftissue destroyed by the inflammatory process with similarfunctionaltissue.
Organization: Organization isthe replacement oftissue destroyed by the inflammatory process with connective(scar)tissue.
Sepsis: The presence of pathogens ortheirtoxic productsin the blood ortissues of an animal. More commonlyknown
assystemic infection.
Asepsis: Freedomfrominfection by excluding allmicroorganisms and spores.
Antisepsis: Prevention ofsepsis by destruction orinhibition ofmicroorganisms using an agentthatmay be safelyapplied to
living tissue.
Sterilization: The destruction of allmicroorganisms and spores.
Antiseptic: A chemical agentthat either kills pathogenicmicroorganisms orinhibitstheir growth aslong asthereis contact
between agent andmicrobe. Antiseptics(in contrastto disinfectants) are applied to the body. Theantisepticmay actually be a
disinfectant used in dilute solutionsto avoid damage to tissues.3
Drain: any device by which a channel or openingmay be established andmaintained forthe exit offluid or
purulentmaterialfromany cavity, wound orinfected area.
Drainage:the systematic withdrawal offluid fromany wound,sore, or cavity in the body.
Penrose Drain:themost commonly used drain,made ofsoft,thinwalled rubbertubing 0.64 to 2.54 cmin
diameter.
Sump Drain: a large tube with a second smallertube in the wall or within the lumen ofthe largertube. Thesmallertube allows
airto enter and facilitates drainage offluid fromcavity.
Infections
Aseptic and sterile techniques, based on sound scientific principle, are carried out primarily to
preventtransmissionofmicroorganismsthat can cause infection. Microorganisms are invisible, butthey are presentin the air
and onanimate and inanimate objects. To preventinfection, all possiblemeasures are taken to create andmaintain
atherapeutic environmentforthe patient.
Infection thatis acquired during the course ofsurgery or general health care is known as a nosocomial infection.
Theinfectionmay occurin the postoperative wound or as a complication unrelated to the surgicalsite. Postoperativeinfection
is a very serious, potentially fatal complication thatmay resultfroma single break in aseptic technique. Therefore knowledge
of causative agents and their control as well asthe principles of aseptic and sterile techniques isthe basis of
prevention.Infectionsmay be caused by one orseveraltypes ofmicroorganisms. Types are numerous and vary in incidence
andsignificance ofinfection produced. Whatfollowsis a very shortlist ofthe pathogens causing infectionsin laboratory
primates.
BacterialInfections
Bacteria are classified by the environmentthatsustainstheirlife with oxygen (aerobic) or without oxygen
(anaerobic), and as grampositive or gramnegative.Gramsstain (Gentian violet)is a laboratory technique foridentifying a
primary characteristic of bacteria. Those thatstain blue/purple are grampositive while those that donotstain are gram
negative. Infectionsmay be caused by aerobic, microaerophilic, or anaerobic bacteria or can bemixed bacterial infections.
Micoaerophilsrequire less oxygen than presentin air. The following are themostcommon bacterial pahtogens:
AerobicBacteria
(a)Grampositive cocci,such as Staphylococcus aureus, Staphylococcus epidermidis, StreptococcusGroup
B,StreptococcusGroupD,methicillinresistant Staphylococcus aureus(MRSA). Infections caused by Staphylococcusaureus are
unfortunately very common inmonkeys. In particular, ifthe animals are brought back to their home cageimmediately
afterthe surgical procedures.Gramnegative cocci,such asNeisseria gonorrhoeae.
(b)Grampositive bacilli,such as Bacillusspecies Mycobacteriumtuberculosis.
(c)Gramnegative bacilli,such as Escherichia coli,Klebsiella species, Pseudomonas aeruginosa, Pseudomonas cepacia,
Proteusspecies, Serratiamarcescens,Salmonella species, Enterobacter cloacae, etc.MicoaerophilicbacteriaGrampositive
cocci,such as hemolytic and nonhemolytic streptococci.
Anaerobicbacteria
(a)Grampositive cocci,such as peptostreptococcus, peptococcus.Grampositive cocci cause often problems with
the animals implants. (b)Grampositive bacilli,such as Clostridiumtetani, Clostridiumwelchii. (c)Gramnegative
bacilli,such as Bacteroidesspecies, Bacteroidesfragilis.4
NonbacterialInfections
Infections may be caused by fungi, protozoa, or viruses. With nonhuman primates the most of the
nonbacterial infections are caused by viruses. Possible pathogens are the hepatitis virus, simian
immunodeficiency virus, herpes B virus, cytomegalovirus, Epstein-Barr virus, etc.
Viability ofOrganisms
Microorganisms needmoisture,food, propertemperature, and time to reproduce. When transferred fromone placeto
another,they passthrough a dormant orlag phase of about 5 hours orlonger. Then each organismdivided itself Most
bacteria,fungi, and viruses are killed easily by the processes ofsterilization anddisinfection, but bacterialspores are not.
Spores are the resting, protective stage ofsome rodshaped bacilli.Dense layers of protein formwithin the cellsthatcan be
compared to the shell of a nut. The thickerthe wall,themore resistantthe spore isto destruction. Whenconditionssuitable for
bacterial growth are reestablished,the spore releases cellsfor active growth andreproduction. Although spores are formed
by only about 150 species of bacilli,they are universally presentin theenvironment.
Sources of Contamination
Many sources contaminate theOR environment. Mostmicrobes grow in a warm,moist host, butsome aerobicbacteria, yeasts,
and fungi can remain viable in the air and on inanimate objects. People and animalsthemselves arealsomajorsource
ofmicroorganismsin the surgical environment. Everything on or around a human being and ofcourse anything on and around
themonkey is contaminated by themin some way. In additions,the actions andinteractions of personnel and animals
contribute to the prevalence of variousmicroorganisms. Themost critical areaforthe introduction and spread
ofmicroorganismsis obviously the area occupied by the operated animal and the surgical team. Usualsources are:
Skin The fur and skin ofthe animals, as well asthe skin oftheOR teammembers constitutes a hazard. Hairfollicles and
sebaceous and sweat glands contain abundantresidentmicrobial flora. An estimated 4000 to 10,000 viable particles are shed
by an average individualsskin perminute! Some people disperse up to 30,000 particles perminute.Shedders are persons who
present an additional hazard, andmust be therefore always appropriately dressed when close to operated animals. True
shedders are estimated to be 1 in 50 persons. Major areas ofmicrobial populationon all persons are the head, neck, axillae,
hands, groin, perineum, legs, and feet.
Hair Hairis a gross contaminant andmajorsource of variousspecies of Staphylococcus.Hairfollicles and filaments harborrich
resident and transientfloras. The extentto which themicrobial population is attracted to and shed fromhairisdirectly related
to the length and cleanliness ofthe hair.
Nasopharynx
Organismsforcibly expelled by talking, coughing, orsneezing give rise to bacterialaden dust and lint as dropletssettle on
surfaces and on the skin. Persons known as carriers harbormany organisms, notableGroup AStreptococcus and
Staphylococcus aureus, whichmay be carried pharyngeally orrectally. Such organisms are usuallytransmitted by direct
contact. Surgeons and anesthesiologists can be often carriers because ofintimate contact withthe animalsrespiratory
tract(intubation, etc.). Carriers do not present a realthreatin the absence of an overtlesion.However,they can be a
serioussource ofinfection in presence of an open surgical wound.
Fomites
Contaminated particles are present on inanimate objectssuch asfurniture,OR surfaces(walls,floors, cabinetshelves),
equipment,supplies, and fabrics. Covert contaminationmay resultfromimproper handling of equipment5such as anesthesia
apparatus orintravenous(IV)lines and fluids. Contaminationmay also resultfromtheadministration of unsterilemedications or
use of unsterile waterto rinse sterile items.
Air
Thousands ofsubmicron sized particles per cubic foot of air are presentin theOR.During a long surgical procedureparticle
count can rise tomore than amillion particles per cubic foot. Air and dust are vehiclesfortransportingmicroorganismladen
particles. Airmovement and thermal currents entrain dust andmicrobial particulates. TheORlights and other heatgenerating
equipment produce convective upcurrents. Particulatesthat become airborne canthen settle on an open wound. Between
80% and 90% ofmicrobial contamination found in an open surgical woundcomesfromambient(room) air. Because airborne
contamination is generated by personnel, everymovementincreases potentialfor wound infection.Microorganisms have an
affinity for horizontalsurfaces, of which the flooristhe largest. Fromit,they are projectedinto the air. Endogenousflora
fromthe patentsskin, oropharynx, tracheobronchialtree, and gastrointestinaltract,as well as exogenousflora, are significant.
Microorganismsfrompatents or carrierssettle on equipment and flatsurfaces,then become airborne. Airborne
particlesincrease significantly during activity before incision and afterwound closure. An effective ventilation systemis
essentialto prevent patents and stafffrombreathing contaminated
air, which would predispose themto respiratory infection and could increase the incidence ofmicrobial carriers amongOR
personnel.
