Instrument Sterilization, Surface Disinfection

[DrBaboon]

Discussion continued from here:

http://www.survivalfiles.info/forums/showthread.php?t=12&page=2

Doc, if you're looking to disinfect a surface (porous or non-porous) a commercial disinfectant like Buckeye Chemical Company's "Quat" which dilutes 1 to 4 (Quat to water) and is then sprayed on the surface and allowed to "dwell" (ie: remain damp) for a minimum of 10 minutes is probably a better way to go then chlorine bleach. Though not approved for surgical instrument sterlization, a careful reading of the literature on Quat would indicate to me that in the absence of an autoclave this might be an alternative.


This is the product family in question:

http://www.buckeyeinternational.com/products/disinfectants/index.html

Some other general information about quaternarny ammonium disinfectants, particularly benzalkonium:

http://en.wikipedia.org/wiki/Benzalkonium_chloride


I have mostly seen benzalkonium used in healthcare for skin preparation.

As you say correctly, dwell time is an essential ingredient of successful disinfection with these products.


The main barrier to using them for instrument disinfection would seem to be the need to remove any remaining chemical from the instruments prior to use.

I suggest thinking about (and adding to the discussion):

1) How to remove the chemical residue from instruments prior to use.

2) Overall burden of supplies, equipment, etc. (comparing chemical disinfection with autoclaving).

3) What one might do (or not be able to do) and what risk/benefit choices one makes in deciding to sterilize instruments. That is - how can one decide whether they can validate they have successfully sterilized their batch of instruments, or if they can't do so, what are their trade-offs?

4) What means of wrapping instruments does one use? Do we seek out a supply of honest-to-goodness medical wrapping materials or do we improvise? How do we fit that into our chosen method of sterilization, and whatever we're able to do/not able to do with showing successful sterilization?


Just for a reference point... The 2 most common means of instrument sterilization used in healthcare are autoclaving (heat/steam/pressure/time) and various "cold" methods - such as "gas" sterilization with ethylene oxide. Some other methods are used in production facilities, but hospitals generally use either autoclaving (if the item can withstand heat/pressure) or ethylene oxide if it can't.

Observation: Some of the vendors which sell foreign military surplus have periodically had medical items. Sometimes those items have either been stainless steel boxes, or have been a medical item with a stainless steel box.

AFAIK - those stainless steel boxes are their for steam sterilization and subsequent short-term storage of the sterilized item.

The question is whether it's sterilized by autoclaving or merely by steaming (lacking the pressure component of autoclaving). Steaming differs from boiling by not immersing the instruments in the boiling water, but literally steaming them above the boiling water.


A related topic would include instrument cleaning prior to sterilization - to remove tiny bits of blood or tissue. Suggestions?

[Jonas Parker]

Discussion continued from here:

http://www.survivalfiles.info/forums/showthread.php?t=12&page=2

This is the product family in question:

http://www.buckeyeinternational.com/products/disinfectants/index.html

Some other general information about quaternarny ammonium disinfectants, particularly benzalkonium:

http://en.wikipedia.org/wiki/Benzalkonium_chloride


I have mostly seen benzalkonium used in healthcare for skin preparation.

We would prep the operation site on a patient with Phiso-hex, alcohol, and benzalkonium. Some surgeons had their own protocols, but the standard was Phiso-hex, alcohol, and benzalkonium.

As you say correctly, dwell time is an essential ingredient of successful disinfection with these products.

The main barrier to using them for instrument disinfection would seem to be the need to remove any remaining chemical from the instruments prior to use.

I suggest thinking about (and adding to the discussion):

1) How to remove the chemical residue from instruments prior to use.

Probably by pouring the disinfectand out of the pan and rinsing with sterile liquid (IV solution comes readily to mind), or rinse with plain water boiled for ten minutes.

2) Overall burden of supplies, equipment, etc. (comparing chemical disinfection with autoclaving).

An 8 oz plastic sample bottle of "Quat" makes 40 oz of disinfectant when diluted as recommended by the manufacturer. It seems to me that an 8 oz bottle and a flat stainless steel pan is easier to transport than a autoclave, or even a pressure cooker. Also no energy, just water is required.

