Autoclaves by Frank Weithöner

All surgical instruments that are in touch with open wounds or enter the
body of a patient must be sterile. Therefore, all surgical instruments and
materials have to be sterilised before surgery. The machine which does the
sterilisation is called autoclave or steriliser. If sterilisation does not
happen or happens insufficiently, life-threatening infections are the result.
For this reason the autoclave is one of the most important pieces of
equipment in a hospital.
The medical steam autoclave is a device that uses pressurised, high
temperature steam to sterilise medical instruments. Although there are still
other methods of sterilisation e.g. dry heat, gas (Ethylene Oxide) or gamma
radiation, the sterilisation with hot steam is the most common method. The
usage is simple, rapid, cost effective and environment friendly. The following
article refers to the steam autoclave.

Sterilisation
Sterilisation is the elimination of all transmissible micro organism, bacteria,
viruses and fungi from the surface of an instrument. This is different from
disinfection, where only organisms are removed by a disinfectant and are
not completely eliminated.
In general, any instrument that enters the body must be sterilised. This
includes all surgical instruments, implants, catheters, syringes, needles,
dressings and others.
Proper sterilisation of instruments is crucial in preventing HIV transmission.
Sterilisation is possible with hot air, chemicals or radiation, but the most
common method is the use of hot steam, which kills all organisms. This
method is easy and cheap to realise.
For a steam sterilisation temperatures above 110°C are needed, which
requires the steam to be applied in a pressure chamber. The sterilisation
time depends on the temperature. The higher the temperature the faster the
instruments get sterile.

Types of autoclaves
All steam autoclaves have a metal chamber to withstand the high pressure
and the temperature. A massive door or lid which is locked during operation
keeps the chamber closed. The chamber is heated by an electric heating
element. In places without electricity supply autoclaves heated up by gas or
fuel are common.
To ensure that an autoclave works correctly, the machine has a temperature
and/or a pressure gauge and often an integrated timer.
Modern autoclaves are all electronically controlled. The control unit controls
temperature, pressure and time and monitors all safety functions.
Hospital autoclaves are available with chamber capacities from 5 l to 900 l.
The smallest and simplest ones work manually and are heated up by a
normal electric or gas stove. The big stationary autoclaves are fully
automatically controlled and need three-phase-power supply and a water
supply installation.

Pressure cooker type

The simplest autoclave with a capacity of 5-25 l is the pressure cooker type.
It is the small and portable version of a vertical autoclave. Usually it is
heated by an integrated electric heating element but sometimes it comes
without a heater. This version is heated like a pressure cooker on a gas
stove. It is made for remote areas without electricity.
The pressure cooker type autoclave has a safety valve, a release valve, a
pressure gauge and a thermometer. The simplest and cheapest ones come
even without a rubber gasket in the lid. The sterilisation process has to be
controlled manually by the user. This type is simple, reliable and almost
indestructible and very common in small hospitals and small health centres.
Vertical
The vertical autoclave is a stationary top-loader with a capacity of 60 l -
100 l. The construction is simple and robust. The vertical autoclave is often
double walled with pressure gauges, thermometer, water level inspection
tube and a mechanical timer. Bigger vertical autoclaves need 3-phase
electrical installation.

Table-top
 Table top autoclaves have a
capacity of 20-80 l. Although it has just small capacity, the table-top is the
most common autoclave. It is found where surgical instruments are needed:
E.g. in maternity wards, laboratories and at the dentist.
Modern table-top autoclaves are a fully automatically controlled, and often
come with a vacuum pump and a drying program for drying the goods after
sterilisation.
Table-tops are designed for front loading use and provide different trays for
surgical instruments. They also have a safety lock for the door and a water
reservoir.

Stationary

Stationary autoclaves are big,

automated or semi-automated machines, built for all sorts of purposes:
Instruments, liquids, clothes and even for waste sterilisation. They are
available with capacities up to 800 l. Stationary autoclaves are normally
located in the sterile processing department (SPD) of a hospital. Often the
autoclaves have two doors, a front and a rear door and are positioned
between two rooms, a sterile and a non-sterile area.
Stationary autoclaves require plumbing and 3-phase electrical installation.

The principle of steam sterilisation

The boiling point of water is 100°C (212°F). This means that water cannot
be heated above 100°C. Further heating does create steam but does not
raise the temperature of the water. Only when water is heated in a closed
vessel is it possible to reach higher temperatures. Then the water steam
creates a pressure in the vessel. With increasing pressure the boiling point of
the water also increases. The temperature gets higher than 100°C and can
then be used for sterilisation.

Temperature and time

For sterilisation a minimum temperature of 110°C (230°F) is needed. The
higher the temperature, the shorter is the needed time to get things sterile.
In practice 121°C (250°F) and 134°C (273°C) are defined as the standard
sterilisation temperatures for hospital autoclaves.

Important: Water and steam temperatures of 121°C or 134°C can only be reached
under pressure.

Sterilisation depends on temperature and time. The higher the temperature,

the shorter the sterilisation time.
Gauge pressure and absolute pressure
It is confusing. The air pressure at sea level is by definition 1 bar
(1013 mbar). This is the true or absolute pressure. The perfect vacuum is
according to this definition 0 bar.
But our pressure gauges for technical applications always show 0 bar at
ambient air pressure. We use a different definition, the so-called technical
pressure or gauge pressure. Our zero-point is the normal air pressure at
sea level. That means, that 0 bar gauge pressure is equal to 1 bar absolute
pressure. That is why we have to be careful and make a clear distinction
between absolute pressure and gauge pressure.

Example: 0 bar of a pressure gauge shows us that a vessel is not under

pressure. But the absolute pressure is 1 bar. A reading of 2 bar showing on a
pressure gauge of an autoclave corresponds to an absolute pressure of
3 bar.
But in practice this fact is not really relevant to us because we are only
interested in the gauge pressure or in the change of pressure. We want to
know the pressure difference of a pressure-less vessel and a vessel under
pressure.

Note: We technicians talk about the gauge pressure, the technical pressure.

