POWERED SURGICAL INSTRUMENTS COMPONENTS OF ......Powered surgical instruments are used most often in...

POWERED SURGICAL INSTRUMENTS:COMPONENTS OF SAFE CARE AND

HANDLING

1959

1959POWERED SURGICAL INSTRUMENTS:

COMPONENTS OF SAFE CARE AND HANDLING

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability,negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions,or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independentverification of diagnoses, medication dosages, and individualized care and treatment should be made. The material containedherein is not intended to be a substitute for the exercise of professional medical or nursing judgment.

The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN,INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDINGBUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRDPARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The followingcredit line must appear on the front page of the photocopied document:

Reprinted with permission from The Association of periOperative Registered Nurses, Inc.

Copyright 2012 “POWERED SURGICAL INSTRUMENTS: COMPONENTS OF SAFE CARE AND HANDLING”

All rights reserved by AORN, Inc.2170 South Parker Road, Suite 400,

Denver, CO 80231-5711(800) 755-2676 www.aorn.org

Video produced by Cine-Med, Inc.127 Main Street North, Woodbury, CT 06798Tel (203) 263-0006 Fax (203) 263-4839

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Powered Surgical Instruments: Components Of Safe Care And Handling

TABLE OF CONTENTS

POWERED SURGICAL INSTRUMENTS: COMPONENTS OF SAFE CARE AND HANDLING

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PURPOSE/GOAL/OBJECTIVES.....................................................................................................4INTRODUCTION.............................................................................................................................5HISTORICAL PERSPECTIVE.........................................................................................................5CURRENT APPLICATIONS............................................................................................................5

Orthopedics..............................................................................................................................6Thoracic Surgery .....................................................................................................................6Plastic and Reconstructive Surgery .........................................................................................6Neurosurgery ...........................................................................................................................6Oral Surgery.............................................................................................................................6

SYSTEM COMPONENTS ...............................................................................................................7Power Source ...........................................................................................................................7Pneumatic Instruments ............................................................................................................7Alternating Current (Wall Current) .........................................................................................7Direct Current (Battery Power) ...............................................................................................8Handpiece and Controls...........................................................................................................8Accessories ..............................................................................................................................8

PREOPERATIVE CARE AND HANDLING...................................................................................8Set Up and Assembly...............................................................................................................8Gas Cylinders ..........................................................................................................................8Electrical Equipment ...............................................................................................................9Inspection.................................................................................................................................9Assembly ...............................................................................................................................10Setting Pneumatic Pressure ...................................................................................................10Testing....................................................................................................................................10

INTRAOPERATIVE CARE AND HANDLING............................................................................10Personnel Protection ..............................................................................................................11Maintain Trigger or Control in Safety Position .....................................................................11Use Saline to Cool Attachments ............................................................................................11Use Plastic Suction Tips ........................................................................................................11Place Powered Equipment On A Separate Table When Not in Use.......................................11Intraoperative Troubleshooting..............................................................................................12

POSTOPERATIVE CARE AND HANDLING ..............................................................................12Cleaning and Decontamination..............................................................................................12Lubrication.............................................................................................................................13Disassembly...........................................................................................................................13Packaging...............................................................................................................................13Sterilization............................................................................................................................14

Steam Sterilization – Saturated Steam Under Pressure .........................................................14Ethylene Oxide Sterilization..................................................................................................14Sterile Storage........................................................................................................................15Nonsterile Storage .................................................................................................................15Preventive Maintenance.........................................................................................................15

CHOOSING POWERED SURGICAL INSTRUMENTS ..............................................................15SUMMARY.....................................................................................................................................15REFERENCES ................................................................................................................................16POST-TEST ....................................................................................................................................17POST-TEST ANSWERS.................................................................................................................19


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PURPOSE/GOALThis video and study guide will describe the various types of powered surgical instruments, their uses, basic components oftheir systems, and requirements for care and handling.

OBJECTIVESUpon completion of this activity, the learner should be able to:

1. Identify three current applications of powered surgical instruments in the perioperative setting.2. Describe the basic components of all powered surgical instruments.3. Discuss the care and handling of powered surgical instruments.4. List criteria for choosing a powered surgical instrument system.