3) What one might do (or not be able to do) and what risk/benefit choices one makes in deciding to sterilize instruments. That is - how can one decide whether they can validate they have successfully sterilized their batch of instruments, or if they can't do so, what are their trade-offs?

Without heat, obviously Dyack indicators won't work. Sterilizing instruments by soaking is obviously not the first or best choice. In an austere wilderness setting, this might just be the only available option at the time. I presume the validation for a successful instrument sterilization would be the lack of massive infection in the wound site. In a truely SHTF situation, I can use a suture set, a scalpel handle and a couple of probes, which is about the extent of my ability to render treatment within the parameters of my training (surgical tech, ortho-tech, paramedic). I was never an independent duty corpsman.

4) What means of wrapping instruments does one use? Do we seek out a supply of honest-to-goodness medical wrapping materials or do we improvise? How do we fit that into our chosen method of sterilization, and whatever we're able to do/not able to do with showing successful sterilization?

If I'm utilizing chemical sterilization, I don't have to wrap instrument sets. All I need wrapped are sterile towels for draping. My gloves are pre-packaged and sterile, as are the scalpel blades and the suture with atraumatic needles.

Just for a reference point... The 2 most common means of instrument sterilization used in healthcare are autoclaving (heat/steam/pressure/time) and various "cold" methods - such as "gas" sterilization with ethylene oxide. Some other methods are used in production facilities, but hospitals generally use either autoclaving (if the item can withstand heat/pressure) or ethylene oxide if it can't.

Observation: Some of the vendors which sell foreign military surplus have periodically had medical items. Sometimes those items have either been stainless steel boxes, or have been a medical item with a stainless steel box.

AFAIK - those stainless steel boxes are their for steam sterilization and subsequent short-term storage of the sterilized item.

The question is whether it's sterilized by autoclaving or merely by steaming (lacking the pressure component of autoclaving). Steaming differs from boiling by not immersing the instruments in the boiling water, but literally steaming them above the boiling water.

The question is rather, do you have stainless steel boxes, an autoclave or a steamer or a pressure cooker, and fuel and time to build a fire and wrap and steam instrument packs with an indicator of some kind in the pack to indicate successful sterilization.

A related topic would include instrument cleaning prior to sterilization - to remove tiny bits of blood or tissue. Suggestions?

Instrument cleaning (and as a surgical tech I sure did enough of this) can best be accomplished with dish soap for soaking, then use a hand-scrub brush (the same as used for scrubbing before surgery) perhaps with some Comet cleanser to preclean the instruments before sterilizing.

You've got some good points, Doctor, and I certainly wouldn't use this soaking method for instrument sterilization if an ER was nearby and open. Nor would I endevor to clamp an artery, suture a laceration, reduce and immobilize a fracture, insert a chest tube, or perform a "trache" unless I was the only medical provider available within the time frame necessary to save the patient. Fortunately, in a true SHTF or TEOTWAWKI situation, I won't have to worry about malpractice suits.

[DrBaboon]

It sounds as if your plan for instrument sterilization is suited to doing so while on the go, away from a reasonably stable location.

I guess I have thought more about remote but stable locations - such as Mission Medicine, or limited quantities of supplies while travelling. Or even a prolonged natural disaster where my emergency supplies overlap with things I might use at home or at my office.

I suspect - we may each be correct, as far as analyzing our needs goes.

I tend to think of these discussions as being better measured by "process" than by "consensus" as a question of the "right" answer.

From a stand point of my own needs (if cold disinfection of instruments is the goal), I would probably opt for a product like Cetylcide.

http://www.cetylite.com/portal.php?category_id=1&product_id=61

It's in pretty widespread use - particularly for disinfecting endoscopes. It's also available as a concentrate.

Admittedly, I have a number of advantages because of what I do for a living -- including having an opportunity to rotate my stock and make use of my supplies in patient care simply in the course of day to day work.

How well Quat would do compared to Cetylcide, I don't know. You are probably correct that it's a reasonably good choice, it's just hard to know without going ahead and doing the research.


On some related topics (looking to seed discussion - since I have periodically been asked about some of these items):

http://www.cheaperthandirt.com/MOLLE606-45516-538.html

http://www.majorsurplusnsurvival.com/Merchant2/merchant.mv?Screen=PROD&Product_Code=100243&Category_Code=19

Similar types of instrument kits are being sold by a variety of vendors, for varying prices.