Pressure and temperature

In a closed vessel, pressure and temperature rise when the vessel is heated
up. When the temperature reaches the boiling point (100°C), steam starts to
be generated. This steam creates a pressure. The higher the pressure, the
higher the temperature gets in the vessel gets. Pressure and temperature
are interdependent. It is not possible that one value increases without the
other.
At 121°C the pressure is always 1 bar and if the pressure reaches 2 bar the
temperature is always 134°C. Thus, it would be enough to look only at one
meter to know if the autoclave works correctly, the pressure gauge or the
temperature. But in practice most of the autoclaves have both, a pressure
gauge and a thermometer.

Pressure at high altitude

The atmospheric pressure changes with the altitude. At sea level it is
1013 mbar (absolute pressure) but it decreases in higher altitudes. That also
means that in higher altitude water reaches the boiling point earlier. It boils
at a lower temperature than at 100°C.
This also has consequences for an autoclave when the autoclave is pressure
controlled and not temperature controlled. When a pressure controlled
autoclave at high altitude reaches the 1 bar (gauge pressure) setting and
switches off, the temperature has not reached 121°C. The instruments in the
steriliser will not get sterile.
For pressure controlled sterilisers we have to increase the pressure limit in
order to reach the needed sterilisation temperature. If this is not possible,
the sterilisation time has to be longer.

Altitude and pressure

When the autoclave is pressure controlled and the pressure valve cannot be
adjusted then it should be done according to the following table.

Altitude Absolute air Temperature at Pressure Temperature at Pressure

pressure 1 bar compensation 2 bar compensation
0m 1.0 bar 121°C +0.0 bar 134°C +0.0 bar
1,000 m 0.9 bar 118°C +0.2 bar 132°C +0.1 bar
2,000 m 0.8 bar 117°C +0.4 bar 131°C +0.2 bar
3,000 m 0.7 bar 115°C +0.6 bar 130°C +0.3 bar
4,000 m 0.6 bar 114°C +0.7 bar 129°C +0.4 bar

Altitude and time

When the autoclave is pressure controlled and the pressure valve can not be
adjusted then the sterilisation time has to be extended according to the
following table.

Altitude Temperature at Sterlisation Time Temperature at Sterilisation Time

1 bar 2 bar
0m 121°C 20 min 134°C 3 min
500 m 120°C 25 min 133°C 10 min
1,000 m 119°C 25 min 132°C 10 min
1,500 m 118°C 30 min 132°C 10 min
2,000 m 117°C 35 min 131°C 10 min
2,500 m 116°C 40 min 131°C 10 min
3,000 m 115°C 45 min 130°C 10 min
3,500 m 114°C 50 min 129°C 10 min
4,000 m 114°C 50 min 129C 10 min

Example 1: In Arusha, Tanzania the altitude is 1,500 m above sea level. A

pressure controlled autoclave would reach the 1 bar setting (121°C) already
at 117.5°C. If the user would run the normal 121°C-program, the
instruments would not be sterile. Either the technician has to adjust the
pressure valve to 1.3 bar or if this is not possible, the user has to extent the
sterilisation time to 30 min.

Example 2: In La Paz, Bolivia the altitude is 4,000 m. Here we only get a

temperature of 114°C when a pressure controlled autoclave switches off the
heating element. In order to get the instruments sterile, the '121°C-cycle'
has to last 50 minutes instead of 20 minutes or the technician adjusts the
pressure valve to 1.7 bar.

Working principle
The working principle of steam autoclaves is always the same. The difference
is the control. Manual autoclaves are simple and robust but the user has
always to be present. Fully electronic controlled autoclaves are easy to use
but more difficult to repair.
Working principle of a simple autoclave (pressure type, vertical)
Water is heated up in the chamber. At 100°C steam develops and after a
short time the pressure increases, the boiling point of the water rises and so
does the temperature (heating phase).
When the predefined pressure or temperature is reached the heating
element is switched off, either by a thermostat or a pressure switch. In
electronic controlled autoclaves a pressure or a temperature sensor delivers
a signal to the control board.

At this point the sterilisation phase begins. Then the temperature drops a
bit and the heating element is switched on again. In this way the
temperature is kept stable. At the same time a timer gets started and after
the set time the autoclave switches off completely. The sterilisation process
is now completed (drying phase), the outlet valve opens and releases the
steam. The sterilisation goods remain a little longer in the chamber and the
radiant heat from the chamber dries the items.

Important: The sterilisation time begins only when the sterilisation temperature
(121°C or 134°C) is reached.

Vacuum pump
Unfortunately the sterilisation process is not that easy. In practice the items
to be sterilised are not packed separately but in packages wrapped in
clothes. When the packages are packed too tight, the steam cannot
penetrate everywhere. Zones of colder air come into being and the items do
not get sterile.
Furthermore some surgical instruments consist of individual parts. In the
joints and spaces between the parts little air bubbles with cool air remain
and prevent the hot steam to penetrate (e.g. the joints of scissors) and the
items will not get sterile.
Simple autoclaves which just use the steam to press the cold air out of the
chamber (gravity displacement) have problems to reach the cold air zones in
the packs between the instruments. Here an additional vacuum pump helps.
Before the sterilisation process begins, the vacuum pump sucks the air out
of the packs and the insulating air bubbles disappear (pre-vacuum). Then
the sterilisation process is started by the control unit.
Later when the autoclave has finish the sterilisation, the vacuum pump is
used again to suck out the steam before the door can be opened (post-
vacuum). In this way the packages get perfectly dry.

Working principle of an automated vacuum autoclave

After switching on the steriliser, the vacuum pump sucks the air out of the
closed chamber. A vacuum develops, the pressure in the chamber is
negative (air removal phase). Then the pump stops, the inlet valve opens
and filtered air gets into the chamber as well as distilled water from the
reservoir.