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INTRODUCTIONIn today’s fast-paced, highly-technical health careenvironment, surgical techniques are constantly evolving.Because of ongoing advancements in surgical practice,surgeons are continually searching for high-qualityinstruments that will allow them to perform a variety ofsurgical interventions quickly and efficiently withoutcompromising patient safety.

Manufacturers of surgical instruments have addressed thesedemands by developing powerful and versatile electrical,battery operated, and pneumatically driven surgicalinstruments and as a result, powered surgical instruments areused in nearly every surgical specialty.

The use of powered surgical instruments provides severaladvantages. Compared to hand-held instruments, poweredsurgical instruments

• allow surgeons to work more quickly and with greaterefficiency, which in turn reduces surgical time forpatients under anesthesia;

• cause less trauma to tissues and surroundingstructures; and

• reduce surgeons’ fatigue.These are all greatadvantages, but poweredsurgical instruments requireadditional safety andprocessing responsibilitiesfor perioperative nurses andcentral sterilization andprocessing departmentpersonnel. Before anysurgical procedure that involves the use of poweredinstruments, health care personnel are responsible forinspecting, assembling, and testing all powered devices.

Intraoperative nursing considerations include ensuring that thesafety is engaged, cooling the blade with sterile saline during

use, and troubleshooting when necessary. Postoperatively,powered surgical instruments must be properly cleaned,decontaminated, inspected, lubricated and assembled,packaged, sterilized, and stored in a controlled environmentfor the next use.

All personnel associated with procedures that involve the useof powered surgical instruments should understand all aspectsof their proper use and care. This study guide is designed toprovide that knowledge in general terms.

For information about the care and handling of specificpowered surgical instruments, health care personnel shouldalways refer to the device manufacturer’s validated writteninstructions.

HISTORICAL PERSPECTIVEThe earliest applications of powered surgical instruments werein the field of dentistry. In 1864, George F. Green, a mechanicemployed by the S. S. White Company, introduced the firstpneumatic engine designed for medical applications. Green’sengine was operated by a foot bellows and was used indentistry, most likely to assist in drilling. With the inventionof batteries and electric motors in the late 1800s, electricallypowered dental drills became available, with the first one putinto practice in 1871. M.H. Cryer developed a motor-drivenosteotome in 1892. In the early 1900s, Dr. J. Vernon Luckcreated a powered circular saw for cutting bone. Soon after,Dr. Homer Hartmen Stryker created an oscillating saw thatwould cut bone but resisted cutting soft tissue. These earlymodels had limited usefulness because they were powered byelectrical motors that were attached to stands.

In 1957, motors driven by compressed air were developed byU.S. Navy research projects. In the 1960s, a small pneumaticmotor powered by compressed nitrogen was introduced foruse in surgical tools. Its use assuaged concerns about sparkformation by electrical tools in the presence of flammableanesthetics. The pneumatic motor in those devices wascontained in the handpiece itself. It is considered theforerunner of the pneumatic motor used in today’s air-poweredsurgical instruments.

CURRENT APPLICATIONSToday, powered surgical instruments are used successfully androutinely in most surgical specialties, with the majority inorthopedics; ear, nose, and throat surgery; thoracic surgery;neurosurgery; oral surgery; and plastic and reconstructivesurgery. Selection of a specific powered instrument orattachment is determined by the surgical specialty, the needsof the planned procedure, and the surgeon’s preference. The


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applications of powered surgical instruments can be as variedas the surgeons who use them.

OrthopedicsPowered surgical instruments are used most often in the fieldof orthopedic surgery, which frequently requires sawing ordrilling through hard bone. Orthopedic surgeons use poweredinstruments to cut, drill, or shape bone, and to drive screws,pins, or K-wires into bone.

One value of using powered instruments is that they makeworking with bone easier and faster than working by hand.Another advantage is that blood loss from bone is reduced bythe tiny particles these high-speed instruments pack into thecut surfaces.

Saw attachments used in orthopedics have several actions.

• Reciprocating saws move forward and backward inthe vertical plane.

• Oscillating saws move in a windshield-wiper motionat a 90-degree angle to the handpiece.

• Sagittal saws move from side to side in line with thehandpiece.

Rotary attachments for powered surgical instruments alsohave orthopedic applications:

• Acetabular reamers prepare the acetabular surface forcup insertion in hip arthroplasty.

