INHS ASVINI

STANDARD OPERATING PROCEDURE FOR

STERILIZATION IN OT & ICU

 GUIDELINES FOR STERILIZATION PROCEDURES IN ICU AND OT

These guidelines can be divided into following subtypes based on situational application: -

GUIDELINES FOR PERSONAL HYGIENE AND PROTECTION: -

1. Wash hands when you enter the OT or ICU- with soap/ hand disinfectants.
2. Use gloves for all patient procedures.
3. Before wearing gloves, use 70% alcohol, specific hand disinfectants: alcoholic rubs with
antiseptic and emollient gels medicated or plain soap and water to clean your hands.
4. Do not use gloves contaminated from attending to one patient on another patient.
5. Avoid touching your nose, eyes face or other body parts when doing procedures.

GUIDELINES FOR PROCEDURES INVOLVING INTRAVASCULAR CATHETERS AND PORTS

1. Designated, trained personnel to insert and maintain catheters.

2. Proper hand hygiene with antiseptic-containing soap and water or with waterless alcohol-based
gel or foam.
3. Aseptic technique during catheter insertion and care.
4. Clean gloves for insertion of peripheral catheters and sterile gloves for arterial and central
catheters.
5. Maximal sterile barrier precautions for Central Venous Cannula insertion.
6. Care of catheter site
(a) Skin disinfection with 2% chlorhexidine or 70% alcohol.
(b) Use of sterile gauze or transparent, semi-permeable dressing.
(c) Replacement of damp, loose, or soiled CVC dressing.
(d) Selection of catheter, insertion technique, and site with lowest complication risk
(e) Prompt removal of catheter that is no longer essential.
(f) Replacement of administration sets not more frequently than every 72 h (unless
infection is suspected).
(g) Cleansing of injection port with 70% alcohol or iodophor before access.
(h) Appropriate preparation and quality control of intravenous admixtures.

GUIDELINES FOR CLEANING AND DISINFECTING ENVIRONMENTAL SURFACES

1. Transferral of microorganisms from environmental surfaces to patients is largely via hand

contact with the surface-
(a) Hand hygiene is important to minimize the impact of this transfer.
 (b) Cleaning and disinfecting the surfaces as appropriate is fundamental.

2. Environmental surfaces can be further divided into: -

(a) Medical equipment surfaces (e.g., knobs or handles on hemodialysis machines, x-
ray machines, ventilators, anaesthesia machines monitors, instrument carts, and
dental units)
(b) Housekeeping surfaces (e.g., floors, walls, and tabletops)

3. Cleaning is the necessary first step of any sterilization or disinfection process. The physical
action of scrubbing with detergents and rinsing with water will remove large numbers of
microorganisms from surfaces.
4. Surfaces of floors and walls to be cleaned with soap and water and dried.
5. Subsequent surface disinfection is to be done with high level surface disinfectant – ‘Virkon’
which is virucidal as 1% solution (10gm in 1 litre luke warm water)- and it is dispersed as an
ultra low volume (ULV) aerosol.
6. Wear gloves and protect eyes and skin from contact. Do not breathe the dust while
preparation.
7. Tabletops in OT and elsewhere being used for sterile instruments are to be wiped with
undiluted carbolic acid before being wrapped in sterile towel and before placing autoclaved
instruments on board.
8. Medical surfaces to be wiped with VIrkon daily or even spirit, periodically. Avoid spirit on
laminated touch panels of sophisticated monitors and ventilators which can turn opaque
after contact with spirit. These can be cleaned only with moist soft cloth under instruction
from the MO in charge or the specialist officer.
9. Windows and door surfaces to be wiped with soap and water and cleaned with glass
cleaner.
10. Grooved tiles on floors to be scrubbed with brush and soap and water to remove grime in
side the crevices.
11. Mops and buckets to be cleaned thoroughly and contaminated cleaning fluid changed
frequently during mopping, cleaning and drying.
12. Cleaning Spills of Blood and Body Substances

(a) Promptly clean off the spill with soap and water.
(b) Treat the area of spill with formaldehyde or sodium hypochlorite solution (1:10 v/v
solution).
(c) Wear gloves during cleaning.

13. Avoid spillage of drugs, antibiotic solution and colored fluids outside the designated bins.
14. Follow guidelines for Biomedical Waste Disposal color codes for proper sorting out of waste
as per category.
GUIDELINES FOR DEALING WITH CONTAMINATED LAUNDRY

1. Used and contaminated or infected laundry should be segregated away from ‘clean’ laundry.
2. It should be placed inside plastic bags and handed over to the laundry.
3. Gloves to be worn when handling contaminated laundry.
4. Laundry may be forewarned to use hot water, bleach or extra soap and water in known
cases of organism-specific contamination.
 5. On receipt of clean laundry it should be ascertained that clothes and towels are dry and
ironed properly.
6. Use of disposable drapes, gowns and OT linen is preferred when taking up known cases who
are HBV or HIV positive.

