STERILIZATION
"Do not disinfect when you can sterilize."
• The approach is to sterilize all reusable instruments contaminated
with blood, or that have penetrated tissue or touched bone (universal
sterilization). This is better than to sterilize some instruments and
disinfect others and is the safest approach to prevent spreading
disease to patients.
“KILL ALL MICROORGANISMS”
• A process cannot be called a sterilization process unless it has been
shown to be capable of killing high numbers of bacterial spores, the
most difficult of microorganisms to kill.
• The CDC views steam under pressure, dry heat, chemical vapour and
ethylene oxide gas as appropriate sterilization methods.
• 4. To assure effective microbial kill with minimal instrument damage
and protection to the staff performing the procedures, several steps
must be performed: pre soaking, cleaning, corrosion control and
lubrication, packaging, sterilization and sterilization monitoring.
PRE SOAKING
• Usually, material allowed to dry on an instrument is more difficult to
remove. If cleaning is delayed, keep the instruments wet in a holding
solution. This may be a mild detergent, or an instrument disinfectant or
sterilant.
• Do not pre soak for more than a few hours, as the longer instruments
remain wet, the greater the chances for corrosion of non-stainless items.
• Wear heavy utility gloves when handling contaminated instruments and
mixing chemical solutions.
• Wear protective eyewear, a mask and protective clothing to prevent
contamination from splashing of the solutions.
CLEANING: the basic first step of all
decontamination
• Clean before you disinfect or sterilize.
• Patient debris and body fluids must be removed from the instruments before
sterilization. Debris can insulate microorganisms from the sterilizing agent, preventing
direct contact and inactivation.
• Two approaches to instrument cleaning are hand-scrubbing and ultrasonic cleaning.
Hand-scrubbing is directly contrary to one of the principles of infection control (reduce
direct contact with contaminated surfaces as much as possible). Hand scrubbing of
contaminated instruments can create spatter and aerosols and increase the chances for
an instrument puncture. When hand-scrubbing, minimize spattering by scrubbing while
the instruments are submerged and then rinse thoroughly under tap water and dry.
• Drying is very important for instruments that will be sterilized in an unsaturated
chemical vaporor in a dry heat sterilizer.
ULTRASONIC CLEANING
• Recommended in place of hand-scrubbing in order to reduce direct staff contact with
contaminated instruments.
• Pre soaked or other instruments should be rinsed and then placed in a cleaning basket
and submerged in the cleaning solution.
• For best results, follow the directions from the manufacturer of the ultrasonic cleaner.
• Place the cover on the cleaner and clean for 6 to 10 minutes or until no debris is visible
on the instruments. Hold the cleaning basket of instruments under tap water and rinse
thoroughly.
• Ultrasonic cleaners cannot be considered sterilizers. Thus, the cleaned instruments are
still contaminated.
• The cleaning solution should be drained and discarded at least daily and the cleaner
chamber rinsed and disinfected at the end of the day.
CORROSION CONTROL AND
LUBRICATION
• Always dry cleaned instruments to be processed through a dry heat,
chemical vapour or ethylene oxide gas sterilizer or packaged in a
paper wrap. Drying reduces the chances of corrosion and rupture of
the paper wrap. A rust inhibitor can be applied to non-stainless items
to be processed through the steam autoclave.
PACKAGING
• Instruments should be pre-packaged before processing through a
sterilizer so they will be protected from contamination after
sterilization.
• Use packaging material designed for the method of sterilization to be
used. Avoid thin paper bags that allow sharp instruments to protrude.
• Unwrapping pre packaged instruments at chair side in front of the
patient can help build patient confidence about the cleanliness of the
office.
STERILIZATION TIME
• Sterilization fails when the sterilizing agent-- steam, hot air, or
chemical vapour--does not contact the processed items for the
appropriate length of time. Sterilization requires varying degrees of
time, depending on the load, arrangement, packaging material, and
temperature as well as the type of sterilizing agent.
• Follow the manufacturers direction and define the proper sterilizing
time by results of routine spore-testing.
STERILIZATION MONITORING
• Sterilization can be monitored by chemical indicators (colour change)
but effectiveness cannot. Chemical indicators are strips, tapes and
markings on bags and pouches that change colour or physical form
after exposure to the sterilizing agent. They immediately indicate that
the items have been processed through the sterilizer and have been
exposed to heat, steam or chemical vapour.
• Chemical indicators do not analyse for microbial kill, they should be
used in conjunction with, but never as a replacement for spore-
testing, which provides the main guarantee of sterilization.
BIOLOGICAL INDICATORS
• Biological indicators are the ultimate criteria for monitoring
sterilization.