Infection of Prosthetic Implants
A common phrase in both research and clinicalsituation is infected implant. Thisis amisnomer,since itisthe tissue
surrounding the implantthatisinfected ratherthan the implantitself. Three types of infection are associated with prosthetic
implants.The firsttype isthe superficial immediate infection, which is due to the growth of organisms on or nearthe skin
inassociation with an implant. Examplesinclude the head fixation devices,the recording chambers, as well as burndressings
and simple suturesthat have not been removed in time. The second type isthe deep immediate infection,
which is a lowfrequency infection commonly seen immediately aftersurgery. The bacteria responsible are usuallyskin
residents carried into the implantsite during the surgical procedure. The third type isthe deep late infection,whichmay occur
years afterthe surgery in sites with no history of infection. The lattertype ofinfectionmay sometimes occurinmonkeysthat
have implanted electrode guidetubes, orinfrequently around the search eye coil.
Principles ofAsepsis
Modern surgery is based on aseptic technique. Asepsismeansthe absence of any infectious agents, and thereforeaseptic
technique is aimed at eliminatingmicroorganisms presentin the surgical environment. Thisincludes
thosemicroorganismsliving harmlessly on the body surface or within it. Aseptic technique is always applied in
combinationwith sterile techniques, which preventthe transfer ofmicroorganismsfromthe environmentinto the body
tissues.The words aseptic and sterile although sound very similarthey are very differentin practice. Aseptic
techniquescontrolthe environment while sterile techniques preventthe contamination of an itemor area
fromtheenvironment bymaintaining sterility ofthatitemor area.
Aseptic technique,for example, includesthe control oftheORs airsystem,the traffic andmovement within theOR,the
establishment of aseptic barriers,such asthe usage of caps, hoods, and gloves, and the appropriatehousekeeping
practicesthatinclude the cleaning and disinfecting ofthe operating rooms and suite,the handling ofsoiled laundry, and the
disposing ofsolid wastes.
Sterile technique on the other hand includesthe sterilization ofinstruments,the creation,maintenance, and termination
ofthe sterile field,the draping ofthe patient or animal with sterilized drapes, etc.
Principles of bacteriology andmicrobiology are applied in developing infection control programsto be followed by
alloperating roompersonnel. Such programsinvolve specific guidelinesforOR attire,sterilizing and packaging
supplies,6scrubbing, gowning and gloving, andmethods of housekeeping. The following practicesstemfromtheoriginal
infection control principles:
1. All items used within a sterile fieldmust be sterile. Ifthere is any doubt aboutthe sterility of an item, itisconsidered
unsterile.
2. A sterile barrierthat has been permeatedmust be considered contaminated. In other words, you have to changegown,
drapes, or glovesif any ofthemis permeated.
3.Gowns ofscrubbed teammembers are considered sterile in the frontfromshoulderto waistlevel, and the sleevesto
approximately 5 cmabove the elbow.Unsterile areas of gowns are shoulders, neckline, axillary region, and back.If you are
scrubbed, do not allow your hands or any sterile itemto fall below waist ortable top level.
4. Tables are sterile attable level only. Any itemthat extends overthe table edge is considered contaminated andcannot be
brought back up to table top level.
5. Scrubbed personsmuststay close to the sterile field and ifthey change positions. If you need to change positionwhile
scrubbed, youmustmove by turning back to back orface to face with othersterile teammembers.
6. The edges of a sterile container are considered unsterile once the package is opened. Because sterile boundariesare not
always well defined,follow the rules below:
Cap edges of a bottle ofsterile solution are considered contaminated once the cap isremoved. Because the capcannot be
replaced without contaminating the pouring edges,the sterility ofthe bottle contentsis notlonger certainand the
remaindermust be discarded.
Package wrappers are usually considered to have a 3 cmsafetymargin around the edge. The flap ends are secured inthe hand
ofthe person opening themto avoid dangling the flap endsloosely.
Peelback packagesshould not be torn open butrather pulled back to expose sterile contents. The inner edge oftheheatseal is
considered to be the boundary between sterile and unsterile.
7. The sterile field should be created as close to the time itis going to be used as possible. The degree of
contamination is proportionalto the length oftime items are left uncovered. Sterile areas are kept continuously inview and
once supplies are opened,someonemustremain in the roomto ensure sterility.
8. Sterile persons and itemstouch only sterile areas; unsterile persons and itemstouch only unsterile areas.Finally one hasto
keep inmind thatthemore people in the surgicalsuite,the greaterthe likelihood ofinfection. In ourfacility surgical
proceduremay be observed through ourinternal video system. There is no need for people to be directly presentin theOR
unlessthey absolutely have to. In all cases visitorsshould also prepare their hands aseptically and wearsterile gowns and
gloves.
Decontaminationof Surgical Supplies
Decontamination isthe firststep toward reducing the potential hazard of direct contact with blood,fluids ortissues left onOR
surfaces, equipment, orinstruments. Decontamination refersto the process by which the contaminantsare removed, either
bymanual ormechanicalmethods, using specific solutions capable ofrendering blood anddebris harmless and removing
itformthe surface of an object orinstrument.
The instruments, along with the other nondisposable supplies exposed to the patient/procedure are placed in a
properreceptacle and covered fortransference to the decontamination room. Itisimportantto note that the contaminated
instruments and nondisposable equipmentmust be covered when traversing hallwaysleading into the decontamination area.
All instruments used during the procedure should be inspected for gross dirt and debris, and cleaned with water and/or a
scrub brush, and soaked with an antimicrobial or bleach solution. This processmust be done underthe waterlevel, preventing
splash dissemination of harmfulmicroorganisms.7
Once the instruments have undergone the initial washing, the second step in the process begins, which involves the terminal
cleaning ofthe instruments and initialsterilization before the assembly ofthe tray. Amanual cleaning procedure, for delicate
and heatsensitive items, isrecommended to preserve the life ofthe instruments and to decontaminate thembefore the
sterilization process. Ifmanual washing isrequired, all personnelmust be protected fromexposure to contaminants during the
cleaning process.
Themost common cleaningmethod ismechanical cleaning which can be accomplished using several differenttools:
ultrasonic washer, washersterilizer, orthe washerdisinfector.
UltrasonicWasher
The ultrasonic cleaning processremoves blood and debrisleft on the instrument by a process known as cavitation,which
occurs when sound waves are passed through water, creating within it cavitiesranging in size fromsubmicroscopic to very
large. These bubbles expand untilthey implode. Thisimplosion generatesminute vacuumareas on the instruments, which
(vacuums) are responsible forthe actual cleaning process.During this processthesmall particlesfloatto the top, while the
larger particlessettle on the bottomofthe tank and are eventually flushedaway. The particles willremain in suspension aslong
asthe water and detergent are fresh. Itisforthisreason thatthe watermust be changed ifthe ultrasonic cleaneris used forthe
initial cleaning process.
Washer-Sterilizer
When the washersterilizeris used,the soiled instruments are cleaned bymechanical agitation in a bath containing
adetergent,rinsed, and then sterilized for 3minutes. in one process.However, itmust have a cold cycle orthe itemsmust be
washed by hand first.
Washer-Disinfector
The newestmethod for decontaminating instrumentsisthe washerdecontaminator, which removes excess amountsof dried
debrisfromthe instruments, eliminating the handcleaning phase ofthe decontamination process. Thenumerous waterjets
and the increased pHofthe detergent allow forthorough cleaning of even grossly soiledinstruments. Initial cleaning
isfollowed by a neutralizing rinse to restore the pHto its neutralstate. Since theagitation ofthe waterisminimal, it cleans
withouttossing the instruments around in the tray,thereby reducing therisk of damage to even delicate instruments. The
washercontaminator cleansinstrumentsso thoroughly thatit notonly eliminatesthe need for hand cleaning, butit can also
replace the ultrasonic washer.

Sterilization
Basic Concepts and Definitions
To sterilizemeansto render an itemtotally free of all livingmicroorganisms, including spores,through one
ofthreeprocesses:(1)steamsterilization, (2) chemicalsterilization or(3) physicalsterilization. Eachmethod hasits
owncharacteristics and requiresspecific parametersfor effective completion ofthe process. Additionally,the processmust be
continuouslymonitored to ensure that all procedural parameters and specifications have beenmet,assuring the sterility and
traceability ofthe itemas well asthe properfunctioning ofthe equipment.Steamalone isincapable ofsterilizing an
item.However, when steamis placed under pressure, itstemperaturerises, and themoist heat produced destroysthe protein
within the cell,rendering it harmless. Itis,therefore,the8relationship between temperature, pressure, and time of exposure
that becomesthe crucialfactorin destroyingmicrobes, and itisthese principlesthat are used in the operation ofthe
steamsterilizer. Sterilizers designed to use steamunder pressure are referred to as autoclaves and are
generallymanufactured to performthistask by one of threemethods:(1) gravity displacement, (2) prevacuum, or(3) high
speed pressure.