I picked up one of these kits a while back, and decided to have some fun with it. I don't recall which vendor I got it from, so it's not really a review.


I removed the plastic items (the penlight, for example), and the consumable items, and left just the instruments in the fabric pouch. I added a needle holder to the kit from another source. Basically, I took out anything that would get trashed by the autoclave.

The kit as I packed it, fit into a sterilyzer pouch, and I autoclaved it.

I periodically see odd lots of sterilyzer pouches on eBay.

Now - I have a shelf-stable sterilized instrument kit, with an outer wrapper that is removed at time of use, and can even be passed to someone wearing sterile gloves. The fabric case becomes a sterile cover for a work surface - such as a table. IOW - I made use of it as if it had "typical" double wrapping of sterile medical supplies. A package of sterilizer pouches will go a long time for an average person.


To me, these are some of the skills that anyone can pick up and use.


I'm posting some of this in case this is helpful to other readers - perhaps because of different needs in planning:

http://www.cheaperthandirt.com/MIL2101-51950-1394.html

I haven't had an opportunity to try this item, but it got my attention.

I suspect the description from the item's listing is incorrect - I believe that the intent is to have the instruments in the tray ABOVE the boiling water, so they get steamed.

Obviously, steaming is not autoclaving (autoclaving adds increased pressure to the heat), but steaming results in more heat transfer than boiling them in water.

Why not simply improvise it with kitchen items? OK - that would work.

OTOH - there's also something to be said for having some dedicated items - particularly if they are for disinfection/sterilization.

[Jonas Parker]

I checked out the link on the instrument pack and I'm not really thrilled with the contents. My own set (which I acquired through the instrument salesman at the hospital some 40+ years ago) consists of three each curved and straight mosquito hemostats, a needle holder, a good pair of surgical scissors, a bayonet forceps, and a #4 scalpel handle.

I also have a leather holder which holds my bandage scissors and a larger straight hemostat and clips onto my belt. It's not sterile, but it's always there.

Ethicon used to put out a great little paperback book on suturing and suture knots. I learned to suture on people, but I have been told that a fresh ham from the local meat market not only makes a great "practice patient", but also a great dinner after you remove the sutures and bake it.

That little sterilizer looks like a neat item. I have forwarded my request to Santa Claus for one to be delivered under the tree on December 25th.

Every now and again, Cheaper Than Dirt also has sales on medical supplies. I picked up ten rolls of 3" adhesive tape and ten rolls of 4" head-roll for under $10.00 for both. You can sign up for Cheaper Than Dirt's e-mail sale flyer which comes out once a week.

I also have bought from Major Surplus in the past - good quality at the right price!

[DrBaboon]

Oh - OK - Yeah, I'd agree that the instruments weren't that exciting in that kit.

They are OK.

What I was actually more interested in was the pouch, and using it as part of the sterile wrapping, combined with an outer wrap (sterilizer pouch).

Even having the pouch become a sterile work area under the instruments is a nice thing.

Plus, having people learn how to handle instruments, and work with a sterile area is a good teaching vehicle. It's also a target or "landing zone" on which to drop other items using sterile technique - such as a syringe for local anesthetic, a sterile scalpel blade, ejecting the inner packet of suture from the outer wrapper, etc.

The other reason I mentioned it was that a number of people had asked me about that type of kit over the last year or 2. I thought I should get one and play with it a little to be able to give people whatever tricks I could come up with to make it more useful.

I appreciate the discussion.

[DrBaboon]

Ethicon used to put out a great little paperback book on suturing and suture knots. I learned to suture on people, but I have been told that a fresh ham from the local meat market not only makes a great "practice patient", but also a great dinner after you remove the sutures and bake it.

http://www.ethicon.com/bgdisplay.jhtml?itemname=healthcare&topic=healthcare

scroll down to the 2 .pdf links...

Knot Tying Manual http://www.jnjgateway.com/public/USENG/Knot_Tying_Manual.pdf

Wound Closure Manual http://www.jnjgateway.com/public/USENG/Ethicon_WCM_Feb2004.pdf