• Femoral reamers prepare the femoral canal forinsertion of stemmed femoral prostheses.

• Drills prepare screw holes and insert guidewires intobone to allow further drilling, reaming, and screwtapping for the repair and reconstruction of fractures.

• Automatic screwdrivers place screws in bone.• K-wire drivers place pins in bone.

Specialty attachments and handpieces also provide otherunique actions that are useful in orthopedic surgery:

• Rasps shape bone.• Osteotomes cut bone.• Powered rongeurs assist with bone removal.• Other special attachments aid in cement removal.• Powered shavers cut the meniscus in the knee.

Thoracic SurgeryThe use of a sternal saw in thoracic surgery was first reportedin 1962. The first model was a modification of a Sears® brandhandyman’s saber saw. Today, open-heart surgeons routinelyuse powered sternal saws to split the sternum. Modern sternalsaws reciprocate in a vertical plane.

Plastic and Reconstructive SurgeryIn plastic and reconstructive surgery, surgeons usedermatomes for removing split-thickness skin grafts fromdonor sites. They obtain a graft with a knife blade that movesback and forth, like the blade of an electric hair clipper. A longsterile cable serves as the drive shaft and runs between thedermatome and its power source. The surgeon can activate themotor using a foot pedal or hand control.

NeurosurgeryIn neurosurgery, the use of powered surgical instrumentationhas been popular since Dr. Robert M. Hall introduced theHall® Neurairtome rotary cutting device in 1965. Today,almost any neurosurgical procedure, such as laminectomies,craniotomies, or skull-based surgery, is performed using aspecial high-speed drill system. The use of high-power drillsystems in spinal surgeries allows laminectomies to beperformed more safely and more quickly, decreasing thelength of hospital stays and the rates of both short- and long-term complications.

Neurosurgeons use powered cranial perforators to create burrholes in the skull. When used properly, the perforator stopsautomatically before the dura is penetrated. A saw blade witha dural guard makes cuts in the skull between the burr holes.A wire pass attachment permits the drilling of small holes toreattach bone flaps.

Surgeons also use power drills to widen the graft area inanterior fusions and to unroof the auditory canal in eighthcranial nerve surgery. For use in less accessible areas, such asthe sphenoidal sinus, pituitary fossa, and vertebral bodies, 20-degree and 90-degree angle attachments are available. A rangeof burs and guards that can be used with straight or angledattachments is available for use in neurosurgery.

Oral SurgeryOral surgeons employ tiny power-driven saws made


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specifically for use in hard-to-reach places. Applications ofpowered surgical instruments in oral surgery include bone-cutting for the removal of impacted teeth, osseous contouringin periodontology, and apical surgery for endodontics.

SYSTEM COMPONENTS

Powered surgical instrument systems are complex and involvea variety of gears, rotating shafts, seals, and other diversecomponents. Most, however, will have the following basicparts:

• A power source, which may be compressed gas,alternating current (AC), or direct current (DC).

• A hose or cord that connects the power source to thehandpiece (AC and pneumatically poweredinstruments only).

• The handpiece itself.• Hand- or foot-operated controls.• Accessory attachments.

Power SourcePowered surgical instruments can be classified by the sourceof their power:

• Compressed gas (air or nitrogen) powers pneumaticinstruments.

• AC (wall current) powers electrical instruments.• DC powers battery-operated instruments.

Pneumatic InstrumentsMedical-grade compressed air or compressed dry nitrogen(99.97% pure) power pneumatic instruments. This gas maybe contained in a metal cylinder or may be piped into thesurgical suite through a wall panel or overhead line.

Most modern facilities use pipe-in technology, where gassystems are centrally located and are constructed as an integralpart of the physical facility. Individual outlets and regulatorsare available in each procedure room for use with surgical

instruments. These outletsmay be part of theanesthesia gas panel,located in booms, or be ina separate location that ismore readily accessible tothe operative field (wallpanels). Wall panelsincorporate pressuregauges that measure theflow of the gas. In some health care facilities, large cylindersof compressed gas may be used to provide pneumatic power.A regulator controls the flow of gas at a specified number ofpounds per square inch (psi). In order for the pneumatic hoseto connect with the power supply, compatible fittings must beavailable.