Gravitydisplacement sterilizer
The gravity displacementsterilizer usesthe principle that airis heavierthan steam. It has an inner chamber wherethe goods
are sterilized and an outer heated jacketthat ejectssteaminto the chamber. When the sterilizerisactivated, pressurized
steamentersthe top ofthe inner chamberfromthe jacket, and exerts pressure on the airinside the chamber, displacing the air
downward to the bottomofthe chamber where itisreleased through atemperaturesensitive valve. When the valve closes,the
pressure inside the jacket chamberincreases,raising thetemperature to the required level. Atthis point,the timing ofthe
sterilization cycle begins. The length ofthe cycledepends on the temperature reached inside the jacket. Most gravity
displacementsterilizers work in a range from250F (121C)to 254F (123C) at 15 to 17 pounds persquare inch (psig), and
take anywhere from15minutesfor aconventional pack to 55minutesforlarge,tightly packed containers. The higherthe
temperature,the shorterthecycle duration required.
Prevacuum (high-vat) sterilizer
The automatic prevacuum, hightemperature sterilizer has generally replaced the gravity displacementmethod, since it does
notrely on gravity to remove the airfromthe chamber. Instead,the airisremoved by a venturi valvethat uses
watermovementto create the vacuum, which simultaneously drawsthe air out while steamisinjectedinto the
chamber,replacing the air. Thismechanismreducesthe time necessary to accomplish the sterilization cycleto aslittle as
5minutes, butthe time varies with the size ofthe sterilizer,the adequacy ofthe steam, and the supplyof water. Thissterilizer, if
efficientin preventing air pockets, has a greater penetrating ability than the gravitydisplacementtype. The recommended
exposure time for prevacuumsteamsterilizersisfourminutes attemperaturesranging from250F (121C)to 274F (134C).
Thissterilizer, like the gravity displacementsterilizer, is
used primarily for wrapped items.
PreparingGoods for theAutoclave
Although sterilization with highpressure steamis a very safe, effectivemethod, certain rulesmust be observed toensure
sterility. The firstrule isthat before any instrumentis putinto the autoclave itmust be absolutely clean.Forthisreason all
instruments are cleaned and dried in the laboratory dishwasher(MieleDesinfektor) beforebeing sterilized. Ifthe instruments
are extremely soiled,theymust be washed by hand before being putinto thedishwasher. The dirt can also be loosened with
ultrasound tomake the task of hand washing easier. Caution!Not allinstruments are suited for ultrasonic cleaning. Problems
can be caused especially by glued parts and certain cheapersurface finishessuch asmost chrome plating. Each
instrumentmust be inspected closely before itis putinto thedishwasher, especially at any joints orteeth.Once they have been
washed and dried in the dishwasher,the instrumentsmay no longer be touched with barehands. Each fingerprint, each drop
of water and each calciumdeposit on an instrumentis an excellent hiding placefor potential germs and can jeopardize the
success ofthe subsequentsterilization.The empty sterilization containers, which have also been washed, are fitted with the
appropriate filtersin the lidand sometimes on the floor.Now they can be loaded with the instrumentsto be sterilized.Do not
pack too tightly.The appropriate indicatorstrip (which changes color when the sterilization temperature has beenmaintained
for acertain length oftime)is putinto the container. To be safe, an indicatorstrip is also put along with the instrumentsinto
the cloth roll, if one is used. Afterthe containeris closed isitsealed with the indicator clampmade forthispurpose.
Chemical (gas) sterilizers
Gassterilization using E.T.O. (ethylene oxide) gas, is dependent upon (1)the concentration ofthe gas being used,(2) the
temperature inside the chamber, (3)the humidity level, and (4)the exposure time. In general, E.T.O. gas concentrationsrange
between 450 and 800mg/L of chamberspace, and operating temperaturesrange from108F(42C)to 132F (55C) with atleast
50% humidity, but notlessthan 30% percentin orderto hydrate the items duringthe process(forty (40%)
percentisrecommended during the sterilization cycle). The duration ofthe cycle varies; itusually takes 2 to 6 hoursforthe
sterilization cycle to be completed.However,the process does not end here. Theitemsmust be aerated before returning the
itemfor animal use.
Preparing items for ethylene oxide sterilization
Itemsto be sterilized by E.T.O.require special preparation before being exposed to the gassterilant. All itemsmustbe cleaned
and completely dried, as watermay unite with E.T.O.to formethylene glycol, which is not eliminated byaeration andmay
resultin toxic reactionsin animals and personnel. Lumens oftubings, needles, and so on shouldbe air dried and left open at
both endsto avoid any accumulation of gasinside the item.Some of ourinstruments and several itemsrelated to the
implantsmust be sterilized in ethylene oxide becauseautoclaving can cause blunting, corrosion, and/or deformation due to
extreme heat.Only those objects are to besterilized in the gassterilizerthat cannot be reliably sterilized by any othermethod
and whose sterility anddesorption characteristics are known. As a rule,thisinformationmust be supplied by
themanufacturer.Goodssterilized with ethylene oxide can only be used without posing a risk to us and the
animalsifthemandatorydesorption times are observed.10 All itemsthat are to be ethylene oxide sterilizedmust be washed
and dried. If atmospheric humidity isless than 30%,rewash the items or place themin a closed pack with a wettowelfor an
hour. Itemsto be sterilized arepacked in the paper/plastic pouchesmade forthis purpose These are available in a variety
ofsizes.One indicatorstrip is placed in one ofthe pouches and anotheris putin loose with the entire batch. The indicator
changes colorwhen exposed to E.T.O. After being filled,the pouches are carefully sealed with a heatsealer.Do not
overstuffthepackages and always be sure thatsharp items are packaged in such a way thatthey do not puncture the pouch
whilebeing handled. Since condensation can formthat hasto be able to drain, hollow objectsmust be placed in thesterilizer
basket with the open end down. Tubes are to be placed so that both endsface down. If at all possible,everything should be
placed upright, foilto paper, and not packed too tightly in the open wire basket. The goodstobe sterilizedmust nottouch the
walls ofthe sterilization chamber.For gassterilization we use the MMM Kombimat 349 with a chambersize of 110 liters.
Itisfully automatic andusesthe negative pressuremethod with a combustion unitto dispose ofthe E.T.O.
Thismakesitsubstantially saferthan oldermodels. The door can only be opened afterthe completion ofthe programcycle.
Thissafety featurefunctions even with a power outage.
Sterilizing by Soaking
Eyecoils can only be sterilized in a liquid such as Lysetol, because the Teflon coating does notrespond welltoethylene oxide.
Ifthe procedure involvesthe placement of an eyecoil,the eyecoilsshould be placed into Cidex atthe beginning ofthe setup
procedure. They require 45minutesto sterilize and will be ready to be rinsed and placedon the sterile field just before the
start ofthe procedure.
Disinfectionand Disinfectants
Basic Concepts
A disinfectantis an agentthat kills growing bacteria and (to some extent)spores. The twomajor purposesfordisinfection are
to kill pathogenicmicroorganisms on inanimate surface and objectsthat cannot be sterilized, and toprevent or arrest growth
ofmicroorganisms on body surfacesthrough the application of an antiseptic solution.
Disinfectants are identified as bacteriostatic, which act by inhibiting growth, or as bactericidal, which will kill
bacteria(sporicides, virucides,fungicides). The terms germicide and bactericidemay be used synonymously with
disinfectantaccording to this definition. Disinfection differsfromsterilization by itslack ofsporicidal power, and agents are
labeled according to theirefficacy in killing fungi (fungicide), viruses(virucide), and/orspores(sporicide). Disinfection can be
accomplished with chemical and physical agents. The application of a disinfection agent depends on the level ofrisk
ofinfection,
and on the environmental contamination. Commonly the levels are:
Low to intermediatelevel: House keeping disinfection ofsurfacessuch asfloors, walls,furniture, and large equipment, and
noncritical itemsthat ordinarily do nottouch the patient or contact only intactskin.
Highlevel: Disinfection ofthe semicritical itemsthat come in contact with nonintactskin ormucousmembranes but do not
penetrate body tissues(i.e., endoscopes,respiratory equipment, and thermometers). Critical items,that is, itemsthat will
penetrate body tissuesmust be sterilized; not disinfected.
SurgicalAttire
Surgical attire is considered to be the appropriate head covering,shoe covers, gloves, gown, and surgicalmask. Allpossible
head and facial hair, including sideburns and neckline,should be covered before entering the operatingroom(O.R.). Long
hairshould be up, underneath the head cover, andmen with beardsshould wear a full headcover, if necessary,to coverfacial
hair. Shoe coversshould also be worn by all personnel entering theO.R.Since large numbers of potentially
pathogenicmicroorganisms reside in the respiratory tract, a highfiltration mask, covering both the nose andmouth,should
be worn at alltimes while in the procedure rooms or nonsterile and scrub areas. Masksmust be changed between each
procedure, ifthey becomemoist or wet, or both. While wearing amask, conversation should be keptto aminimumto
preventmoisture buildup. Masksshould be removed by the strings and properly discarded before leaving the procedure
room. Masks are never worn outside the surgicalsuite.