The pressure again is 0 bar. The valve closes and the water heater starts
heating. The temperature in the closed chamber rises slowly. In the
meantime the vacuum pump creates some more vacuums (air
removal phase) which suck the trapped air out of the sterilisation packs.
After some minutes the boiling point of the water is reached and the vacuum
pump switches off completely. Now steam is created. The steam gets more
and creates a pressure. Under pressure the boiling point start to shift and
the temperature rises (heating phase). After some more minutes the pre-
set temperature or pressure is reached and the heater is switched off.
Now the sterilisation period begins and the timer starts. The pre-set time
which is related to the temperature (20 minutes at 121° or 3 minutes at
134°) is counted down. A temperature or pressure sensor controls the whole
process and lets the heater restart when the temperature drops
(sterilisation phase).
When the sterilisation process is finished an outlet valve opens and steam is
released from the chamber, condenses in a special condenser and the hot
water gets back into the reservoir. The temperature in the chamber
decreases. Now the vacuum pump supports the drying process by sucking
the steam out of the chamber (drying phase).
Sometimes a special chamber heater is switched on additionally in order to
improve the drying process.

Water quality
The water quality is very important for the usage of autoclaves. In principle
only distilled water or de-mineralised water should be used because the
water has to be pure and free of any minerals.
But often normal tap water is use, which causes serious problems. The tap
water leaves deposits on the components of the autoclave and the
sterilisation items. Surfaces of surgical instruments get destroyed after some
time and valves and the tubing in the autoclave get blocked or damaged. On
heating elements a layer of lime is formed which gets thicker and thicker.
One day the heating element cannot conduct the heat sufficiently and the
heating element will burn out.

In order to prevent all these problems only

distilled water has to be used. The hospital technician should ensure that
only distilled water is used and should check the water quality from time to
time. The instrument needed for such a water test is the conductivity meter.
It is also sold as aquarium accessory and is not expensive.
When distilled water is not available, sometimes drinking water is an
alternative when it does not contain minerals. In some places drinking water
is processed by reverse osmosis plants. In this case you can also take this
drinking water. But also here, you should test the water first with a
conductivity meter.
Another alternative is filtered rain water. Rain water is in principle free of
minerals and thus perfect for an autoclave.

Using the autoclave

The user has to be trained in the correct usage of the autoclave. They have
to know how to run the different sterilisation programs and how to clean the
autoclave after usage. This instruction in the operation of an autoclave
should be given by the hospital technician with the help of the user manual.
But beside the correct usage of the machine the preparation of the
sterilisation goods is even more important. The cleaning and packing has to
follow strict international guidelines and has to be carried out by qualified
personnel only. To perform such a user training is however not the task of
the hospital technician.

Precautions for usage and service

Be very careful while operating and servicing an autoclave. Autoclaves
generate extreme heat and high pressure. Simple autoclaves only have little
or no heat shielding around the chamber.
Do not place paper, cardboard, plastic or flammable liquids next to an
autoclave.
The operation has to follow exactly the user manual of the manufacturer.
In addition, always consider the following safety precautions:

1. Make sure that the chamber is filled up with enough water.

2. Check if the door gasket is in place and the door is locked firmly before
starting the
autoclave.
3. After sterilisation make sure the autoclave is switched off.
4. Make sure that the chamber is pressure-less and cooled down before
opening the door.
5. Open the door slowly, keeping head, face, and hands away from the
opening.
6. Wait at least 30 seconds after opening the door before reaching or
looking into the
autoclave.
7. Remove solutions from the autoclave slowly and gently. Some solutions
can boil over
when moved.
 8. Clean up any spills immediately.
9. Hospital staff should report any malfunctions or accidents immediately.

User manual
The usage of the autoclave has to be followed strictly according the user
manual. One copy of the user manual has to present in the department
where the autoclave is operating and one should be available in the
workshop.
It is also a good idea to create a 'Quick User Chart', a one-page to-do-table
with the most important information for the operator. Additionally, the
phone number of the hospital technician should not be missing. This
instruction can be laminated in plastic and hang up close to the autoclave.

Using a vertical autoclave

The following is an example for the usage of a standard vertical autoclave.
Every single step has influence on the quality of the sterilisation. Any
mistake results in unsterile or wet packages.

1. Fill the autoclave with the right amount of distilled water.

2. Place a Bowie-Dick indicator strip in the centre of the load.
(see ↓Bowie-Dick-test)
3. Load the autoclave with the packs. Do not overload. Packs must not
touch the chamber
wall.
4. Close the lid tightly.
5. Open the air outlet valve so that the air can escape when heating up
the autoclave.
6. Heat up the autoclave.
7. After water is boiling and all cold air is escaped, close the air outlet
valve.
8. After some minutes when the pressure reached 1 bar (15 psi) reduce
the heat and start
the timer. The sterilisation time is shown in table ↑Temperature and
time.
9. When sterilisation time is over, turn off the autoclave or the gas supply
and let the
autoclave cool down. At 80°C the vent valve can be opened and after
this the lid. This
step may differ from one manufacturer to another.
10. It is a good idea to keep the packs in the warm autoclave for a while
so that the
 packs can better dry.

Cleaning by the user

An autoclave has to be perfectly clean at all times. It is the operators who
are responsible for the condition of the autoclaves. Together with the
hospital technician they should think about an appropriate procedure and
schedule. This plan should be adapted to the situation on site. If the water
quality is not perfect and the cleaning technique of the user also not
sufficient, then the autoclave has to be cleaned more often.
A typical procedure for cleaning is the following:

Daily (by the user)

1. Remove and clean the outlet sieve under running water.
2. Clean the chamber using a cloth. Do not use abrasive cleansers or steel
wool, as these
will scratch the surface and increase corrosion.
3. Clean the trays or baskets with multi-purpose cleaner and a cloth.
4. Clean the door or lid gaskets with a cloth and check for defects.
5. Do a performance test by using indicator strips (see ↓Bowie-Dick-test).

Weekly (by the user)

1. Flush the chamber drain to keep it free of residues.
2. Remove the outlet sieve. Pour 1 litre of multi-purpose cleaner and hot
water down the
drain with a funnel. Rinse drain with 1 litre of hot water. Clean the
sieve with multi-
purpose cleaner and put it back into place.
3. Do a performance test by using indicator strips.

