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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5784_Библиотеки_им_академика_М_И_Перельмана.pdf
252
Fig. 15.6 Clean probe
storage
J.T. Nomura and A.D. Nagdev
Fig. 15.7 Wiping gel off
probe
Initial Steps ofDisinfection ofAll Probes
1. Remove barrier (if used) and dispose.
2. Wipe gel and debris off probe with towel (Fig.15.7).
3. Wipe dry probe with germicidal wipes (Fig.15.8) or spray with disinfection
spray (Fig.15.9) (or washing with soap and water prior to HLD).
4. Follow disinfection protocols based on infection control categorization below.
15 Ultrasound Safety andInfection Control
Fig. 15.8 Disinfecting dry
external probe with
germicidal wipe
Fig. 15.9 Disinfecting dry
external probe with
germicidal spray
253
US Probe Infection Control Classication
Medical devices are classied into one of three categories: non-critical, semi-critical,
and critical. This categorization informs the clinician of the type of disinfection or
sterilization that must be performed to keep the device pathogen free.
Noncritical Devices (Noninvasive Probes)
Noncritical devices are those that come in contact with intact skin, which is thought
to act as a barrier to most microorganisms. Ultrasound transcutaneous transducers
(linear, phased array, curvilinear, etc.) are considered noncritical medical devices.
Low-level disinfection (LLD) is thought to be adequate when cleaning noncritical
medical devices, and should be performed between each use in a similar manner.
LLD cleaning products include isopropyl alcohol (Fig. 15.10), bleach wipes
254
Do not use alcohol in this area
J.T. Nomura and A.D. Nagdev
Cleaning the Distal Tip of the Transducer with Isopropyl Alcohol
A
Fig. 15.10 LLD—isopropyl alcohol
B
C
1 inch
(2.5cm)
E
D
F
A - Cable
B - Strain Relief
C - Strain relief/housing joint
D - Housing
E -
F - You may use alcohol in this area
(Fig.15.11), quaternary sprays (Fig.15.12), ammonium chloride sprays (Fig.15.13),
and any other approved LLD cleaning solution (Table15.2) in a standard cleaning
format between transducer uses had been shown to be efcacious in removing most
pathogens (bacteria, virus and fungus) [34]. Betadine is not recommended due to
staining of the plastic or rubber on the probe (Fig.15.14). Methicillin resistant Staph
Aureus (MRSA) has been shown to be present on uncovered transducers, but can be
easily removed with germicidal wipes cleaning (LLD) [34]. When performing ultrasound examinations on non-intact skin (cellulitis, abscess, etc.), we recommend
placing a transparent dressing securely on the transducer before beginning the
examination.
15 Ultrasound Safety andInfection Control
Fig. 15.11 LLD—bleach
wipe
255
Fig. 15.12 LLD—
quaternary spray
256
J.T. Nomura and A.D. Nagdev
Fig. 15.13 LLD—ammonium chloride reagent
Table 15.2 Cleaning solutions for surface or noncritical devices
Ethyl or isopropyl alcohol (70–90%)
Sodium hypochlorite (5.25–6.15% household bleach diluted 1:500 provides >100ppm available
chlorine)
Phenolic germicidal detergent solution (follow product label for use-dilution)
Iodophor germicidal detergent solution (follow product label for use-dilution)
Quaternary ammonium germicidal detergent solution (follow product label for use-dilution)
15 Ultrasound Safety andInfection Control
Fig. 15.14 Betadine
staining of probe
Semi-Critical Devices
257
Semi-critical devices are those that come into contact with non-intact skin or
mucosa. These devices include transesophageal echocardiography (TEE) transducers and endocavitary ultrasound transducers (Fig.15.15). Even though probe covers
are always used with endocavitary transducers, preventing direct contact of the
probe surface and mucosal membranes, most governing bodies (CDC, AIUM and
ACOG, ACEP*) classify these probes as semi-critical devices [23, 25–27].
Semi-critical medical devices require high-level disinfection (HLD) in order to
eliminate all bacterial microorganisms except for a small number of bacterial
spores. Chemical disinfectants considered acceptable semi-critical medical devices
are listed (Table15.3) and/or can be obtained from the ultrasound transducer manufacturer. Medical centers using either endocavitary or TEE transducers should
have a well-dened method for high-level disinfection or enlist the aid of hospital
258
Fig. 15.15 Examples of semi-critical devices—Endocavitary and TEE probes
Table 15.3 Sterilants and high-level disinfectants listed by the FDA
Name Composition/Action
Glutaraldehyde Organic compound (CH
Induces cell death by cross-linking cellular proteins; usually used
alone or mixed with formaldehyde
Hydrogen peroxide Inorganic compound (H
Antiseptic and antibacterial; a very strong oxidizer with oxidation
potential of 1.8V
Peracetic acid Organic compound (CH
Antimicrobial agent (high oxidization potential)
Οrtho-Phthalaldehyde Organic compound (C
Strong binding to outer cell wall of contaminant organisms
Hypochlorite/
hypochlorous acid
Phenol/phenolate Organic compound (C
Hibidil Chlorhexidine gluconate (C
Inorganic compound (HClO)
Myeloperoxidase-mediated peroxidation of chloride ions
Antiseptic
Chemical antiseptic
(CH2CHO)2)
2
)
2O2
H)
3CO3
(CHO)2)
6H4
OH)
5H5
22H30Cl2N10
J.T. Nomura and A.D. Nagdev
)
based sterile processing to ensure compliance. Obstetrics, cardiology and other
services will be complying with HLD standards for their ultrasound transducers,
and learning your hospital’s current method for disinfection is often the rst step in
building a high-level disinfection method that is compliant with current
recommendations.
The process of HLD involves multiple steps accomplished in either the clinical
department or by hospital based sterile processing. Examples of ED department
disinfection devices include glutaraldehyde-related solution hood and soaking stations (Fig.15.16 and Fig.15.17) and portable or mounted heated hydrogen peroxide
stations (Figs.15.18 and 15.19). There is no standard format for HLD of endocavitary probes. Rather, recommendations from transducer manufacturers in conjunction with CDC guidelines should guide the process. Documentation of a procedural
log (Fig.15.20) and replacement of disinfection solution should be standardized
and in accordance with hospital and regulatory practices.
15 Ultrasound Safety andInfection Control
Fig. 15.16 HLD—
glutaraldehyde
Fig. 15.17 Mounted
portable HLD soak station
259
Even though probe covers or condoms are always used with endocavitary probes
(Fig.15.21), low-level disinfection with germicidal wipes have been shown to not
remove all bacteria and viruses [31, 32]. Probe cover perforation (Fig.15.22) after
routine endocavitary probe use is reported to range from 1 to 9% [28]. Higher perforation rates are reported to occur with commercial probe covers as compared to
condoms, 8.3 vs. 1.7% [28]. Higher rates of condom perforation (25–815) are seen
with ultrasound- guided procedural interventions (oocyte retrieval for IVF) [29]. In
a series of 168 patients who had a TEE procedure performed, the latex condom
perforation rate post procedure was reported to be 4.4% [30]. Because of the risk of
pathogen transmission, current CDC standards mandate HDL in between patient
usage when using covered endocavitary transducers.
260
Fig. 15.18 Trophon mounted
J.T. Nomura and A.D. Nagdev
Fig. 15.19 Open Trophon
15 Ultrasound Safety andInfection Control
Fig. 15.20 HLD
disinfection log
Fig. 15.21 Probe barriers
261
Fig. 15.22 Leakage from
endocavitary barrier