Masksshould fitsnugly around the nose and chin, and tied securely to prevent accidentalslipping during a
procedure.
Scrubbing
Allsterile teammembers performa surgicalscrub before entering the procedure room,to remove gross dirtfrom their hands
and arms priorto applying theirsterile gown and gloves. Scrubbing isthe same for allmembers ofthe14sterile surgicalteam.
Since the scrubbed teammembers receive sterile equipmentfromthe circulator (nonsterilemember), and since sterile can
only touch sterile, a bacterial barrieris needed between the circulator andthe sterile item. That bacterial barrieristhe sterile
gown and gloves. The goals ofthe surgicalscrub include: (1)mechanicalremoval ofsoil and transientmicrobesfromthe hands
and forearms,(2) chemicalreduction ofthe residentmicrobial countto aslow a level as possible, and (3)reduction of the
potentialrapid rebound growth ofmicrobes.
Gowning
The gownmust already be open on a sterile field. The scrubbed person approachesthe sterile field andmust nowbe careful
notto touch anything unsterile and notto drip on anything. The towel is picked by an exposed corner(orhanded to a
nonsterile person by a sterile person) and opened by gentle shaking in an area ofthe roomwhere thereis no danger of
contamination. The hands are dried, one at a time, by using one half ofthe towelto pat one hand15dry fromfingersto elbow.
Do notrub the towel around or up and down the arm. Dry around and between thefingersfirst,then proceed down the armto
the elbow, patting only, and do notmove back up the arm. After onearmis dry, use itto grab the other half ofthe towel in a
sterile region. Flip the towel overso the used portion is onthe bottom, and repeatthe drying procedure on the other
armusing a sterile part ofthe towel. Then discard the towel into a waste bin or onto the floor. If one is being assisted during
gowning,the gown will be held up so that
ones arms can be slid directly into the sleeves. The person assistingmust be certain to keep their hands on the sterile front
ofthe gown at alltimes and protectthemselvesfromcontamination. The neck snap will always be fastened by a
nonsterilemember ofthe team. If, however, one is gowning themselves without assistance,thefollowingmust be done.
Identify the sleeve openings ofthe gown, place your handsin the openings, pick up the gown withoutletting itunfold, and
back away fromthe sterile field into a clear area ofthe room. Hold the gown up, with your handsin the sleeve openings, and
allow itto unfold while slipping your armsinto the sleeves. Do not go allthe way to the end ofthe sleeves asthe outer aspect
ofthe sleeve endsmustremain sterile tomanipulate the gloves and tie off. Thecirculatorshould now snap the neck snap and
tie the secondary tie in the back ofthe gown. With the handsstill in the sleeves, offer one end ofthe primary tie (the end with
the card)to the circulator while holding onto the other
end ofthe tie. Spin around and pullthe end ofthe tie (which isin the card held by the circulator)free fromthe cardand tie the
gown closed. Always be aware of yoursurroundingsto avoid contamination.
The parameters ofsterility forthe gown have been established: (1) The gown is considered sterile in frontfrochestto the level
ofthe sterile field. (2) The sleeves are considered sterile from2 inches above the elbow to thestockinette cuff, and therefore
the cuffmust be covered, at alltimes, by sterile gloves. The areas not consideredsterile,for variousmonitoring reasons,
include the neckline,shoulders, areas underthe arms, and the back ofthegown. To preserve the sterility ofthe gloved
hands,they should be kept within the sterile boundary ofthe gown,and since the axillary region is notsterile,the armsshould
never be crossed with hands positioned into the axilla.Should either ofthese barriers be compromised,theymust be
discarded, and a new gown, gloves or both applied,depending on the nature ofthe break in technique.

Gloving
Sterile gloves can be applied using one oftwomethods:the openmethod orthe closedmethod. The closedglovemethod
should be used anytime the person isinitially applying sterile gown and gloves, while the openglovemethod should be used
when changing a glove during a procedure (self orteammember), or when a sterile scrub orgown is notrequired (aseptic
procedures). The scrub personmust performunassisted gowning and gloving, while the rest ofthe sterile teammembers will
be assisted by the scrub person (assisted gowning and gloving).When gloving oneself using the closed glovemethod,the
procedure goes asfollows. With your handsstill in thesleeves ofthe gown, open the glove package completely. The fingers
ofthe glovesshould be pointing toward you. You will glove your preferred hand first. Reach acrossthe field with your
preferred hand to the appropriate glove,and slip yourthumb underthe cuff with yourfingers extended toward the opening
(away fromthe fingers ofthe
glove). Pick up the glove, and grabbing the opposite side ofthe cuff with the other hand,slip yourfingersinto the opening
while pulling the glove onto your hand with the opposite hand. Alwaystouching the surface ofthe glove through the gown
(notthe stockinet cuff, asitis considered unsterile), pullthe glove onto your hand,maneuvering yourfingers and thumb
appropriately. Itis bestto touch the distalregions ofthe glove aslittle as possible. Thegown can be pulled outfromunderthe
glove in orderto help getit on, however,the stockinetshould not be exposed. Once the first hand is gloved,the second glove
can be picked up by slipping the fingers ofthe gloved hand underthe cuffed region ofthe other glove. The fingers ofthe
second hand are now exposed fromthe gown sleeve and slipped into the glove opening, being careful notto touch any
externalsterile surface (in particularthe hand doing the gloving). Now the glove can simple be pulled on and overthe
stockinet cuff ofthe gown sleeve.
When gloving anothermember ofthe team, the sterile internal package containing the glovesis offered to the sterilemember
ofthe teamwho will do the gloving oristransferred,maintaining sterility, onto the sterile field where it can be accessed by a
sterilemember ofthe team. The package is opened, and a glove isremoved. The glove is held by the cuff with the fingers
ofthe sterile person underthe fold. The glove is held with the fingers16 dangling downward, and the cuffisstretched open
allowing the nonsterilemember ofthe teamto reach into the glove without danger oftouching the fingers ofthe
sterilemember. The glove is pulled up over the stockinette ofthe gown and then released. The procedure isrepeated forthe
other hand.
SurgicalTools
Instrument Metals
Today, all quality surgical instruments are fabricated frommedically grated stainlesssteel.Ofthe standard stainless steels
produced, only a few are used in hospitals.Ofthese,the 300 and 400 seriesstainlesssteels aremost often selected forsurgical
instrument production. Stainlesssteels consist primarily ofiron, chromium, and carbon, with other elementssuch as nickel
combined in different proportionsto achieve desired properties. The higher carbon, lower chromium400 series(martensitic)
stainlesssteels provide greater hardnessthrough heattreatment. Thisimparts wearresistance which is especially
importantfor cutting surgical instruments;theymustmaintain fine edges and exhibiting the strength and durability
ofstainlesssteel. The hardmartensitic stainlesssteels are usedmost commonly in themanufacture ofsurgical instruments.
The austenitic, or 300 series,stainlesssteels are not hardenable by heattreatment but are occasionally used for surgical
instrumentmanufacture. The lack of hardness exhibited by these alloysis offsetsomewhat by their higher resistance to
corrosion. Austenitic steels are of greatest value when some degree ofmalleability in an instrumentis desired. A few surgical
instruments aremade primarily oftitaniumalloys. They are usedmost commonly inmicrosurgical instruments. They are said to
have excellent corrosion resistance (comparable to that ofstainlesssteels) and high temperature strength (comparable to
that of austenitic stainlesssteel). The internalstructuremakesthese alloys
somewhat brittle, and this can presentmanufacturing problems. Its greatest usemay be as a substitute forstainless steels
when weightsaving isimportant. Tungsten carbide inserts add a new dimension to gripping and cutting surfaces. These
substances are very hard and very resistantto wear. The inserts are attached to the stainlesssteel instruments by
variousmeans and can be removed and replaced by themanufacturer.