Bowie-Dick-test
We technicians check the temperature and the sterilisation time to ensure
that the autoclave meets the technical conditions for the sterilisation
process.
A performance test does more, it shows if the whole sterilisation process
was successful, if the packages were packed correctly and the autoclave not
overfilled.
Such a test is performed with indicator strips or tape and is called Bowie-
Dick-test.
According to the international standards Bowie-Dick-test has to be done
every day by the autoclave operator.
For this purpose a test strip is placed in the centre of the load and the
sterilisation cycle is started. After sterilisation a colour change indicates
whether the steriliser works correctly or not. A failed test can be the result
of a defect autoclave or, and this is more likely, of an overfilled or wrongly
packed autoclave.
When a Bowie-Dick-test fails and the operator does not find a packing
problem, the hospital technician has to come to do a technical check. Then
the sterilisation temperature and the time have to be measured.
To do a Bowie-Dick-test in the workshop after maintenance or repair is
pointless because we run the autoclave empty and a Bowie-Dick-test would
always pass.
In addition to the daily Bowie-Dick-test, a more precise test with biological
indicators should be done twice a year. These indicators have to be sent for
analysing to a certified laboratory.

Validation
An autoclave validation goes even further. A validation monitors the whole
sterilisation process from the cleaning and packing to the sterilisation
process and unpacking. It also covers technical issues like measuring the
sterilisation temperature but mainly the organisational aspects.
For validation national or international standards apply.

Common problems during usage

During the sterilisation process some problems can occur. Here are the most
common ones:

Wet material after sterilisation

This is probably not a technical problem. It is more likely that the autoclave
is overloaded, the air-release valve was not opened completely, the door
was not briefly opened after sterilisation, or the packs are too close to the
wall, etc. However, the only correct way to achieve the best drying result is
described in the user manual and the operator should follow these
instructions.
Basically, the wet steam has to be released out of the chamber after the
sterilisation. If this does not happen the steam will condense, becomes
water and the sterilisation goods become wet. A typical procedure to
improve the drying is that the user opens the door briefly after sterilisation
so that the steam can escape and then leave the door ajar.
But this is only one possibility. There is no general perfect method. Every
autoclave is different. So please read the user manual!

Door locked after power outage

After a power failure many electronically controlled autoclaves are reset and
are not able to continue the sterilisation cycle. The chamber is under
pressure, contains hot steam and hot water and the door is locked by the
safety lock mechanism. The user manual explains how to open the door in
this case. But be careful, hot steam and hot water will escape when opening
the door.

Here are some more suggestions to prevent problems during usage:

Use only distilled water. Never use tap water.

Use towels to separate instruments and absorb moisture if needed.
Hinged instruments must be autoclaved in the open position.
No sharp instruments should be allowed to touch other instruments.
Do not over-pack the autoclave. Otherwise, steam does not get
everywhere.
Make a daily performance test.

Steam-pulsing
Pressure cooker types and vertical autoclaves without a vacuum pump have
problems to remove the air of porous sterilisation goods. In this case
some experts suggest to use the steam-pulsing technique in order to
improve the sterilisation result.
Therefore, the air-removal valve is opened and closed briefly for a few times
at the beginning of the sterilisation phase. These pressure pulses flushes out
the trapped air in the porous sterilisation goods. The sterilisation phase has
of course to be extended by a few minutes.
This method really works fine for sterilisation of porous sterilisation goods.
But to make it clear: It is an improvement for an otherwise functioning
procedure.
The steam-pulsing method is no solution for wrong usage and it cannot
replace the procedure described in the user manual. Instead of
implementing another (complicated) procedure, make sure that the operator
first follows the instructions in the user manual.

Construction of a vertical autoclave

The typical vertical autoclave is manually controlled and very common in
smaller hospitals. The components are simple and can be repaired and
replaced easily.
Such an autoclave consists of the following parts:
Pressure control valve
The pressure control valve opens when the working pressure (and thus the
temperature) is reached. It works with a counter weight or a spring and can
be adjusted manually.

Air-removal valve
Is opened manually when the sterilisation process is finished. It releases the
steam out of the chamber. This can be done by opening a mechanical valve
or by a solenoid when pushing a switch.

Thermometer or temperature gauge

The thermometer shows the temperature inside the chamber and thus
indicates to the user when the sterilisation temperature is reached and the
sterilisation process can be started.

Safety valve
The safety valve opens and releases the pressure out of the vessel if the
pressure control valve fails and the pressure gets too high.
With pulling the safety valve also the steam pulse can be applied (↑Steam-
pulsing)
Pressure gauge
The pressure gauge shows the pressure in the vessel but is not really
needed when a thermometer is built in.

Lid and lid gasket

A heavy lid closes the vessel airtight. The lid is sealed with a silicon gasket.
The gasket has to be checked and cleaned frequently. A leaking gasket
allows hot steam to escape and can create serious burns.

Pressure vessel
The high pressure chamber is made out of stainless steel. It contains the
sterilisation goods.

Heating element
The heating element (sometimes three elements for a three-phases power
supply) heats up the water. It is important that it is always covered with
water. A dry heating element will burn out within seconds.

Drain valve
It is used to drain remaining water from the chamber after sterilisation and
during cleaning.

Variations
Some vertical autoclaves are double walled where the sterilisation goods
are not placed directly over the heated water in the upstream steam but in
another chamber. This inner chamber is placed in such a way, that the
steam can only enter from above. That helps to achieve a more
homogeneous and safer sterilisation result.
Because the water level is no more visible in a double walled autoclave, this
type has a gauge glass that shows the water level inside the outer chamber.
Most of the autoclaves have an integrated timer. The timer starts when the
sterilisation temperature is reached and switches off the heating elements
when the sterilisation time is over. The timer is often a mechanical one,
driven by a little motor. In modern autoclaves the timer is a small electronic
circuit.

