Basic recommendations for surgical instrument's pre-desinfection, cleaning and sterilization.

Reception - Cleaning of new instruments
Reception of a new instrument must be carried out by a qualified staff. Unpack the instruments only after checking the delivery conformity. Before any treatment, check all instruments are in good working order. An instrument that seems to be defective must be returned in its original packaging without any hazardous repair attempt, at the risk of a warranty cancellation. The copper sulphate test recommended by AFNOR has no value regarding the quality validation of a Martenstictype stainless-steel, and might only lead to fake positive results. The boiling water test recommended by AFNOR is useless if instruments are provided from a highly qualified supplier.
If the instrument are not to be immediately put into service:
• After controlling the compliance with the purchase order,
• Achieve a full cleaning cycle specific to new instruments (see next paragraph),
• Control aspect and smooth operation.
Then it shall be stored:
• In a cool, dry and clean room,
• Out of its packaging,
• Away from any acid solution, even if in closed container,
• Away from metals of different composition, especially ferrous (i.e. old chrome plated box or instruments…),
• Protected from any overload,
• According to a classification that allows an easy identification.
If the instruments have to be put directly into service:
• 1st machine wash with usual cycle, WITHOUT lubrication,
• Instruments examination to identify any eventual abnormality,
• 2nd machine wash with usual cycle, WITHOUT lubrication,
• Instruments examination to identify any quality issue,
• 3rd machine wash with usual cycle, WITH final lubrication,
• Checking of aspect and smooth operation of the entire instrument bath:-
Instruments with manufacturing corrosion marks must be soaked in an renovation bath using Landax or similar chemical validated by the supplier,
- Devices still not-conform after this protocol must be isolated and the manufacturer informed,
- Compliant devices can be directed to the regular processing cycle:
------Packaging,
------Sterilisation,
------Storage.
We recommanded not to:
• Wash together new instruments and instruments that have already been used,
• Wash together new instruments from different suppliers,
• Wash together stainless and chrome steel instruments,
• Contact with aggressive solutions based on:
- Halide ions (chlorides),
- Iodides (iodized polyvinylpyrrolidone : Betadine®),
- Chlorhexidine (Hibitane®).
• Detergents containing:
- Chlorine or chlorides,
- Acids,
- Abrasives.
Use spot-remover detergents containing:
• Phosphates,
• Polyphosphates,
• Polyethoxylated fatty alcohols,
• Mineral salts with "dabbed" alkalinity.
Water used for cleaning must be:
• Filtered,
• Drinkable quality,
• Low- grade limestone (softened if necessary),
• Low-chlorine or chloride content,
• Low content in minerals (especially copper and iron).
Distrust too soft water (may contain corrosive chlorides).
Prefer deionized or reversed osmosis water for rinsing.

Pre-disinfection
Shall be excluded of selection: products containing phenols, active chlorines or chlorides, because of their corroding power. Shall also be excluded the aldehydes, because of their capacity to reinforce prions under saturated steam action, their allergenic power and their capacity to corrode.
How to desinfect:
• Treat separately from chrome-plated instruments,
• Desinfection shall be achieved as soon as the instrument is removed from the sterile field in the operating room.
• Hardness of the water must be between 4°TH and 8°TH. Hard water inhibits the antimicrobial action and can lead to limestone deposits on the instrument when combined with detergents.
• The chlorine content of dilution water has to be lower than 20 mg/L, to avoid any risk of surgical instruments corrosion.
• The mineral elements (iron, copper, manganese,…) content of water shall be as low as possible, in order to prevent those elements being coated on the instruments and give them, through time, a bronze or rusty-coloured surface aspect.
• Scrupulously conform to the chemical product concentration that shall not be increased nor decreased at the risk of compromising the efficiency or increasing the unsolicited effects.
• Do never mix products together, above all, do never add detergents to disinfection solution.
• Bath temperature shall be of 20°C, except for proteolytic enzymes.

If the smell of the soaking solution spreads, it means the water temperature is too high, and the active ingredients volatilize to the detriment of the efficiency.
Instrument's immersion shall be total, for the desinfection to get extended to the whole instrument's surface, and to avoid electrolytic reaction.
Respect soaking time. A too short soaking time would compromise the desinfection action and a too long with some corrosive products would lead to an irreversible damage to the instruments. As a rule, regardless the selected product, soaking time shall never exceed 30 minutes, while scrupulously respecting the recommended concentration.

Steam sterilization
Regardless the method of steam production, the quality of water used for it shall be controlled and regularly analyzed
This water shall be:
• Drinkable, filtered in each case,
• Its hardness must not exceed 5 to 7°TH (1°TH = 10 mg calcium carbonate / L of water),
• Completely devoid of chlorine elements and of chlorides: < 2 mg/L,
• Content in phosphate lower then 0,5 mg/L,
• And an almost null content in minerals :
—> Silica : < 1 mg/L,
—> Iron : < 0.2 mg/L,
—> Cadmium : < 0.005 mg/L,
—> Lead : < 0.05 mg/L,
This water shall content:
• No tanates,
• No sulfites,
• No amines,
• No hydrazine,
• No chlorides,
• No permovapoline.
• Products often used by heating engineers to prevent corrosion or remedy to sedimentations in the pipes. Those products are very corrosive to surgical instruments, as well as to the steam steriliser tank which is usually made off 316 L stainless steel.

Processing of instruments after being used in operating room
1. Pre-disinfection soaking + brushing, then visual examination,
2. Manual rinsing,
3. Machine cleaning,
4. Machine rinsing: if possible with reversed osmosis water,
5. Visual control,
• Eliminate unclean instruments,
• Repeat cleaning manually or in an ultrasonic bath,
• Process instruments in a renovation bath (Landax or similar) if necessary,
• Manuel rinsing and drying,
• Lubrication.
6. Packaging,
7. Autoclave sterilization,
8. Storage.