Pneumatic instruments do not require sizeable motors oradditional attachments; therefore, they are small, lightweight,self contained, free of vibration, and easy to handle forpinpoint accuracy at high speeds. Because they operate athigher speeds than electrically powered instruments, theycause less heating of the target tissue.

Disadvantages of pneumatic instruments include the fact thatthey can be relatively expensive, and the hose that runs fromthe gas supply to the handpiece may restrict the surgeon’smaneuverability. In addition, the surgical team must take careto ensure that the connections to the instrument and the gassource are secure to decrease the risk of injury if they becomedisconnected during use.

Alternating Current (Wall Current)Some powered surgical instruments may be plugged into wallcurrent, also known as AC.

Electrically poweredinstruments, such assaws, drills, dermatomes,and nerve stimulators,were at one timeconsidered potentialexplosion hazards in theOR because of the use offlammable anesthetics.With the introduction of less flammable anesthetic gases, thisrisk is reduced; however, all electrical motors should bedesigned to be explosion-proof and must have spark-proofconnectors.

Flexible drive shaft electric drills are relatively inexpensivebut can be tiring to use because of the weight of the drive shaft.


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Their top speed is limited to moderate levels, but their torque,or rotating force, is good. Micromotor electric drills, oftenused in dental surgery, have small, low-voltage motors in thedrill handpiece. They are lightweight and easy to manipulate,with only a thin flexible tube leading to the power supply.They have high top speeds and good torque over the wholespeed range.

Direct Current (Battery Power)Battery-powered surgical instruments are becoming thestandard in health care today. Most battery-poweredinstruments are cordless, with a rechargeable battery packmounted into the handpiece.

The battery pack can becharged when the instrumentis not in use and sterilizedimmediately before theinstrument is used. Batterypowered instruments eliminatethe need for compressed gas orwall power, and there is noneed for a hose or cord

connecting the sterile field to the power source.Manufacturer’s written directions should be followed for careand handling of the battery.

Handpiece and ControlsFingertip controls on thehandpieces of some battery-powered or pneumaticinstruments permit the surgeonto vary the speed and torquedelivered by powered saws,drills, and reamers. Somepowered surgical instrumentscan be activated by foot pedal controls.

AccessoriesDepending on thefunction required, adrill bit, bur, blade,reamer, acetabular orfemoral reamer, orother attachment ofappropriate size maybe inserted into thehandpiece. Many ofthese accessories aresupplied sterile and considered single use items.

PREOPERATIVE CARE AND HANDLINGPowered surgical instruments represent a major financialinvestment for health care facilities, and they are expensive torepair or replace. Following manufacturers’ writteninstructions for proper care and handling helps to protect thisinvestment. Proper care of powered surgical instruments canonly be achieved through collaboration with surgical servicesand central sterile processing personnel, surgeons, andmanufacturers.

The following are general recommendations for use and careof powered surgical instruments. However, becausemanufacturers continue to improve and develop their poweredinstruments, each powered surgical instrument will have itsown specific requirements for assembly, intraoperativehandling, troubleshooting, cleaning, decontamination,lubrication, packaging, and sterilization. Be sure to followspecific written instructions for use and care of suchequipment provided by the manufacturer at the time ofpurchase. These written instructions should be readilyaccessible for reference in the health care facility.

Facility staff members should receive initial and ongoingeducation on powered surgical instruments. This could beprovided by the vendor during an inservice presentation or itcould be provided by a facility resource, such as an OReducator or clinical specialist who has confirmed care andhandling guidelines with the manufacturer.

Set Up and AssemblyBefore the surgical procedure begins, all powered instrumentsmust be assembled and tested with the appropriateattachments in place. Additional precautions may be required,depending on the power source used.

Gas CylindersIf gas cylinders are used, the health care facility should havewritten guidelines for handling, storing, and cleaning gascylinders. Cylinders should be secured by a chain to asupporting wall, a portable stand or dolly. When moving gascylinders, always use a cylinder carrier and lock the cylindersecurely into the carrier before transportation. Never allow agas cylinder to fall over—if a cylinder falls and breaks, it canact as a projectile, potentially causing serious damage or evendeath.