Circuit diagram of a semi-automated vertical autoclave

Here a circuit diagram of a typical vertical autoclave with some interesting
features such as a timer and a low-water protection.
The circuit diagram consists of two parts: On the left the three-phase power
circuit with the heating elements and on the right side the single phase
control circuit.
At the top left we find the mains power supply input. The contactor K1 is
connected to the mains power supply and switches the two triple heating
elements (in parallel) on and off.
The coil of the contactor K1 we find in the right part of the diagram. This
part runs on single phase (via the main switch, fuse F1 to L1). The common
reference point is N (neutral) which also comes from the mains.
The solenoid is activated when the thermostat S5 is not closed, the pressure
sensor S4 below the release point, the timer A1 is wound up, the water level
is sufficient (S2) and the autoclave is switched on by S1.
When winding up the timer, the switch A1 closes, the heater can be started
but the timer itself does not run because the timer part of S5 is open. The
switch will only close when the sterilisation temperature is reached. Then the
other part of the switch opens the contactor part.
Tricky also the low-water detector. This detector consists of two parts, the
micro heating element E3 and the temperature sensor S2. This sensor has
nothing to do with the sterilisation temperature. In fact the release
temperature is clearly higher than the sterilisation temperature. This
thermostat is mounted directly to the micro heating element next to the
main heating elements in the water. If everything is OK, the thermostat
does not get hotter than the sterilisation temperature. But if the water level
is too low, the micro heating element cannot emit the heat to the water,
gets much hotter and the thermostat switches off the whole system.

Construction of a table top autoclave

The general function sequence of a table top autoclave is the same as for a
manual vertical autoclave. The only difference is, that a table top autoclave
runs semi- or fully automatically.
After the door has been closed, the autoclave can be started.

The valve 2 opens and water runs from the reservoir 1 through a
filter 3 into the chamber 4. When the water level reaches the level
sensor 6 the valve closes and the heater switches on. After a while, steam is
generated. The steam rises and pushes the cooler air through valve 9 and
the condenser 10 out of the chamber. When the temperature reaches the
boiling point (measured by the temperature sensor 7), the outlet
valve 9 closes. Then the pressure in the chamber rises (shown by the
pressure gauge 8) as well as the temperature. When the sterilisation
temperature is reached (sensor 7), the heating element switches off. If the
temperature control fails and the pressure gets too high, the pressure is
released by safety valve 11. For cleaning and servicing, the water can be
drained by the manual valve 12.

In addition, modern table top autoclaves provide more safety features like a
door lock and an internal water tester and most of all a suction pump.
Mechanical sensors and meters are replaced by electronic ones. An
electronic board or a microprocessor controls and monitors the sterilisation
process.
1 Heating element
2 Water inlet
3 Level sensor
4 Steam to reservoir
5 Test port for external
thermometer
6 Safety valve
7 Sensor for thermometer
8 Pressure meter
9 Sensor for temperature
control

Door lock / door switch

Only after closing and locking the door properly can the steriliser be
switched on. A micro switch at the door mechanism gives the information to
the electronic board and a solenoid blocks or releases the door mechanism.

Level switch for water inlet

A certain amount of distilled water is let into the chamber automatically. The
water intake is either time or level controlled. In the second case a water
sensor in the chamber is needed. It is usually just a piece of metal that
works as a sensor together with a little electronic circuit. This circuit
measures the electrical resistance between the sensor and the chamber.
When water reaches the sensor the resistance becomes low and the
electronics switches off the inlet valve or the water pump.

Temperature sensor
The actual temperature in the chamber is measured by a temperature
sensor. The sensor delivers the measurement to the control unit. Here the
actual and the pre-set temperature are compared and a control voltage for
switching the heating elements is created.

Chamber heating / thermal fuse

Often the outside of the chamber is also heated. This heating supports the
drying process after sterilisation.
This chamber heating is usually protected against over-heating by a thermal
fuse.

Steam valve
After the sterilisation phase, the release valve (outlet valve) opens. Steam
gets out of the chamber, flows through a condenser and gets back as hot
water into the reservoir.

Safety valve
The safety valve is designed to release steam in case the chamber pressure
is increasing beyond the normal range due to a fault in the control elements.
Without safety valve the chamber would burst with catastrophic
consequences.

Variations
Modern table top autoclaves always provide a vacuum pump. Whenever
a vacuum pump is used, an additional ventilation valve with a bacterial
filter is needed.
Often table top autoclaves also have an internal water quality tester.
Before the distilled water is led into the chamber, the water conductivity is
automatically tested. When the quality is not good enough, the autoclave
cannot be started.

Construction of a stationary autoclave

Large stationary autoclaves, especially when they consist of several
sterilisation chambers are run by steam from an external water boiler. The
advantage is that hot steam is available immediately, the pressure in the
chamber builds up faster and the overall sterilisation time gets shorter.
When the sterilisation of one batch is finished, the next batch can already be
loaded and started.
Additionally, each chamber is surrounded by an outer shell, the jacket. Here
hot steam circulates and pre-heats the chamber before it is used.
Also the chamber is post-heated that way when the steam is released out of
the chamber after sterilisation. This prevents water condensation and
ensures a dry sterilisation result.

When the inlet valve 1 is open, hot steam from the external boiler enters the
jacket 2 of the autoclave. The chamber gets preheated. The pressure gauge
shows 3 the jacket pressure. When valve 4 is opened, the steam gets into
the chamber. The colder air escapes through the open valve 6. The valve is
a temperature controlled one-way valve. The valve closes when the steam is
hot enough. Now the pressure rises until it is as high as the inlet pressure.
The chamber pressure is shown by the pressure gauge 8 and the
temperature by the thermometer 5. It is placed at the bottom of the
chamber, where the lowest temperature is. When the sterilisation time is
over, the inlet valve has to be closed and the outlet valve 7 opened. Steam
escapes through the drainage pipe. The pressure and the temperature in the
chamber decrease but the jacket is still under hot steam pressure. This
supports drying the load. After a while the steam from the jacket can also be
released by opening valve 4 or it can be kept if another load has to be
sterilised.
The safety valve 9 opens when the steam pressure is too high. In principle
this valve is not needed because the boiler already contains one and the
pressure in jacket and chamber cannot get higher than the pressure in the
boiler.
Variations
Simple, manually controlled autoclaves are still widespread. They are robust
and relatively easy to repair. Spare parts can be found in every larger city.
Modern stationary autoclaves are fully electronically controlled. There
are no more manual valves and also the instruments for pressure and
temperature are often digital ones.
Also in stationary autoclaves a vacuum pump provides a better sterilisation
result and has already become standard. Wherever a vacuum pump is used,
an additional ventilation valve with a bacterial filter is needed to ensure only
uncontaminated air can enter the chamber when equalizing the pressure at
the end of the cycle.