GUIDELINES FOR TREATMENT OF BIOMEDICAL WASTE

1. Biomedical waste must be segregated at the point of its generation- viz. anaesthesiologist’s
work station or OT table at the side of the surgeon. It should not be left to the biomedical
waste handler to endanger himself in exposing his hands to needle stick or ‘sharps’ related
injury or touching contaminated waste material.
2. All sharps which are contaminated with blood or body fluids must be exposed to 1% Sodium
hypochlorite solution for 30 to 40 minutes before going into the proper color coded basket.
3. Sodium hypochlorite solution must be changed every 8 hours.
4. All sharps must be disposed of later by burial in bleaching powder.
5. Broad color codes: -
(a) Blue plastic bags- for rubber lines, IV plastic bottles and hypochlorite- treated plastic
syringes
(b) Yellow plastic bags for –blood and fluid contaminated dressings and tissues.
(c) Black bags for plastic wrappers, paper and office waste.
6. Needle and syringe destroyers must be used for proper destruction of syringes and needles
prior to treatment in hypochlorite.
7. Detailed guidelines are already promulgated vide Enclosure II to INHS Asvini DO no
173/2009 of 01 Aug 09.

GUIDELINES FOR PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA (VAP)

1. HOB (head over body) elevated greater than 30 degrees.

(a) Reduces frequency and risk of nosocomial pneumonia
(b) Simple, no-cost intervention
(c) Incidence of aspirations reduced 30%
(d) Ventilator and ICU LOS reduced

2. Use of sterile technique including hand hygiene, gloves and due precautions for
procedure.
3. Use of dedicated suction cannulae for tracheal and endo bronchial suctioning.
4. Use of closed suction system if available.

GUIDELINES FOR INSTRUMENT STERILIZATION

FORMALIN TABLETS, PERASAFE & GLUTARALDEHYDE–
( PVMS no 010142 &010144 ‘VIRKON’ -1% POTASSIUM MONOPERASULPHATE

1. Perasafe is used for 10 minute instrument sterilization- for flexible fibreoptic

endoscopes, TEE transducers etc.
2. Use also for stainless steel instruments with inert material valves.
3. It is effective for 24 hours.
4. Instructions
 (a) Use 16.2 gm sachet per liter of water.
(b) Water temperature to be in range 20 +/- 5 degrees Celsius.
(c) Immerse instruments for 10 minutes.
(d) Rinse with sterile water prior to use.

5. It is biodegradable, aldehyde free, sporicidal, tuberculocidal, virucidal, fugicidal and

virucidal.
6. Perasafe is a viable alternative to Glutaraldehyde especially in a setting of Hepatitis B
virus contamination or suspected HIV infection since the ‘Cidex’ will require minimum I
hour of contact time as compared to 10 minutes with Perasafe.
7. For delicate endoscopy instruments requiring storage overnight – formalin tablets are
placed inside the acrylic packing cases of the instruments so that once the endoscope
has been thoroughly cleaned wiped and dried- it may be placed inside the formaldehyde
rich atmosphere within the packing case.
8. Thus method is also useful for diathermy leads, wired extensions of electronic
equipment and video cables for overnight storage and sterilization.

GUIDELINES FOR STERILIZATION USING HEAT

1. Sterilization using heat is of two types : -

(a) Dry Heat in ovens for glassware and containers where preservation of sharp
cutting edges is not the issue. Here temperatures of 170 degrees Celsius are
used for 2 hours in an oven for effective dry heat sterilization.
(b) Moist heat – ‘AUTOCLAVING’-steam under pressure is more effective. Three
types of cycles are applied-
i. 134- 138 degrees Celsius for 3 minutes
ii. 121-124 degrees Celsius for 15 minutes
iii. 115 degrees Celsius for 30 minutes
Moist heat is used for blunt instruments, towels and gowns and other non thermo
labile items which can withstand the steam and vacuum treatment.
GUIDELINES FOR STERILIZATION USING ETHYLENE OXIDE
1. This method is applicable to thermo-labile goods such as sutures, anaesthesia and
ventilator circuits, breathing circuits, lensed equipment, heart valves, mattresses, linens,
delicate silicon cannulae, PVC catheters and lines which are reusable – thus saving cost
of repurchase.
2. Ethylene oxide is a cytotoxic, explosive, carcinogenic and mutagenic and needs to be
used with caution with special venting arrangements.
3. It is used in specialized sterilizing chambers where items for exposure are placed after
thorough cleaning, overnight drying and sealed packing in laminated pouches before
being placed inside.
4. The items are exposed four times for 4 hours in a 24 hour cycle to the ETO gas and the
chamber is opened only after careful venting of the deadly gas out of the room.

GUIDELINES FOR TERMINAL DISINFECTION OF A ROOM

1. This is done when a patient who has been under source isolation is discharged.
2. Fumigation of the room is not necessary though it may be done if so required.
3. Domestic staff should wear personal protective equipment such as plastic apron, gloves
and mask.
4. Discard all disposable items and seal clinical waste bags as per biomedical waste
disposal code.
5. Permanent items and equipment to be sterilized as per nature of the item.
6. All linen to be carefully packed into plastic bags and sealed.
7. Dusting of all areas such as ledges, top of tables, cupboards, curtains and cracks to be
done.
8. Wet clean all ledges, window frames, ledges, fixtures and fittings including taps and
door handles.
9. Vacuum clean all fixtures, fittings and floor. Use only suitable vacuum cleaner with high
filtering mechanism.
10. Bed mattresses should be wiped with warm water and detergent and dried thoroughly.
If disinfection is required, use freshly prepared hypochlorite in 1:100 dilution.
11. Wash the sink with warm water and detergent. Rinse and dry thoroughly, hypochlorite
or detergent may be used.
12. Wash floor and spot clean walls with detergent solution. Rinse and dry thoroughly.
13. Open windows and facilitate drying of all surfaces.
14. The room may be reused again by the next patient when all the surfaces are thoroughly
dry.