If using a gas cylinder, take the following steps to attach aregulator before bringing the cylinder into the procedureroom:

• Identify the gas cylinder. The medical gas in thecylinder must be clearly identified by the color of the

cylinder, a label, and a pin index safety system.• Wipe off the cylinder and carrier.• Open the tank valve very slowly.• Allow only enough gas to escape to remove any dust

that may have accumulated.• Attach the regulator by hand and secure it with a

wrench.• Ensure that the regulator is turned completely off.

Electrical EquipmentCare should be taken when using all electrical equipment.Cords should be laid flaton the floor to eliminatethe potential for trippingor accidental unpluggingof electrical equipment.Keep cords away frompooled fluids. Cords withundetected frays ordamage that are lying inwater or other fluidpresent electrical hazardsto personnel. Onlygrounded outlets shouldbe used for electricalpowered equipment.

InspectionAORN’s recommended practices for the cleaning and care ofsurgical instruments and powered equipment specify that“Powered surgical instruments and all attachments should bedecontaminated, lubricated, assembled, sterilized and testedbefore use according to the manufacturers’ writteninstructions.” Whenever a new powered surgical instrumentis purchased and delivered to the facility, it should beinspected carefully. The packaging should be checked fordamage that may have occurred during shipment. All contentsshould be confirmed for completeness and number of parts.A device manufacturer’s validated written instructions shouldbe included. Upon arrival and before sterilization, instrumentsshould be decontaminated to remove any contaminants, suchas loose debris and lubricants that may be present forprotection during shipment.

Before presentation of a powered surgical instrument to thesterile field, the sterile packaging should be inspected for anyevidence of being dropped or damaged, such as tears or holesin the packaging material. If potential packaging damage issuspected, the instrument should be checked by the

biomedical engineering department (or the manufacturer)before being used. If the package is intact, carefully open thewrapper or container and deliver the contents to the sterilefield using aseptic technique.

Before using a pneumatic instrument, the manufacturer’swritten instructions should be consulted to determine thecorrect gas pressure setting required to operate the equipmentsafely. This pressure is measured when the equipment isoperating. Pneumatic instruments that will be powered by agas cylinder will also require that the RN circulator check theamount of pressure remaining in the cylinder that will be used.Cylinders should be replaced when the pressure falls to a levelof 500 psi or less. Using cylinders with a remaining pressureof less than 500 psi or less is not recommended.

If an AC-powered device will be used, the RN circulatorshould check electrical cords for integrity and check theprongs of electrical plugs for alignment, because shock mayresult if the cord is frayed or the prongs are not properlyaligned. Electrical outlets should be accessible and in properworking order, because damaged outlets and switch platesmay result in excessive current leakage and cause patient orpersonnel injury. If an electrical cord is passed from theoperative field to an electrical outlet, make sure it is longenough to reach the floor and that it lies flat on the floor. Thisprevents accidental tripping by OR personnel and decreasesthe possibility of accidental disconnection of the cord fromthe power source. Cords may be secured to the floor if desired.

Before use of any powered surgical equipment on the sterilefield, scrub personnel should inspect it thoroughly. Steps toensure safe use include:

• The air hose should be inspected for damage or wearbefore and after decontamination and before use. Ifthe hose shows evidence of wear or damage, do notuse it. A damaged hose could cause injury to thepatient or personnel.

• If applicable, inspect batteries and batterycompartments for corrosion and other possibledamage or defects.

• To avoid accidental activation, make sure the triggeron the handpiece is in the safety position and that on-off switches are in the off position.

• Inspect accessories to ensure the integrity andsharpness of cutting edges. Blunt drill bits, forexample, may cause unnecessary thermal damage. Inaddition, the increased force required for penetrationof a dull drill bit may result in sudden bursting throughthe bony cortex, with inadvertent damage to soft


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tissues. The increased force required may also resultin broken drill bits and possible injury from the sharpends.

• Inspect the straightness of all accessories. Bent sawblades could decrease the life of the instrument due tothe increased force that must be exerted by the motorfor the blade to function. A bent bur may snap duringuse, presenting a major safety hazard to the patient andpersonnel. To test a bur shaft for straightness, roll iton a flat surface—a bent bur will not roll freely.

AssemblyBefore assembling a powered surgical instrument, it isimportant to read and understand the assembly and useinstructions provided by the manufacturer. There are a varietyof connectors for use with powered surgical instruments, andconnecting systems cannot be used interchangeably. Whenusing pneumatic powered surgical instruments the diffuser endof the hose should attach firmly to the regulator. An improperdiffuser/regulator connection could result in faulty operationof the instrument, gas leakage, and undue stress on theinstrument.