Maintenance
Beside the routine checks by the user personnel, autoclaves should be
maintained at least once a year by the technicians of the hospital workshop.
Many manufactures suggest even semi-annual maintenance according to
their guidelines.
The maintenance of an autoclave covers the cleaning from inside and
outside, a functional check and the control of the temperature. A calibration
has to be done if the temperature check was not successful.
Very often a service manual is needed to set the autoclave in a defined
service mode and to find the calibration points for the temperature and the
display.

Note: Be very careful while doing service on an autoclave. Some older autoclaves have
only little or no heat shielding around the chamber. The chamber, tubes and valves get very
hot.

Needed tools
Beside the standard tools you need a calibrated thermometer with an
external sensor. Only with such a reference thermometer are you allowed to
check and adjust the temperature. The built-in (digital) thermometer of the
autoclave cannot be taken for the temperature check. When the display of
the autoclave does not show the correct temperature you do not really know
if the temperature is wrong or the thermometer itself shows a wrong result.
For some models it is useful to have a 2 mm rod sensor which can be
inserted in a special test port.
More under ↓Calibration.
A pressure meter is not needed, even if the manufacturer recommends this.
Stay with the temperature measurement. It is safer, more practical and
cheaper.
The maintenance should also include a water conductivity test. A lot of
problems with autoclaves are caused by the usage of water of poor quality.
More under ↑Distilled water.
Then, we need of course cleaning material like: A bucket, dish washing
liquid, a sponge and a stainless steel scouring pad.

Maintenance procedure
A typical annual or better semi-annual maintenance procedure is the
following:

1. Fill steriliser with distilled water.

2. Place temperature sensor for external thermometer in the centre of the
chamber.
3. Perform a test run at 121°C.
4. Check the temperatures inside the chamber. If it is lower than 121°C,
do a calibration.
↓Temperature calibration
5. Check the display of the internal thermometer. Adjust it if necessary.
↓Temperature calibration
6. Check the function of the safety valve. Pull a few times with long pliers
or a
screwdriver when the chamber is under pressure. Be careful, hot steam
will come out.
7. Monitor the sterilisation time with a stop watch, your watch or your
mobile phone.
8. Do a visual check for leakages from inside and outside.

Let the autoclave cool down and then continue:

9. Clean chamber, heating element and rinse the drainage

(see ↓Cleaning).
10. Clean or exchange the drainage filter and the air filter.
11. Check door gasket for damages. Lubricate gaskets with silicon oil.
12. Lubricate door hinges and check the door closing mechanism.
13. Visual check for leakages: chamber, door, piping, valves, water
reservoir.
14. Check electrical connections.
15. Check the electronic board for cold solder points and water damages.
16. Check contacts of relays.

17. Make a final test run at 134°C.

18. Do a calibration for the temperature display if needed.

19. Replace cover.

20. Drain the water and clean the autoclave from outside with soap water.
21. Fill out the maintenance protocol.

Cleaning by the technician

It is the task of the user to keep the chamber clean, as well as the autoclave
from outside. The user has to clean all parts which are visible and reachable
on a weekly or monthly base. The technician however must be able to
demonstrate the correct cleaning to the user.
Everything that needs disassembling for cleaning is the task of the
technician, which includes cleaning of filters, valves and pipes and the
heating element.
The correct cleaning of an autoclave is very important not only to achieve a
satisfactory sterilisation result but also because most of the technical
problems are created by residues due to insufficient cleaning after
sterilisation.
It is advisable that the technician starts with general cleaning as described
above under ↓Cleaning by the user.
Then, we can continue with our 'technical' cleaning:

1. Drain the water from the reservoir. Clean the reservoir with a sponge
and distilled
water or with a soap solution if needed.
2. Remove the water filter (between reservoir and chamber). Rinse it
under running water
in reverse direction.
3. Remove also the water outlet filter which is found at the bottom of the
chamber. Rinse
this filter under running water.
4. The air inlet filter for ventilating the chamber after sterilisation has to
be replaced once
a year.
5. Do not forget to rinse all the cleaned parts with distilled water when
you are finished.
6. If the hospital uses rain water, make sure that the water is filtered
before it gets used
for the autoclave. In case of a doubt, talk
with the operator and find a solution. Maybe an additional filter (e.g. a
fuel filter from
 a car accessory shop) can be added.

Limestone
Often the chamber and the heating element are covered with lime scale and
the tubes and valves are blocked with lime deposits.
The chamber can be cleaned by scraping of the scale with a scouring pad
which is used in the kitchen for cleaning pots and pans. Avoid steel wool, as
steel wool scratches the metal surface of the chamber.
Heating elements should be handled with care. They are made from soft
copper or brass pipes and are then coated or chrome-plated. They are less
durable than the thick stainless steel of the chamber. If you want to remove
lime scale from a heating element by scratching, you will destroy the surface
of heating element. The copper tube of the element is then visible and it will
not take much time until holes appear. That is very dangerous because the
intruding water creates an electrical connection to the power supply. The
whole autoclave is then under power then, which is particularly dangerous
when the electrical installation is poorly done and no earth-leakage circuit
breaker is installed in the mails supply.
The best way to remove limestone from a heating element is to remove the
heating element and put it in de-scaler which is used for water kettles and
coffee machines and leave it over night. Vinegar also works, but it takes
longer. You can also try denture cleaner.

Do not forget, better than removing limestone is to prevent it. Teach the operators in the
correct cleaning and ensure that they are using distilled water only.