• The CDC states the proper functioning of sterilization cycles should be
verified by the periodic use (at least weekly) of biologic indicators
(i.e., spore tests).
• OSHA recommends following CDC guidelines for standard sterilization
procedures.
• Proper spore-testing in the medical, surgical, dental, orpodiatric office or clinic
involves placing the appropriate type of biological indicator (spore test) inside a
normal instrument pack, bag, or tray.
• Biological indicators operate on the premise that destruction of heat-resistant
spores implies destruction of viruses and bacteria, which are more easily
inactivated. The biological indicator is included in a sterilization load and
subjected to the cycle. It is then incubated in a nutrient medium and evaluated.
• It is the responsibility of each the medical, surgical, dental, or podiatric office or
clinic to assure their staff and patients that products at point-of-use are sterile.
• Appropriate records should be kept to document sterilization verification.
References
• (1.) Department of Labor, Occupational Safety and Health
Administration. 29CFR Part 1910.1030, Occupational exposure to
blood borne pathogens; final rule. Fed Reg 1991,56:64004-182.
• (2.) Infection control guidelines. Denver: Office Sterilization and
Asepsis Procedures Research Foundation; 1992.
• (3.) Office Sterilization and Asepsis Procedures Research Foundation.
Infection control guidelines. Denver; 1991.
• (4.) Centers for Disease Control. Recommended Infection- Control
Practices. MMWR 1993; 42:1-10.
METHODS OF STERILIZATION
1. PHYSICAL METHODS
2. CHEMICAL METHODS
1. PHYSICAL METHODS
• Steam Thermal
• Definition -- a self-locking apparatus for the sterilization of material by
means of steam under pressure.
• Settings for general wrapped items: Temp. - 250oF Pressure - Time --
30 min Setting -- Fast Exhaust & Dry
• Settings for bottled solutions: Always vent bottles to avoid bursting!
Temp. - 250oF Pressure - 20 PSI Time -- 30 min Setting -- Slow Exhaust
• Setting for "Flashing" an unwrapped instrument: Temp. - 270oF
Pressure Time -- 4-7 Min Setting -- Fast Exhaust Notes -- The above
are general steam autoclave settings. Different models may operate
with varying settings. Always refer to the appliance literature before
operating a new piece of equipment. Radiation
• Use on materials that cannot be sterilized by heat or chemicals
Radiant energy destroys microorganisms Filtration -- is a method
utilizing filters capable of screening out microorganisms
2. CHEMICAL METHODS
2. CHEMICAL METHODS
• Ethylene Oxide Gas, Colourless gas at room temperature, Odor similar
to ether, Very toxic and irritating to skin and mucous membranes
• Microorganism destruction is caused by a chemical reaction
• Materials sterilized need to be aerated in well ventilated room or
placed in an aerator.
• Length of time required for aeration depends on items sterilized.
• Effective sterilization is dependent on concentration of gas, exposure
time, temperature, and relative humidity Hazardous chemical, use
great care
Cold Sterilization
• Instruments should be completely dry before soaking to prevent
dilution
• Instrument soaking solution - 10-20 minute emersion only disinfects
• Incomplete destruction of spores, unless soak is for 10 hours
Examples: Instrument Germicide (Phenol and Ethyl alcohol), CidexTM
(Glutaraldehyde)
• Most require thorough rinsing before using instrument
• Contact time required varies with product used
STERILIZATION SHELF LIFE
OFPACKAGED SUPPLIES
TWO (2) PACKAGING METHODS ARE
STERILEFOR UP TO SIX (6) MONTHS:
• MonarchR Instrument Canisters -- Special box system with single use
filters for use in steam autoclaves
• Sterility Maintenance Covers -- Sealable plastic covers to place over
freshly autoclaved and cooled packs to extend shelf life by diminishing
air penetration
THE FOLLOWING WRAPPED ITEMS, IF CAREFULLY
MAINTAINED, ARE STERILEFOR UP TO ONE (1) MONTH
• Double cloth wrapped instruments
• Double paper wrapped instruments
• Inexpensive peel pouches for gauze sponges
• NalgeneR saline bottles
• HEAT SEALED PACKAGES
• COMMERCIALLY PREPARED IN TUBE OR PEEL POUCH FORM MAY BE
CONSIDERED STERILE FOR UP TO ONE (1) YEAR.
BEFORE ASSUMING A PACK IS STERILE, ALWAYS EVALUATE
THE FOLLOWING BEFORE OPENING THEPACK
Sterility Check List
• Expiration or sterilization date
• Indicator color change
• General condition of wrapper and
• how it had been stored
• Always check for holes or moisture damage