Before inserting a sterile attachment into a sterile handpiece,check to make sure that it is not bent. Less than perfect shaftstraightness on a bur, for example, can cause whipping, eventhough the bur appears to fit properly. Securely affix theappropriate attachment to the handpiece. Use only attachmentsclearly specified for use on that particular instrument. Do notmix one brand of attachment with another brand of handpieceunless the manufacturers specifically state that these productsare compatible. When changing sterile attachments onpowered surgical instruments, make sure the trigger handle isin the safety position. Accidental activation of poweredequipment can cause injury to patients or personnel. Be certainthat attachments are completely seated and locked in thehandpiece. Improperly seated attachments can be thrown frompowered equipment with great force, resulting in injury topatients and personnel.

Setting Pneumatic PressureWhen using pneumatic instruments, the correct pressure(usually measured in psi), as determined by the manufacturerof the instrument, should be used. This pressure should bemeasured with the instrument activated to ensure correctoperating pressure. Unless the pressure is set while pneumaticequipment is operating, the resulting operating pressures maybe too high or too low. A gas pressure that is too high candamage the instrument and place great stress on the hose. Agas pressure that is less than what is recommended by themanufacturer can place unnecessary or unwanted stress on theinstrument, because it must work harder to meet the demandsplaced on it. This stress will cause overheating and prematurewear and tear on the motor and other moving parts. Thepressure required to drive the motor in a pneumatic instrumentmay vary with the task expected for the equipment. Formicrodrills, such as those used in microsurgery on the ear, 80to 90 psi is an appropriate pressure. For sculpting or cuttinglarge, hard bones, a larger drill system that operates at apressure of 110 psi with up to 20,000 revolutions per minuteshould be used.

TestingAll powered surgical instruments should be tested withattachments in place prior to the beginning of the procedureto ensure that all parts are functional and running smoothly.Test each individual component to verify its function. Whentesting the operation of the handpiece, be sure to test the safety,reverse, forward, or other controls according to themanufacturer’s instructions.

When testing pneumatic pressure, open the cylinder valveslowly with the face of the gauge on the regulator pointedaway from any person. Repair or replace any improperlyfunctioning valves. Do not automatically increase the gaspressure if the operation of a pneumatic instrument is sluggishor erratic. Instead, follow the sequence of steps listed in the“Intraoperative Troubleshooting” section.

INTRAOPERATIVE CARE AND HANDLINGOnce the surgical procedure begins, the scrub person isresponsible for making surethe proper accessories aresupplied according to thesurgeon’s preference, andthat the accessories areproperly attached to thehandpiece and continue tofunction properly.


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Personnel ProtectionDuring operation of high-speed powered surgical instruments,a fine mist of blood and bone cells may be dispersed. For thisreason, the American Academy of Orthopaedic Surgeonsrecommends that personnel wear protective eyewear whenpowered instruments are in use. Similarly, the OccupationalSafety and Health Administration bloodborne pathogensstandard requires that employers supply masks in combinationwith eye protection devices, such as goggles or glasses withsolid side shields or chin-length face shields, wheneversplashes, spray, spatter, or droplets of blood or otherpotentially infectious materials may be generated, and eye,nose, or mouth contamination can be reasonably anticipated.

It is important for perioperative team members to be aware ofsharps safety procedures when working with powered surgicalequipment. Unless the movement of powered surgicalinstruments is carefully controlled, nontarget tissue, includingthe surgeon’s orassistant’s fingers,can be caught in arapidly spinning drillor oscillating saw.The instrument maycut more than desired.Whenever a poweredinstrument is beingused, particularly onewith rotating movement, all team members must be verycareful to keep their hands away from the blade.

Some tips for safely passing powered surgical instrumentsinclude

• keeping the safety on,• using a safe zone, and• verbally indicating when you are passing the

equipment to avoid injury to yourself or others.When you are finished usingthe instrument, remove alldisposable sharp items anddispose of them into theappropriate sharps containers.

After the procedure is over,when breaking down thesterile field, segregate the sharp instruments and arrange themto decrease the potential for injury to the staff members whowill be reprocessing the equipment.