Temperature calibration
For the calibration you need an external calibrated (digital) thermometer.
Only with such a reference meter are you allowed to calibrate the autoclave.
Never trust the internal thermometer.
The calibration of the equipment is only as good as your measurement
device. Do not use the cheapest and keep in mind that even the expensive
ones have to be calibrated after some time.

Inexpensive quality multimeter with thermometer adapter.

High quality multimeter with 2 mm sensor. This sensor fits e.g. into the test
port of Eschmann table top autoclaves.

In principle the calibration of an autoclave consists of two adjustments. First

the calibration of the control unit and then the adjustment of the internal
thermometer. Again, never do the calibration according the internal
instrument.
Insert the sensor of your reference thermometer into the chamber and close
the door. The rubber gasket prevents the cable from being damaged. Start
the autoclave. The gasket might not be perfectly sealed now and some
steam will escape. Technically it does not matter as long as more steam is
created than can escape and the pressure rises. But do not burn yourself.
The calibration procedure varies from case to case. Do the calibration always
according the service manual of the manufacturer. If no manual is available,
you have to do the calibration by yourself. In a simple case you find two
trimmer pots on the control board. One trimmer pot is for 121°C and the
other one for 134°C. Start with the temperature calibration.

Memorise the original settings of the trimmers. Or better make a sketch

or mark them
with a pen. For adjusting a ten-turn-trimmer count the turns.
Make changes only in small steps.
Keep in mind that changes of the temperature setting need some time to
take effect. Turn
the trimmer only a little and wait until the temperature is stabilised.
Cheap trimmers are not insulated. Be careful by inserting the screw driver
that you do not
make a short to other metal pieces.

After the temperature is set, the thermometer can be adjusted if necessary.

There should be also a trim-pot for the thermometer close to the display
where it can be calibrated. Mechanical meters can be adjusted by turning a
little screw which shifts the pointer. With round meters the scale often can
be twisted or even the whole meter housing. If all this does not work, keep
in mind it is just a meter. It has nothing to do with the function of the
equipment. Also a calibrated autoclave with an inaccurate thermometer
performs a safe sterilisation. But then you have to inform the user.

Installation

When a new autoclave has to be

installed, some preparations have to be done beforehand. We have to
prepare the electrical installation, the water supply and the water drainage.
Sometimes also a tap water connection is needed when the autoclave has an
active cooling system. Or an additional water distiller has to be installed.
The electrical installation needs a circuit breaker for each phase and should
have a 30 mA earth-leakage circuit breaker. Note the power consumption
and choose the right fuses and wire size.
For a 230 V system up to 3.5 kW a 16 A circuit breaker is fine and a
1.5 mm² cable can be used. For higher currents up to 21 A, a 2.5 mm² cable
has to be used.

Here an undersized main switch caused a fire

The autoclave also has to stand perfectly horizontal. If not, the water
amount which is let in the chamber and detected by a level sensor can be
wrong.

Repair
Before starting a repair...

read the user and the service manual of your autoclave.

fill out a service record/job card with all equipment data and the fault
description.
make sure that distilled water is available in your workshop when you
repair a table-top
in your workshop.

Error code
In case of a fault, microprocessor controlled autoclaves show an error code
in the display. With the help of the service manual the fault can be identified
easily.

Typical technical problems

Below some typical problems in connection with autoclaves:

Burnt-out heating elements

Burnt-out heating elements are the number one problem with autoclaves in
hospitals with poor maintenance service.
Pressure cooker types or vertical autoclaves are often used with too little or
without water. Then the heating elements burn out within seconds.
Or the heating elements are covered with lime scale. Then the heating
elements cannot give off the heat, get overheated and will also burn out.
(Removing lime scale see ↑Lime scale.)
It is also possible that the water supply is blocked with debris or the water
level sensor delivers a wrong signal. This happens when the water sensor is
dirty. Then the control unit measures a resistance and 'thinks' that there is
already enough water in the chamber and switches on the heating elements.
Therefore it is important not only to change a burnt heating element but also
to look for the reason. Make sure that the chamber really is filling up with
water. When you start a table top autoclave, look into the water reservoir
and check if the water level in the tank falls.
Heating elements are not repairable. We have to get a replacement either
from the manufacturer directly or try to find a similar one somewhere else.
Universal heating elements might be available in the repair shops in bigger
town. These are spare parts for water heaters which can also be used for
autoclaves. But it is not so easy to find the right one. The mounting and the
shape of the heating element must be similar because it has to be covered
with water all the time. It is no problem if the wattage is slightly smaller or
bigger. The sterilisation will then take just more or less time.
It is advisable to have a spare heating element in stock and if you have
more than one autoclave of the same type in your hospital, it is a must.

Solid state relays

The heating elements are switched on and off by electromechanical
contactors or in modern autoclaves by solid state relays. These relays do not
contain mechanical contacts but a so-called triac.
The function of the mechanical relays is clearly to see and to hear but there
is nothing to see and hear of a solid state relay. Even the voltage
measurement can be confusing, because the frequency of switching can be
much faster. While mechanical relays are switched on and off every 10 to 30
seconds, the solid state relays can be triggered in milliseconds. This
switching is faster than our voltmeter and as a result we measure an
average voltage. This 'reduced voltage' is correct and not an unwanted
voltage drop.

Leaking door gasket

Rubber gaskets get hard over time and crack. A leaking gasket will not
necessarily affect the performance of the autoclave. As long as the heating
element produces more steam than escapes trough the leakage, the
autoclave will work. But the escaping steam is of course dangerous for the
user and thus the gasket must be exchanged.
The gaskets should be checked and cleaned weekly and lubricated with
silicon oil during the maintenance.
After removing a silicon gasket it is sometimes difficult to put it back into the
groove of the lid or door. It seems to be too long. Do not inserting the
gasket bit by bit around the lid but start with inserting it at the 12 o'clock
position, then continue at 6, 3 and then 9 o'clock.

