BRIEF REPORT

Potassium Permanganate Reduces Protein Contamination of

Reusable Laryngeal Mask Airways
Wendy Laupu,

EN*,

and Joseph Brimacombe,

MB ChB, FRCA, MD*

*Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia; and James Cook University,
Cairns, Australia

We tested the hypothesis that supplementary cleaning

with potassium permanganate 2 mg/L eliminates protein deposits from reusable laryngeal mask airways
(LMAs). Sixty previously used classic LMAs were
hand-washed, machine-washed, dried, autoclaved,
and then randomly allocated into two groups for supplementary cleaning. In Group A, the cuff was immersed in potassium permanganate 2 mg/L at 20C for
20 min. In Group B (control), the cuff was immersed in
sterile water at 20C for 20 min. After supplementary
cleaning, the LMAs were immersed in a protein staining solution and rinsed, and a high-resolution digital
image was taken of the dorsal surface. The severity of

ew-variant Creutzfeldt-Jacob disease was first

recognized having crossed the species barrier to
humans in 1996 (1). It is caused by an infectious
prion protein (2) that is highly resistant to decontamination by routine cleaning and autoclaving procedures (1,3). Although little is known about the risk of
cross-infection from reusable surgical and anesthesia
equipment, perhaps all equipment should be disposable (4,5); however, disposable equipment may not
function as well (6). One of the most common reusable
items of anesthesia equipment is the laryngeal mask
airway (LMA), but routine cleaning and sterilization
(4,7,8)and even supplementary cleaning with
guided scrubbing or ultrasonic cleaning (9) does not
remove protein contamination from reusable LMA
devices. We tested the hypothesis that supplementary
cleaning with potassium permanganate 2 mg/L eliminates protein deposits from the LMA.

Accepted for publication February 5, 2004.

Address correspondence and reprint requests to Joseph Brimacombe, MB ChB, FRCA, MD, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns 4870,
Australia. Address e-mail to jbrimaco@bigpond.net.au.
DOI: 10.1213/01.ANE.0000124033.87558.56

614

Anesth Analg 2004;99:6146

staining was scored by an observer blinded to the type

of supplementary cleaning. The severity of protein contamination was reduced after supplementary cleaning
in potassium permanganate (P 0.00001). Protein contamination was detected on 20% of LMAs after supplementary cleaning in potassium permanganate, compared with all LMAs in the control group. We conclude
that supplementary cleaning with potassium permanganate 2 mg/L does not eliminate protein deposits
from all LMAs, but it does reduce the number of devices
contaminated from 100% to 20%.
(Anesth Analg 2004;99:614 6)

Methods
Sixty previously used Classic LMAs (Laryngeal Mask
Co., Henley-on-Thames, UK) were tested at the end of a
working day (20 40 uses; preuse check tests were
passed) (10). Each LMA was cleaned and sterilized as
follows: 1) immersion in a mild enzymatic solution (Enzyme Rapid; 3M, Pymble, Australia) for 3 min; 2) washing the external surfaces with a cloth for at least 1 min or
until all visible material was removed; 3) washing the
airway tube with a soft bristled brush or until all visible
material was removed; 4) placing the LMA in an automatic washer for 14 min, which included warm washing
at 55C with a disinfectant and hot washing at 85C; 5)
placing in a dryer for 30 min at 75C; and 6) autoclaving
at 134C for 4 min at 206 kPa.
The LMAs were randomly allocated (by opening an
opaque envelope) into two equal-sized groups for
supplementary cleaning. In Group A, the cuff was
immersed in potassium permanganate 2 mg/L at 20C
for 20 min. In Group B (control), the cuff was immersed in sterile water at 20C for 20 min. After supplementary cleaning, the LMAs were immersed for
30 min in a protein staining solution (1.2% erythrosin
B) (11) and rinsed in sterile water at 20C for 1 min,
and a high-resolution digital image (3.3 megapixels)
was taken of the dorsal surface. The severity of staining was scored according to the percentage of area
2004 by the International Anesthesia Research Society
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2004;99:614 6

stained: none (0%), mild (0%25%), moderate

(25%50%), heavy (50%75%), and severe (75%).
The images were analyzed by an observer blinded to
the type of supplementary cleaning. Sample size was
selected for a Type I error of 0.05 and a power of 0.95.
Statistical analysis was performed with the 2 test.