When attaching or detaching the power source to theequipment, follow the device manufacturer’s instructions to

secure the connections appropriately and power the equipmentas severe injuries can and have occurred when the poweredsurgical equipment and hoses are connected and/ordisconnected.

Maintain Trigger or Control in Safety PositionAfter the powered surgical instrument has been connected tothe power source and tested for proper functioning, the triggeror finger control should be placed in the safety position, andkept in that position whenever the instrument is not in use.Accidental activation can cause serious injury. The trigger orcontrol should also be maintained in the safety position duringplacement and replacement of attachments intraoperatively.Be sure to seat attachments securely in the handpiece.

Use Saline to Cool AttachmentsAs early as 500 BC, Hippocrates suggested that coolingshould be applied to the trepanning tool (trephine) when disksof bone were removed from the skull. Today, there iswidespread agreement that powered cutting instrumentsshould be cooled to minimize temperature rise. Another meansof minimizing temperature rise is to use sharp drills, saws, andblades. Using overheated components can heat bone cellsabove 50° C, which causes irreversible change to the physicalproperties of bone due to changes in the collagen matrix. Theextent of the necrosis that results from using overheatedcomponents depends on the temperature reached and itsduration. When powered instruments are used on bone, a bulbsyringe should be used to dispense saline solution onto thecutting edge. This will disperse the heat generated by the bladeand wash away particles of bone and tissue. The saline alsoreduces friction and prevents the tissue from drying out.

Use Plastic Suction TipsHigh-speed burs used in conjunction with metal suction tipscan disperse very fine metallic particles into the soft tissueadjacent to the operative area. Although the particlesthemselves have no immediate clinical effects, they may causea distortion effect if the patient requires magnetic resonanceimaging (MRI) studies of the area in the future. For thisreason, plastic suction tips should always be used with high-speed burs or drills.

Place Powered Equipment On A Separate TableWhen Not in UseNever rest powered surgical instruments on the patient. If theinstrument is too large or cumbersome to be placed on theback table when not in use, prepare a separate sterile table orMayo stand to hold it.

This practice prevents serious injury to the patient from the


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weight of the instrumentor from accidentalactivation. It alsoprevents the instrumentfrom falling off thesterile field and avoidsaccidental contaminationfrom saws and bladestearing through draping materials. When the equipment is setup and not in use, the scrub person should place the equipmentin a secure area on the sterile field to avoid accidental sharpsinjury to the scrubbed team members.

Intraoperative TroubleshootingIf a malfunction occurs, check all components sequentially inorder to locate and correct the problem. Components shouldbe checked in the following order:

1. Power source2. Hose, cord, or battery3. Throttle4. Handpiece5. Accessory attachments6. Controls and/or safety switch

Standardized troubleshooting can save costly repair fees,decrease surgical delays, eliminate unnecessary downtime forrepairs, and reduce stress for all members of the surgical team.

If a pneumatic hose connection appears to be leaking, it maybe the result of a damaged or missing O-ring. Often the O-ring can be replaced without sending the powered instrumentback to the manufacturer.

POSTOPERATIVE CARE AND HANDLINGAll components of powered surgical instruments requirespecial postoperative care and handling, including cleaning,decontamination, inspection, lubrication, assembly,packaging, sterilization, preventive maintenance, and repairs.With the assistance of central services personnel and specialtynursing team leaders, each manufacturer’s instructions for

reprocessing poweredsurgical instrumentsshould be availablefor review at alltimes. It is importantto note that eachpowered instrumentand its componentparts have different

processing requirements.

Sterilization cycle parameters that are recommended by thedevice manufacturer should be reconciled with themanufacturer’s written instructions for the type of sterilizerand the specific sterilization cycle and load configuration thatwill be used. If the sterilizer and the device manufacturer’swritten recommendations cannot be reconciled, the devicemanufacturer’s instructions should be used. Manypneumatically powered instruments and rigid containersystems may require longer exposure times or drying timesthan other types of equipment.

The number of microorganisms present on a powered surgicalinstrument varies, depending on the instrument’s size, design,complexity, and condition; the degree of contamination duringuse; and the effectiveness of subsequent decontamination andcleaning procedures. Manufacturers validate sterilizationmethods for their instruments with a specific biologicalchallenge in the most difficult area to sterilize and recommendsterilization cycle parameters accordingly.