TIP! DIY Door Gasket

The door gasket usually lays in a groove. If the gasket is damaged and no exchange part is
available, it is possible to make a gasket by filling out the groove with elastic silicone. Once
dried the silicon is elastic, durable and heat resistant. Silicon cartridges are cheap and
available in hardware stores.
Take off the door and lay it flat on the workbench. Check the thickness of the old gasket and
take it out. Clean the groove thoroughly with soap water and then with alcohol. Get a small
flat bowl with dishwashing liquid and some rugs or paper tissues. Prepare the silicon
cartridge and the pump. Fill the groove with the silicon. Now flatten the silicon with a finger.
To do this, wet the finger with dishwashing liquid glide over the silicon so that it gets flat and
even. Keep your finger always wet or the silicon will stick to your finger and the silicon
surface gets destroyed.
After finishing, the silicon has to dry. This can take a few days depending on the thickness.
After drying, mount the door and check if the door closes properly. Make a test run and
check for leakages.

Water level sensor

Often the water level in the chamber is detected by a piece of metal and a
conductivity measurement circuit. When the sensor gets wet the resistance
against the metal chamber gets low and the connected electronics switches
the water inlet valve off and the electrical heater on. But this also happens
when debris bypasses the sensor. In this case the heater starts without
water and a damaged heating element is the consequence.
Here the level sensor touches the heating element. As the result of this
short circuit to ground the control 'thought' that already enough water was
in the chamber. The water inlet was kept closed and the heating element
was started. Some of the sterilisation goods caught fire.

The sensor has to be clean and free of debris. Check also the insulation and
the mounting of the sensor. But it is better to remove the sensor and clean
the individual parts.
The autoclave also has to stand perfectly horizontal. If not, the amount of
water which is let into the chamber and detected by the sensor can be
wrong.

Thermostat and mechanical Thermometer

Mechanical thermostats and thermometers are common in simple
autoclaves. Both consist of a sensor and a pressure can. The sensor is a thin
capillary tube which leads into the pressure can (or expansion chamber).
This chamber has a moveable metal lid or diaphragm. This closed system
contains a liquid or gas which expands when getting warmer. The lid moves
and activates a connected electrical switch or in case of a thermometer
moves the pointer of a meter.
The thin capillary tube is often rolled up. This is correct. Do not cut it. It is
not a wire. Also avoid bending the tube. It can get kinks and will then not
work any more.

Temperature switch or fuse

When the autoclave is heated up by a chamber heater (a heater around the
chamber), the chamber heater is connected to a temperature switch or fuse.
This switch is mounted at the outside of the chamber and protects the
chamber heater from over-heating in case the electronic control fails.
In case this fuse is burned or the switch is triggered there must be a reason
and you should find out.
Safety valve
Check the safety valve for correct operation when the autoclave is in
operation. Do not burn yourself. Take pliers to pull the metal pin to release
some steam. Be careful - do not burn yourself!
Pull several times. This cleans the mechanism from possible debris, which
can easily block the release mechanism.

Black or burned relay contacts

Black relay contacts can be perfectly cleaned with a fibreglass brush. Never
file contacts. This destroys the surface of the contacts.

Wet material after sterilisation

This is unlikely to be a technical problem. See ↑Common problems during
usage.

After the repair

When the autoclave is repaired, continue with a full maintenance
procedure as described
under ↑Maintenance including a thorough cleaning.
Make a test run with a temperature check.
Finally, fill out your job card/service report and put a new service sticker
to the autoclave
 showing the next maintenance date.
Before returning it to the laboratory, make sure the autoclave is complete
with all trays
and baskets.

Service manual
Service manuals are hard to come by. Some manufacturers are helpful and
send a copy on request, but most of the manufacturers do not.
If you need a manual you can also check here.

Spare parts
It is advisable to have a spare heating element in stock and if you have
more than one autoclave of the same type in your hospital, it is a must.
The same applies to door gasket. It is only a matter of time when a door
gasket will leak. Put one in stock.
Filters should also be kept in stock, especially bacterial filters which are
disposable and cannot be cleaned.

Alternatives for steam sterilisation

Some products such as plastics, paper and liquids cannot be exposed to high
temperatures or humid air and sterilisation has to be done in different way.
Alternatives are dry heat provided by hot air ovens or sterilisation using
specific gas through gas sterilisers.

Hot air ovens

Dry heat can also be used to sterilise products but is less efficient than the
sterilisation with steam. The process takes longer and the temperature has
to be higher. Dry heat is used for the sterilisation of some plastics, papers,
special liquids and powders which cannot be sterilised with steam.
One advantage of dry heat is, that it does not cause rusting of steel
products.
The hot air can be applied without high pressure.

The standard setting for a hot air oven is:

160°C (320°F) for 120 minutes

190°C (374°F) for 12 minutes
 Note: Hot steam at 134 °C can achieve in 3 minutes the same sterility as hot air at 160°C in
two hours.

Gas steriliser
Some specific types of gas can also be used for sterilisation. Ethylene oxide
is such a gas which is used in special gas steriliser. It is a chemical agent
that kills micro-organisms, including spores.
Because a mixture of ethylene oxide in air is explosive and toxic, the gas
technology is complex and expensive and is only used where steam
sterilisation cannot be used.
The sterilisation process with gas depends on the gas concentration,
temperature and humidity but generally it takes much longer than the
sterilisation by steam. A typical sterilisation by ethylene oxide takes 16-28
hours at 50-60°C. After sterilisation, all materials have to be ventilated at
least 24 hours before contact with the skin.

Manufacturers
Important manufacturer of autoclaves are:

3M Should be avoided. Prohibited the download of service

manuals.
AJC
ASP Sterrad Should be avoided. Prohibited the download of
service manuals.
Belimed
Getinge
Eschmann
LTE
Matachana
Melag
Midmark
Pelton & Crane
Reimers
Reverberi
Steris Should be avoided. Prohibited the download of service
manuals.
SciSan
Tuttnauer
Links and sources
Here are some Wikipedia Medical Equipment articles:

Autoclave
Autoclave tape
Sterilisation
Pressure
Pressure measurement

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