ResistanceTo Corrosion
Producing a surgical instrumentthatisresistantto staining and corrosion begins with selecting the propersteel. A smooth
surface is desired and is achieved by buffing and polishing. Three types ofinstrumentfinishes are presently available. The
highly polished finish seemsmostresistantto spotting and discoloration; however, itreflectslight easily and can causemild eye
irritation. More recently a dull orsatin finish has become popular; its greatest advantage isreduced eye strain. The
dullfinishes are applied by silicone or glassbead sandblasting or by fine abrasion using varioustypes of polishing wheels. The
third type of finish, a (black) ebonizing finish, is achieved by coating the instrumentin a chemical bath. The final
processinstruments go through to become corrosion resistantis passivation. This process(nitric acid bath)removes any
foreign particles(iron)imbedded on the instrumentsurface. Additionally, a thin layer of chromiumoxidesforms on the
stainlesssteelsurface, providingmore corrosion resistance. A subsequent polishing is usually needed to produce a very
smooth surface,removing any rough sites where corrosion could begin. Once an instrumentis used it can further passivate
itself. Exposure of an instrumentto the atmosphere orto certain oxidizing agents during its handling and use can continue
this oxidation process, building andmaintaining the continuity ofthe chromiumoxide layer. Certain cleaning and handling
processes can damage this protective layer and should be avoided. Abrasive cleaners and instrumentmarking with vibrating
etching equipment can disturb the
oxide layer, promoting the development of corrosion.Once the chromiumoxide layeris altered and corrosion
begins,repassivation and repolishing by themanufacturer become necessary.17
Instrument Cleaning
Instrument cleaning and handling technique is extremely importantfor either hospitals orlaboratories, asitsaves
enormoussums ofmoney in yearly instrumentreplacement. Proprietors of hospitals and laboratory technicians are usually
aware thatsurgical instruments are expensive, delicate, andmust be handled correctly in the operating room to ensure
longevity. A sometimesforgotten fact, however, isthatinappropriate cleaning and sterilizing have a significantimpact on
instrumentlife. Mostinstrumentmanufacturers provide detailed information on the cleaning and handling oftheir product.
Theirrecommendationsshould be followed. Here we give a brief description ofthe
techniquesthat will be used in ourlaboratory.
Manual Cleaning
Gross visible debrisshould be removed fromthe instruments immediately aftertheir use. Saline solution is very corrosive to
stainlesssteel; consequently, distilled or deionized watershould be used forthe initialremoval of debris.
Subsequentinstrument cleaning willthen be easier, as blood and tissue debris do not have a chance to dry in serrations and
box locks. If further processing is notimmediately possible, instrumentsshould be submerged in warmdeionized waterthat
contains amild noncorrosive, lowsudsing, neutral detergent. Adequate soaking time allowsthe detergentto loosen
inaccessible soilfilms. Prolonged soakingmust be discouraged, however, as detergentaction on the instrumentsurfacemay
cause damage.The final cleaning processshould be conducted with care. Each instrumentis carefully scrubbed, including
thebox locks,ratchets,serrations, and other areas not easily exposed. A hand brush with stiff plastic bristlesisappropriate for
cleaning. Abrasive tools or cleanersshould be avoided, however, asrepeated cleanings can damage the instrumentssurface
and promote corrosion. Amoderately alkaline (pH<8), lowsudsing detergentismost satisfactory.Ordinary soap should not be
used, especially with hard water, asinsoluble alkali earth films can formonthe instruments, protecting trapped bacteria
fromsterilization. The finalrinse should be carried outthoroughly with distilled or deionized water. It has a pHof 6.7 to 7.2
and leaves a neutralsurface pHasthe alkaline wash waterresidue isrinsed away. Alkaline earth deposits(calcium, magnesium,
phosphate) andmetals(iron, copper, cadmium) will not depositthemselves on the surface to promote corrosion.Distilled
water also contains no dissolved or undissolved solidsto adhere to the instrumentsurface. The instrumentmust be dried
completely, especially ifitisto be stored for a period oftime priorto sterilization.
The heat of hotrinse watermay aid the drying process. Inadequate drying willresultin rusting during storage.
Washer-Sterilizer
Institutionsthat processlarge volumes ofsurgical instruments have adoptedmechanicalmethods
Forroutine cleaning. The washing processis accomplished in an instrument washersterilizer bymeans of a vigorously
agitateddetergent bath,the result of a combination of highvelocity jetstreams ofsteamand air, which produces violent
underwaterturbulence. Themachine has presoak, wash, and sterilize cycles, after which the instrumentsmay be removed
and immediately used orstored forfuture use. Many factorsinfluence the effectiveness ofsoilremoval fromsurgical
instruments cleaned in a washersterilizer, including the kind ofsoil, quality of water,type of detergent, concentration of
detergent,types ofinstrumentsto be cleaned,time the detergentsolution is permittedto act, and efficiency ofthe
washer sterilize Blood,tissue fats, and other organicmatter are common types ofsoil encountered on surgical instruments.
Better cleaning in the washersterilizeris achieved when soil is not allowed to dry on the instruments and
processingoccursshortly after use.
Water plays amajorrole in cleaning and alone accountsformuch ofthe solvent action that occurs during
instrument cleaning. The quality oftapwaterinmany areasis poor, and careful consideration should be given tomatching
water quality with the appropriate detergent. Softened, demineralized, or distilled watershould beconsidered to eliminate
the deposition of hard watersalts on instruments.18
A good, lowsudsing, neutralto slightly alkaline detergentisstrongly recommended. According to
Perkins,some ofthe common phosphate detergentsrecommended formechanical dishwashers are ineffective inwasher
sterilizers. Cleaning ofthe instrumentsis not adequate, and the polyphosphated detergents have a solubilizing effect on
internal copperin the washersterilizer. The resultis a brassymetallic staining of the instruments due to copper deposition by
electrolytic action.
The type ofsurgical instrument, its configuration, and its condition play amajorrole in cleaning effectiveness. Ithas been
demonstrated quantitatively thatsoilretention is greatest with instruments with a poor geometricconfiguration and those
whose serrated tipsshowed visible corrosion. They showed that corroded serrations andcavities nearthe hinges of worn
joints were particularly effective in retaining soil and thatthere is a clear correlation between soilretention and
themicroscopic state ofthe instrumentsurface.Finally,the washersterilizer affords a degree of protection to those who clean
surgical instruments. Manualcleaning contributesto the dissemination ofmicroorganisms by aerosols and droplets during the
cleaning process,whereas automatedmechanical cleaning controlsthis problem.
Ultrasonic Cleaner
Ultrasonic cleaners can remove up to 90 per cent of instrumentsoil in fiveminutes and farsurpassmanual cleaning
procedures. Thisis demonstrated by the effective removal ofsoilfromareasthat are inaccessible to brushing such as box locks,
deep grooves,serrations, and even cracksin the instrument.Ultrasonic cleaners do notsterilize. Ultrasonic instrument
cleaners produce sinusoidal energy waves at either oftwo frequencies. Ifmetallic transducers are used,the frequency of
vibrationsis 600 persecond. If crystaltransducers are used,the frequency of vibrationsis 38,000 persecond. The latter unitis
believed to be themore efficient. The effectiveness of ultrasonic cleaning is based on a process called cavitation. Ultrasonic
energy formsminutebubblesfromgas nuclei within the cleaning solution. Theseminute bubblesformon every surface
ofsoiledinstruments. The size ofthe gas nuclei and subsequent bubblesformed depends on the surface tension ofthe
liquid,temperature ofthe solution, wetting action ofthe detergent, and the frequency ofthe ultrasonic energy used.
Thesebubbles continue to expand untiltheirsurface becomes unstable. They then collapse by implosion (bursting inward).
The bubblesimplode asfast asthey form, creating small vacuumareas. This processreleases energy that breaksthebondsthat
hold soilto instrumentsurfaces. The soil and bindingmaterial are dislodged or dissolved into thesolution.The effectiveness of
an ultrasonic cleaner can be altered bymany variables, including temperature, gas content ofthe solution, and the detergent
used. The temperature ofthe bath solution should be kept below 60C to preventprotein coagulation. Coagulated protein
tendsto absorb ultrasonic vibrations, which reducesthe energy available forbond breaking andmakesthe soilmore difficultto
remove. Bath solutions containing toomuch dissolved gaslosecleaning effectiveness because the gasfillsthe cavitation
bubbles. This cushionsthe shock due to implosion andreducesthe energy released. Water can be deaerated by running the
ultrasonic cleanerforfiveminutes before use
orletting the waterstand overnight.Detergentspecifically formulated for ultrasonic cleanersshould be usedbecause they
decrease aeration problems. In addition,the detergentis chosen forits cleaning abilities and itschemical effects on the
instruments being cleaned.Highly alkaline or highly acid detergentshould not be used, asthey can induce corrosion or
cracking, which can lead to early instrumentfailure. The detergentshould have aneutral pH, contain a wetting agent, and be
low sudsing and free rinsing. Finally,the proper concentration of cleanershould be employed,since the heat ofthe ultrasonic
cleanerincreasesthe strength ofthe cleaner. Iftoomuchdetergent or heatis employed,the cleaning solution can become very
caustic. Thisleadsto removal ofthechromiumoxide layer, which isso importantin corrosion resistance. The impassivated
instrumentisthen susceptible
to rusting and breakage.Instrumentsremoved froman ultrasonic cleanermust be rinsed thoroughly. The cleaner effectively
removesthesoil into solution orsuspension, and when the instruments are removed they become covered with
thisfinelydispersed soil. Thissoil, although not always visible to the eye,must be rinsed away. Rinsing also removesresidual19
detergentthatmay be present.Dissimilarmetalsshould not be processed togetherin an ultrasonic cleaner.Stainlesssteelshould
not bemixed with brass, copper, or aluminum, otherwise electrolytic etching and redepositionmay occur. Chromeplated
instrumentsthatshow pitting orflaking can be further damaged in an ultrasonic cleaner.
