Venugopal, the most illiterate among you again with a silly question!

In most of the hospitals I know, the Orthopaedic Surgeon instructs for "Double sterilization" of his instruments - to sterilize all his equipments twice (some guys will satisfy with double the exposure period (which even otherwise is nothing less than an hour!!) but some stubborn Surgeons need loading it twice and exposing it twice!! Nobody could give me a justification for this! I know it's a waste of both manpower and electricity!
Most of the Surgeons would have also worked abroad but in India he asks for this absurd practice! Is it a modification of "repeat sterilization" done on implants (sterilizing normally once and just before implanting sterilizing them once again in the flash autoclave inside the OT)? I think so! Can anyone help me?

Foolishly yours
Venu

Good day Venugopal,

I agree with your sentiments that "Double sterilization" of instruments appears to be a waste of manpower, supplies and wrappers, and energy. I have not previously encountered the practice of planned "repeat sterilization" of implants. If the instruments and implants are sterile with no living microbes on them, why deliberately contaminate them by opening the wrapper and re-wrapping the previously sterile items? Or transfer sterile instruments or implants to a flash sterilizer?

I can understand why extending the length of the cycle could be required for some very heavy pieces of equipment. Dense, heavy metal objects can take longer to heat up to sterilizing temperatures than a typical forceps. The manufacturer should give adequate instructions on how to sterilize an item. I find that keeping a reference book in the sterilizing area that lists all items that according to the manufacturer can not be sterilized using a typical sterilizer cycle is a very useful tool. The manufacturer recommendations for sterilization should be followed unless you have very strong research results to validate an alternate sterilization method. If the manufacturer does not instruct "Double sterilization" and the doctor does not have any valid reason to extend the length of sterilization cycle, I think the practice should be discontinued because it is against the instrument or implants' manufacturer's recommendations. If the doctors' concern is that the items may not be sterile after a normal sterilization cycle is because the instruments are not cleaned properly, "Double washing" would be a more effective solution to the problem.

Warm Regards,

Pete Bobb

Dear Pete

Yes! You were also speaking out what I have been thinking. You know, in India, the CSSD (even the name may be strange in some hospital!) is the most ignored area and is riddled with misconceptions and erroneous practices.

The manufacturers of instruments/equipment here never ever give any instructions for their sterilization and most of us do what we have heard or seen from others. Usually we have a 121 degrees, Gravity Displacement, Cylindrical, horizontal/vertical sterilizer. Everything is presumed to be cleaned, wrapped properly and dumped into this. When the jacket pressure reaches abour 24 ponds, the bell valve is put on "sterile" and kept for a minimum of 45 minutes to .......? Unloading is also without any protocol and since the main wrap is linen, it is not uncommon to see some wet packs but the whole load is considered sterile and happily handed over. Sterile store is seldom seen and the packs are kept inside the OT for about a week (mind you linen wrapped ones and Bins!!) and the returened for the same fate as before.

Yes! Some of the corporate hospitals do have better facilities and a few protocols but an average Indian hospital only has this scenario. The surgeons are confident of loading the patient with prophylactic spectrum of antibiotics to counter the possibility of post op infections. The more the number of days the patient in the hospital the better! No one knows about these and no one is bothered.

I along with a couple of friends have tried to propagate the need for proper sterilization and disinfection by offering a consultancy on these critical aspects (we know, we dont know much or are not highly qualified to offer consultancy, but something is better than...) but there are few takers. A few hospitals in Mumabi (Bombay) and Delhi do have well developed CSSDs and qualified personnel to handle the Hospital Infection Society but their spectrum is limited to the hospitals they work in.I am sure some of my colleagues may also see this and our earnest wish is bring in some reformation in this area. (unfortunately we have no government control over Sterilization & disinfection but surprisingly a lot of regulations in wastage disposal)

Can you help us with some light on the various instruments routinely used and their required tme of stean sterilisation? When it comes to alternate methods of sterilization, the things are still worse. Except for a few EO sterilizers, most of them resort to either Glutrealdehyde HLD (improperly done without any concentration indicator) or keeping the instruments in acrylic chambers with formaldehyde fuming in it (No one is bothered about the concentration, RH, Temp & Time). I am sorry that I have not much of a rosy picture about my country's standards of IC but we sincerely hope to do something about it within our reach and expertise.

Thanks once again Pete!
Venugopal.K.G