Results
Data on the severity of staining are given in Table 1.
The severity of protein contamination was reduced
after supplementary cleaning in potassium permanganate (2 43; P 0.00001). Protein contamination was
detected on six LMAs after supplementary cleaning in
potassium permanganate compared with all LMAs in
the control group.

Discussion
There are four studies which have examined protein
contamination with reusable LMAs. Miller et al. (4),
Chu et al. (7), and Clery et al. (8) found that all
reusable LMAs had some protein contamination after
routine cleaning and autoclaving. Coetzee (9) found
that systematic cleaning and scrubbing was more effective than routine cleaning, but only for accessible
locations, and that ultrasonic cleaning was more effective than routine cleaning, but only for inaccessible
locations; however, none of these techniques eliminated staining altogether. In contrast, we found that
potassium permanganate 2 mg/L eliminated protein
deposits from 80% of reusable LMAs.
Potassium permanganate, also known as chameleon
mineral, is a powerful antioxidant that chemically
burns up organic material. It is widely used as a
disinfectant when diluted with water or acetone. It has
been used in humans to treat leg venous ulcers (12)
and psoriasis (13) and as an abortifacient (14). Interestingly, Kimberlin et al. (15), in a 1983 study, found
that potassium permanganate 2 mg/L reduced the
infectivity titer of mouse-passaged scrapie, but it was
not considered sufficiently powerful to be used as a
decontaminant.
A limitation of our study is that we did not quantify
the mass of residual protein removed by the potassium permanganate. This is a difficult measurement to
make because the protein is too adherent to be dissolved into solution for a protein assay. However, an
approximation of the amount removed can be made
by assuming that the density of protein staining is
uniform and that the actual area of staining for mild
(0%25%), moderate (25%50%), and heavy (50%
75%) is the midpoint of these values, that is, 12.5%,
37.5%, and 62.5%, respectively. A simple calculation
reveals that the average area of staining per LMA after
permanganate was 2.5% [(12.5% 6)/30] and after

BRIEF REPORT

615

Table 1. Severity of Staining

Variable

Permanganate

Control

None
Mild
Moderate
Heavy
Severe

24 (80)
6 (20)
0 (0)
0 (0)
0 (0)

0 (0)
13 (43)
14 (46)
3 (10)
0 (0)

Data are n (%).

saline was 29% [(12.5% 13 37.5 14 62.5

3)/30], suggesting that potassium permanganate removes 91% (26.5/29) of residual protein.
It is not known whether potassium permanganate
reduces the longevity of reusable LMAs, but bench
testing by one of the authors (JB) revealed no change
in elastance after 10 cleaning/autoclaving cycles,
which included soaking in potassium permanganate. Also, potassium permanganate is recommended by some manufacturers for cleaning silicone tubing (ESCO technical data catalog; http://
www.bibby-sterilin.com/cat/esco/esctids1.htm).
To prevent patient-to-patient transmission, it has
been suggested that all patients should be screened for
prion disease or that all equipment should be disposable; however, the economic consequences of each of
these options on the health care system would be
enormous. Tordoff and Scott (16) suggested that when
considering the relative risks and options, we should
ask ourselves whether we would use a second-hand
LMA on our children and then follow the golden
rule. Work is urgently required to determine the risk
of infection so that evidence-based policies can be
made; however, in the meantime, we consider that
there is no justification for abandoning the use of
clinically proven reusable LMA devices for clinically
unproven disposable LMA devices. Patients with suspected new-variant Creutzfeldt-Jacob disease should
be managed with disposable airway devices provided
that they are functionally comparable to their reusable
counterparts; if a reusable device is used, it should be
discarded. Supplementary cleaning of reusable LMA
devices in potassium permanganate 2 mg/L should
reduce the infection risk, but it is not sufficiently effective to permit the safe reuse of an LMA that has
been exposed to prion proteins.
We conclude that supplementary cleaning with potassium permanganate 2 mg/L does not eliminate
protein deposits from all LMAs, but it does reduce the
number of devices contaminated from 100% to 20%.
We thank V. Maguire, J. Batey, and G. Laupu for their assistance.

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BRIEF REPORT

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