Instrument Lubrication
Surgical instruments with box locks often become stiff with repeated use, especially if cleaned inadequately.Dried blood,
alkaline deposits, and debris can build up in box locks and serrations. Autoclaving bakesthismaterial on
theinstrument,furtherretardingmovement. Cleaning procedures, when employed properly, help to
preventthisproblem.Instrumentlubrication is commonly practiced but can present problemsif not properly performed.
Mineral oil, machine oils, grease, and some siliconesmust be avoided, asthey leave an oily filmon the instrumentsurface. This
can prevent adequate steamcontact with organisms, and spores can become trapped in the oilfilmduring steamsterilization.
Continuous use ofthesematerials can also leave undesirable residues on the instrumentsthat becomegumlike and retard box
lockmovement. Instrumentmanufacturersrecommend the routine lubrication ofinstruments with antimicrobial water
soluble lubricants(instrumentmilk). These lubricants are wateroil emulsion preparationsthat do notinterfere with steam
sterilization. Many also contain antimicrobial materialsinhibiting organismgrowth in bath preparations. Rust inhibiting
agents provide an additionalmeasure of protection by retarding electrolysis and preventingmineral deposition on
instrumentsurfaces. Mechanical instrument processing especially with ultrasonic cleaners, removes alltraces oflubricant.
Lubrication should therefore be carried out after cleaning. The lubricant bath should be prepared with deionized or
distilledwater atthemanufacturersrecommended concentration. Instrumentsshould be dipped in the bath for 30 seconds
with box locks open. Afterremovalfromthe bath,the lubricantsolution should be allowed to drain away without rinsing
ormanual drying. The lubricantremains on the instrument during steamsterilization and storage. This gives added protection
againstrusting,staining, and corrosion.
InstrumentPackaging
Properinstrument packaging and storage are important considerationsfor veterinary institutions and small clinics.
Universally accepted standardsforinstrument packaging have not been established. Problems are compounded by
manufacturers who are continually developing new and often better packaging products. Packagingmaterials used
frequently today are classified astextiles(linen andmuslin), nonwoven fabric, paper, plastic, and paper and plastic
combinations.
Textiles
Linen ormuslin wrappers aremost commonly used forinstrumentset packaging. Standard, doublethickness, 140 thread
countlinen isflexible, easy to use,memory free, and long lasting. The weave of one thicknessisperpendicularto the other, and
the wrap issewn atthe edges only. Linen packs are easily contaminated by contactwithmoisture, and the contamination
becomes undetectable afterthemoisture dries. Laundry proceduresmust be carefullymonitored. If harsh detergents not
adequately rinsed fromthe fabric come in contact with stainlesssteel instruments,staining and corrosion can be induced.
The necessity of double wrapping surgical packs with twolayerlinen has been repeatedly demonstrated.
Photographs of a singlethicknessstandardmuslin at 40 Xmagnification demonstrate a small opening at almost every thread
junction. Single wrapping with twolayerlinen can allowmicrobial penetration ofthe pack within three days.Double wrapping
with twolayerlinen increasessafe storage time to three to four weeks. Longerstorage timemay be obtained by using outside
(dust cover) wraps of water repellent paper drape fabrics orsterile 3ml plastic
Bags.Open shelfstorage ofsterile packs has been shown to allow up to ten timesmore viablemicrobial
contamination ofthe outside ofthe pack than closed shelf or cabinetsstorage,thusreducing safe storage time.Otherfactors
also have been incriminated in surgical pack contamination.Unnecessary handling and vibrationshould beminimized along
with rapidly changing atmospheric conditions. Finally, double wrapping ofsterile packages provides amargin ofsafety during
package opening. Microbiological
contamination that hassettled on a package isthrown into the surrounding air during openingmaking
contamination of contents very likely. A second wrap greatly reducesthisrisk.
Consideration can be given to the use of 288 thread countlinen. Thismaterial hastwice the thread perinch as the standard
140thread count general use linen. A single thickness ofthismaterial can replace the standard double layer wrappers. This
wrap is a goodmoisture retardant and is an improved barriertomicrobiological and liquid penetration over 140thread
countlinen.Good penetration ofsterilantsis allowed, although as a generalrule the higherthe thread countthe less
penetration by steam. Themajor disadvantage ofthismoistureretardantlinen isits higher cost.
NonwovenFabrics
Nonwoven wraps are a product of disposable surgical drape programs and offersome advantages over general use linen,
including reduced labor and laundry costs.Nonwoven wraps are waterresistant,strong and tearresistant. Sterilantssuch as
ethylene oxide and steampenetrate readily and do not change the handling characteristics orquality ofthematerialfor use as
a wrapper or drape. Although product quality excellent, nonwoven fabricsshouldbe used as disposable items. Repeated
sterilization can resultin breakage offibers, especially along foldsin thematerial, which could resultin pack contamination.
Nonwoven fabrics are available in light,medium, or heavy weight. The lightweightmaterial does not withstand handling well
and is notrecommended for operating roompackaging. Themediumweight wrappermaterial is bestsuited forsterile
packaging wraps.
PaperWraps
Paper wraps have come into wide use asreplacementforlinen. Several disadvantages are recognized, however. Like linen,
paper has good wick action and can absorbmoisture and dry quickly,making it difficultto detect a contaminated pack. Also,
paper hasmemory and will not open flatly. The paperflips back along fold lines, oftenresulting in contamination during
opening. Paper wrapsshould not be reused, asminute cracksin the paperfabricare difficultto detect and can easily
compromise sterility. Personnelshould be aware ofthese sources ofcontamination when using paper drapes.
PlasticWraps
Plastic wraps usually come in pouches presealed by themanufacturer on two orthree sides. Their greatest use isin individual
article packaging. Polyethylene, polypropylene, and polyvinyl chloride pouches are produced only for ethylene oxide
sterilization, astheymay be heatsensitive and impermeable to steam.Detailed opening instructions are necessary, assterile
removal ofitemsfromthese pouchesis difficult. Plastic wraps can also be used as dust covers on previously
sterilizedmuslin or paperwrapped surgical packsthat are stored for variable periods before use. Any plastic cover used
forthis purpose that has accumulated dustshould be removed before the surgical pack is
placed inside the clean zone ofthe operating room.



Plastic andPaperWraps
Plastic and paper combinations are used extensively. They offerseveral advantages. Materials are available that withstand
steamand ethylene oxide sterilization.Good steampenetration and aeration is evidentthrough the paper backing, and the
article is visible through the plastic. Peelback opening for presentation ofsterile itemslessensthe possibility of
contamination. Sealing ofthe pouch can be accomplished by sterilizerindicatortape or heat.21Dating and labeling ofthese
packages with felttip markersshould he done on the plastic side only, as puncture orink bleed through the paperis possible.
Also,sterile indicatortape should be placed on the plastic side, asthe sterilize indicating device incorporated into the paperis
often overlooked during opening.
Neurosurgery Instruments
SurgicalKnifeHandles
Surgical knife handles(Figure IV1) with detachable blades aremost popular. The BardParker #3mediumhandle is available
with variousscalpel blade attachments(#10, 11, 12, 15). This handle seemsto be themost applicable for small animalsurgery.
The #3 handle is also available in a longerform. Fine handles #7 and #9 receive the same blades. The #4 BardParker handle
islarger and uses detachable blades #20, 21, 22. This handleandblade combination ismore appropriate forlarge
animalsurgery.
Scissors
Many types ofsurgicalscissors are available formany different uses(Figure IV2). Thosemost applicable for general surgical
use in veterinary surgery are the Mayo and the Metzenbaum. Each surgery pack should have a scissors designated as a
suture scissors. Repeated cutting ofsuturematerial with delicate tissue scissors,such as the Metzenbaum, leadsto dulling
and/ormisalignment of blades. A short(5 inches)straight Mayo dissecting scissors withouttungsten carbide inserts can
function well. Itis durable and will last a long time. Special wirecutting scissors should be employed for orthopedic wire
cutting. Tissue dissecting (blunt and sharp)requires a high quality tissue scissors. The curved Mayo dissecting scissors with
or withouttungsten carbide insertsis excellentfor connective tissue dissection and separation oftougherfacial plains. The
Metzenbaumtissuedissecting scissorsismore delicate andshould be reserved forlessstrenuous dissecting and cutting. It
would seeminappropriate to use a fine Metzenbaumto open the linea alba. Fine, delicate cutting, asrequired in hollow organ
surgery or controlled delicate dissecting,would bemore applicable to Metzenbaums. Tungsten carbide inserts and gold
colored handles designate the finestquality surgicalscissors.
Retractors
Many types ofsofttissue retractors are available (Figure IV3). Amost useful classification would distinguish between hand
held and selfretaining retractors. The greatest disadvantage of handheld retractorsisthe need for an assistanttomanually
retractthe tissue. Thisinconvenience issignificantin veterinary surgical procedures, where extra surgical assistants are often
not available.
Selfretaining retractors offerthe advantage ofmaintaining tissue separation once placed without additional assistants. The
Finochietto rib retractorforthoracic surgery and the Balfourretractorfor abdomina1 surgery are sturdy and very effective.
These selfretaining retractors are necessitiesif adequate exposure to thoracic andabdominal viscera isto he achieved
andmaintained. TheGelpi and Weitlanerretractors are two smallerself retaining retractorsthat offer versatility in tissue
separation and exposure during surgical procedures.

Forceps
Halsted Mosquito Hemostatic Forceps
Mosquito forceps are available in 3% and 5inch lengthsin both curved and straight configurations. Theseinstruments are
very delicate and should be used only forthe control of point bleeders. Stump or pedicle ligations,where additionaltissue is
often included in the ligature,should be avoided, as damage to the instrument can result.Mosquito forceps have been
recently introduced with rattooth (1 X 2)teeth located atthe very tip ofthe grippingblades. Thismodification preventsthe
instrumentfromslipping fromthe tissue itis holding. Ifthe instruments are ingood working order and are used
fortheirintended purpose,this additionmay be unnecessary.
Kelly or Crile Hemostatic Forceps
These two forceps are very similarin design and use. The only difference isin the extent ofthe transverse grooveson their
gripping surfaces. The Kelly forceps has only the distal half ofitstips grooved. The intended use ofthesehemostatic
forcepsissimilarto that ofthemosquito forceps.However,they are larger (5,5 inches) andmuchsturdierso thatthey can
withstandmore aggressive use.
RochesterCarmalf Hemostatic Forceps
The RochesterCarmalt hemostatic forcepsis primarily used in veterinary surgery in stump or pedicle ligations. Itissturdy and
the grooves on the gripping bladesrun longitudinally (with a few cross grooves atthe tip), allowing foreasy removal during
ligation. When a Carmalt clamp is placed on a pedicle oftissue for crushing priorto ligation,thetissue isforced outward in the
clamp and is, in effect,spread. When ligation occurs,the clampmust be loosenedbefore the ligature issecured orthe tissue
cannot be drawn togetherto collapse the vessel being ligated.Onemustalso keep thisspreading effectinmind when ligating
close to a second Carmalt clamp that has been placed. Thisspreading effect on tissue by the clamp can resultin loose
ligatures.
Tissue Forceps
Tissue forceps of varioussizes,shapes, and uses are available. Several have found extensive use as generalsurgical tissue
forcepsin small animalsurgery.
Allis Tissue Forceps
Allistissue forceps(Fig. IV5, bottom) are very popularin veterinary surgery. The plane of grip is perpendicularto the direction
of pull. The tip ofthe Allisforceps hasintermeshing teeth that provide a secure grip on tissue. The Allisis said to be atraumatic
to tissue; however,thisfeature seemsto be commonly abused. The Allisshould be used to gripconnective tissue and facial
planes only. Itshould never be used to grasp the skin orto grip hollow organssuch as the stomach. The crushing effect ofthis
grip istoo traumatizing forthese delicate tissues.
Babcock Tissue Forceps
The Babcock forcepsissimilarin design to the Allis exceptthatthere are no gripping teeth. Its uses would be similarto those
ofthe Allis. The Babcock hasreceived some use in hollow organ surgery; however, its gripmay beexcessively traumatizing.
Themore appropriate use ofstay suturestomanipulate hollow organs would seemprudent.
KocherOschner Tissue Forceps
The KocherOschnertissue forceps(Fig. IV5)is very sturdy and can withstand aggressive use. The 2 x 1 rattooth
tipallowssecure gripping oftissue. Thisinstrument has very limited softtissue use; however, orthopedic surgeonsfindthe
instrument helpful inmanipulating bone fragmentsin fracture repair.
Alligator Tissue Forceps
Thisspecial instrumentis very delicate but provides a needed capability. The long shaft and pivot point nearthe tiporitsjaws
allow introduction and grasping through a small narrow opening. Removal offoreign bodiesfromearcanals and discmaterial
during thoracolumbarfenestrations are appropriate applications.
RightAngle Tissue Forceps
The rightangle tissue forceps(Lahey gall ductforceps haslongitudinal grooves on its gripping surface. Itis verysuitable for
delicate dissection, especially in hard to visualize areas. The instrumentis excellentfor dissecting behinda patent ductus
arteriosus and is used extensively in otherthoracic surgeries.
Adson Tissue Forceps
The Adson (delicate) (Fig. IV6)is probably themost common tissue forcepsin use. The 2 x 1 rattooth tips are smalland
provide good tissue grip withminimal pressure on the blades. Itismost applicable when suturing skin and facialplanes.
Although itisrelatively atraumatic when used properly, bettertissue forceps are available for hollow organsurgery.
BrownAdson Tissue Forceps
The BrownAdson (Fig. IV6) also has extensive use. Itissimilarto the Adson exceptforitstip. Multiple intermeshingfine teeth
provide a broad tip forsecure gripping. When suturing,thisfeaturemakes gripping of a needle beingpulled through tissue
easierthan with the Adson. The BrownAdson isrelatively atraumatic if used properly i.e., on skin and facial planes only.
DeBakey Tissue Forceps
Every surgery pack should have a delicate thumb forcepsfor atraumatic work. TheDeBakey tissue forceps wasinitially
developed for cardiovascularsurgery. The tips are slightly ribbed in a longitudinal direction. Various widths(1to 2mm) on the
tip and weights(delicate to regular) are available. Thisinstrumentis excellentforthoracic andabdominalsurgery. Very delicate
handling of a tissue being sutured is possible.
Towel Forceps
The Backhaustowelforceps(Fig. IV7)is used forsecuring surgical drapesto skin. Itis also used to secure suctionlines,
electrocautery cables, and power equipmentlinesto drapes. Two sizes are commonly seen, and the smaller(3% inches)ismore
appropriate forsmall animalsurgery. Some towelforceps(Roeder) have ametal bead or ballstop on theirtipsto preventthe
drapesfrommoving up. The Jonestowelforcepsmay be used inmore delicateapplications.
NeedleHolders
Themost common needle holder used in veterinary surgery isthe MayoHegar needle holder(Figure IV8). Various lengths(5
to 12 inches) are available. The smaller needle holders aremore delicate and probably find greater use in small
animalsurgery.No surgical instrumentreceives greater abuse than the needle holder. Its use requires constant metal to
metal contact. The size and weight ofthe needle holderselected shouldmatch those ofthe needle being used. Small needle
holders can be damaged when used to grip large needles. Ifthe ratchetistightly applied the box lock orshank can be
damaged. Small needles can be damaged orinadequately gripped iflarge needle holders are used. There is a greattendency,
especially in orthopedic proceduresto use the needle holderinappropriately.Using
the needle holderto twist wire or as pliersleadsto early failure.The betterquality needle holders can easily he identified by
the tungsten carbide inserts oftheir gripping jaws. These inserts greatly crease grip and durability. Somemanufacturers also
identify their betterquality instruments by gold colored handles.OlsenHegar needle holders are a combination needle
holder and scissors. Theymay have an
advantage forthe individual who is doing surgery alone. The suturematerial can be cut after placement without asuture
scissors. The disadvantage of accidental cutting ofsuturematerial during suturing can be troublesome. Tungsten carbide
inserts are available with the needle holder portion ofthe instrument.
Maintenance ofNeurosurgery Instruments
Periodic evaluation ofinstrument performancemay indicate that preventivemaintenance is needed. Instrument
manufacturersstressthe economics of preventivemaintenance programs. Costsforrestorations vary but can be aslow as one
fifth replacement costs and onehalfrepair costs. A preventivemaintenance programincludes evaluating, refurbishing,
adjusting, and refinishing each instrument. Carbide inserts are replaced if worn or cracked,tips of instruments are re
aligned,shanks and springs are adjusted for propertension and conformation,ratchets and jaws are redefined and reset,
cutting edges are sharpened, and allmissing parts are replaced. Afterthis complete24 refurbishing each instrumentis
ultrasonically cleaned. Preventivemaintenance programsfor good qualitysurgical instrumentsreduce costs and increase
instrumentlongevity.
Ophthalmic Surgery Instruments
Eyelid Specula
Eyelid specula are designed to retractthe eyelids andmaximize the opening ofthe palpebralfissure. The ideal eyelid
speculumshould be strong, lightweight, and should not contribute to direct pressure on the globe. Part of eachblade should
extend overthe eyelidmargin along the palpebral conjunctiva forseveralmillimetersto avoid the untimely dislodgment ofthe
speculum. The larger eyelid specula usually have slightly curved armsto conformto the palpebralfissure. Occasionally the
curvature ofthese specula is altered slightly to obtain the bestfitforthemonkey. The pediatric size Barraquerspeculummay is
usually appropriate formonkeys.
Tissue FixationForceps
A large number ofspecialtissue forceps have been developed tominimize traumatic handling ofthe oculartissues. Their
handles are usually flat with serration or knurling to facilitate grasp and are usually 50100mmlong. Theseinstruments are
held like a pen during surgery. Several differenttips have been developed forthese fixation forceps.The handle orthe tips
ofmostfixation forcepsformicrosurgery have some angulation to prevent blockage ofthesurgeon's view during use. For
handling ofthe eyelids atleasttwo differenttypes oftissue fixation forceps are useful. When handling large amounts
oftissue,theGraefe fixation forceps with 3.5 or 4.5mmjaws with fine teeth are useful. Whenmanipulating small amounts of
eyelid and conjunctivaltissue, one ofseveraltypes offixation forceps with a 1 x 2 teeth tip isrecommended. The bulbar
conjunctiva is handled with fine, plain forceps without
teeth to avoid excessive trauma and tearing. Ifthe tissue isslippery oris handled atitsmargin,such asthe edge of a corneal
wound,tissue forceps with fine teeth (Colibri or Bonn type) are indicated
Knives
Themostfrequently used knivesin ophthalmic surgery ofsmall animals are the BardParker and Beaver handles. The Bard
Parkerscalpel handle withNos. 10 and 15 bladesis used primarily for orbital and eyelid surgery. The smaller Beaver handle
withNos. 64, 65 and otherspecial purpose bladesis used for eyelid, conjunctival, and corneal surgery. Both types of handles
are positioned in the hand like a pen,for bestresults.


Ophthalmic Scissors
There are a large number of ophthalmic scissors available, and several have been developed forspecializedpurposes. No
single pair ofscissors can performadequately on the wide range of oculartissuesthat one commonly confronts.
Forthemajority of eyelid and conjunctival dissections,the Steven'stenotomy scissors are recommended. The standard size
ring handle with straight orslightly curved blunttipsisthemost versatile. The overall length of the ring handlesis about 100
110mm, and the blades are about 1820mmlong. For cutting and dissection ofthebulbar conjunctiva, curved scissors
conformto the globe's curvature and are lesslikely to buttonhole theconjunctiva. Cutting with these scissorsshould be
reserved forthe distaltip ofthe blades. These conjunctival scissors are also used to cut 40 to 120 ophthalmic sutures.
OphthalmicNeedleHolders
Themajority ofthe ophthalmic needle holders possess a design very similarto corneal and corneosclera scissors.The serrated
flat orround knurled handles are 100120mmlong and are designed to be held like a pen. Theproximal portions ofthe handle
are highly flexible and function as a spring,therebymaintaining the needle holder'sjaws open. The straight or gently curved
jaws are 712mmlong and have eithersmooth orserrated surfaces. Thelockingmechanisms aremounted on the inside of each
handle and are durable to provide longtermuse.Compressing the handleslocks and closesthe tips; compressing the locked
handles a second time releasesthe lockand opensthe tips. Inmodels withoutthe lockingmechanism, a pin stop is usually
added to prevent excessivecompression ofthe handles.25
For general extraocularsurgery,the Castroviejo needle holder with flatserrated handles and a lock is
recommended. The jaws are about 9mmlong andmay be straight or gently curved. Formicrosurgery involving thecornea,the
Storz or Barraque needle holder with curved jaws and no lock preferred. All ophthalmic needle holdersare designed for only
the small ophthalmic needles and sutures; large needles and sutureslargerthan 40 willgradually distortthe jaws ofthese
needle holders,rendering the instrument useless.
Spatulas
Spatulas are semisharp to dull instruments designed tomanipulate the irisfromthe cornea,for example in irisprolapse,
ortease the vitreousfromthe posteriorlenssurface during intracapsularlensremoval. Three basic typesofspatula tips are
available with a fairly standard round orflatserrated handle of 120140mmin length. Somespatulas possessspecialtips at both
ends ofthe handle. Themost versatile spatula, designed to sweep the irisfromthe cornea orthe vitreousfromthe
posteriorlens, has a round blunttip thatis 1012mmlong. These spatulas havealso been incorporated into cannulae that
permitthe injection ofsolution or air with the same instrument.
Calipers
Occasionally in eyelid, corneal and intraocular procedures, precisemeasurements are needed. Eitherthe Jameson or
Castroviejo caliper permitsmeasurementsin 1mmincrements and both are relatively inexpensive.
Sutures
Asin generalsofttissue surgery, continued refinement ofthe swaged needles and sutures permitted use ofprogressively
smallersutures with lesstissue reactivity but excellent holding strength. These smaller needles andsutures have also been
vitalforthe development of ophthalmicmicrosurgery. Forsurgery ofthe orbit,suture sizeapproximatesthat of generalsofttissue
surgery, with 20 to 40 absorbable sutures used forligation and closure ofthe deeper orbitalfascia tissues. Skin closure is
usually with nonabsorbable 30 to 40 nylon, polypropylene,polyester,Dacron, orsilk.
Forsurgery ofthe eyelids 30 to 40 sutures are recommended with the absorbable sutures buried and the skinapposed with
nonabsorbable 30 to 40 single interrupted sutures. Most conjunctival and cornealsutures areabsorbable 9to eliminated
the need forsuture removal), and 30 to 70 in size tominimize tissue reaction. Buriedsuturesinvolving the
nictitatingmembranemay be either absorbable or nonabsorbable depending on theprocedure.The generalrule stating
thatthe strength ofthe suture should approximate the surrounding tissues also pertainsto ophthalmic sutures. Often the
choice ofthe skin suturesis personal preference and nearly alwaysthe nonabsorbable type. Silk skin sutures are usually
black,soft and pliable; ifsuture contact with the eye occurs ocularirritation is unlikely. Unfortunately silk sutures are braided
and bacteria can penetrate the sutures, hence suture
removalshould be performed 1014 days post operatively. When nylon andpolypropylenemonofilaments are employed
forskin sutures,the surgeon and square knots are usually combined to secure each knot. Asthese suturesare fairly stiff,suture
contact with the conjunctiva and/or cornea usually causes ocularirritation. Thisstiffness canhowever be an advantage during
parotid ducttransposition when these sutures are inserted into the duct'slumen tofacilitate its detection and handling.
TheDacron polyestersuture ismore pliable than nylon or polypropylenesutures, butits knotstend to loosen.
Absorbable sutures aremostfrequently used forthe deeperlayers ofthe eyelids, all layers ofthe conjunctiva
andnictitatingmembrane, and the cornea. Our preference is polyglactin, amultifilamentoussuture, with strength
andresorption ratesthat approximate surgical gut(about 6 weeks). Thissuture, dyed violet, is nonantigenic
andproducesminimaltissue reaction. The uncoated polyglactin is associated with excessive tissue drag during
suturing;coating greatly reducesthis drag but additionalties are indicated for knotsecurity. Polyglactin sutures are stable
inseptic wounds, and can be used in infected corneas.26
Needles
In general,reverse cutting semicircle needles are recommended forthemajority ofthe extraocularsurgicalprocedures. Skin
closure generally employsthe conventional cutting needles;the subcutaneous and deeper orbitalfascial layers are apposed
using spatula and taper needles. Corneal and scleraltissuesrequire reverse cuttingneedles, and theG6 semicircular needle
isthemost useful.
Maintenance ofOphthalmic Surgery instrumentsCare and Storage
All ophthalmic instruments are quite delicate and whetherin storage and notsterile, orready for use and sterile,special
ophthalmic holders are recommended. Allfixation forcepsshould be covered, with small pieces ofintravenoustubing,to
protecttheir delicate tips. Flatfeltlined trays provide inexpensive storage and severaltrayscan be accommodated in an
instrumentstorage box. Specialstainlesssteeltrays, with eitherfoamorrubberlinings, provide themost convenientmethod
forsafe handling ofsterile ophthalmic instruments. The liners hold each instrumentseparately and prevent contact
withotherinstrumentsthat could damage the delicate tips and blades. These trays are easily sterilized and can be used
indefinitely.
Cleaning and Sterilization
Because ofthe delicate tips of ophthalmic instruments, cleaning is generally achieved by ultrasound and theappropriate
cleaner. Each instrumentis carefully placed on the bottomofthe ultrasonic cleaner(and not piled ontop of otherinstruments).
Some ofthe largersoiled instruments can be easily cleanedmanually, usually using asmalltoothbrush. The instrumentsshould
be dried using a hot air blowerratherthan risking damage by hand dryingwith towels. Occasionaltreatment with
instrumentmilk will preserve the instrument'sfinish, and lubrication ofthescissors' and needle holders hinges will facilitate
longtermuse. Sterilization of all ophthalmic instrumentsis usuallyachieved by the standardmethods using hot air,
autoclaving (steam), or ethylene oxide gas.