Cleaning and DecontaminationThroughout the surgical procedure, powered surgicalinstruments should be kept free of blood and other organicdebris by continually wiping them with radiopaque 4x4s, lapsponges, or a towel dampened with sterile water. Do not usesaline, which can cause pitting and corrosion of metal. Simplewiping decreases the bioburden on the instrument and helpskeep debris away from moving parts. If organic debris is lefton powered equipment, it can hinder the sterilization processand may interfere with proper functioning.

After the surgical procedure, AORN recommends thatpowered equipment be cleaned and decontaminatedimmediately, in accordance with the manufacturer’s writteninstructions. Manufacturers have specific recommendationsfor the correct method of cleaning and decontaminatingpowered instruments. These instruments contain complex


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lumens, movable parts, and intricate internal components.Most are not immersible and therefore present challenges inthe cleaning process.

Cleaning instructions vary with each manufacturer, but thefollowing are general guidelines for cleaning powered surgicalinstruments:

Blades and drill bits should beremoved from poweredinstruments in the OR by thescrub person after theprocedure has ended. Blades,bits, and other disposablesharp items should bedisposed of in appropriatesharps containers and sharpreusable items should besegregated into a containerthat is easily recognizable toindicate sharp objects.

1. If specified by the manufacturer, disassembleattachments for thorough cleaning.

2. Powered surgical instruments should not be immersedor placed under running water, in ultrasonic cleaners,washer disinfectors, or washer sterilizers unless this isindicated in the manufacturer’s written directions.

3. To prevent entry of moisture into the connection, leavethe air hose attached to the handpiece of pneumaticinstruments during cleaning. Permanent damage canresult from water or other fluid entering the internalmechanism of the instrument.

4. Wipe the surfaces of air hoses, electrical cords, andhand pieces with a mild detergent/disinfectant solutionrecommended by the manufacturer, taking care not toallow any solution to enter the internal mechanism.Use a cloth or soft-bristled brush. Hold the hose coiledwith both ends hanging down to prevent water fromentering the open ends. If the equipment has anelectrical cord, inspect it for cracks in the insulationand wipe it with a cloth soaked with mild detergentsolution. Clean other components with lukewarmwater, a mild detergent, and a soft brush, asrecommended by the manufacturer.

5. All traces of the detergent or disinfectant should bewiped off with a damp cloth.

6. Rinse carefully with distilled or de-ionized water toremove all traces of detergent solution, debris, ortissue irritants.

7. While cleaning, hold the handpiece with the nosepointed down to ensure that moisture does not run intothe instrument.

8. Pay special attention to cannulated areas, triggers, andintricate crevices to ensure removal of all blood andtissue debris.

9. To prevent spotting, dry the outside of the handpiecewith a clean, lint-free towel.

10. Dry small or delicate areas with cotton-tippedapplicators.

11. Dry lumens by attaching a syringe and forcing airthrough the lumen. Pipe cleaners may also be used.

12. If the instrument is to be sterilized with ethylene oxide,the manufacturer may recommend drying of channelsusing compressed air. Complete drying is necessaryto eliminate the formation of ethylene glycol (alsoknown as antifreeze), a harmful residue that resultswhen ethylene oxide combines with water.

LubricationDue to different manufacturing designs, powered instrumentsmay or may not require the use of solvents and lubricants toincrease instrument life. Some powered surgical instrumentsdo not require any lubrication, but when lubrication isrecommended by the manufacturer, it is essential for properfunctioning and sterilization.

If lubrication is recommended, lubricate powered equipmentand attachments according to manufacturers’ writteninstructions. The component or components to be lubricatedmay vary. Correlate the method and type of lubrication withthe method of sterilization. Each manufacturer can specify theappropriate product for their equipment. Some manufacturerssupply the lubricant, usually silicone oil. Some poweredsurgical instruments must be run after lubrication to ensuredispersion of the lubricant.

DisassemblyAfter the instrument has been thoroughly cleaned anddecontaminated, it is ready to be packaged and sterilizedaccording to the manufacturer’s recommendations. Beforesterilization, disassemble all powered instruments to ensurethat the sterilizing agent contacts all component parts.

PackagingAORN’s recommended practices state that “Powered surgicalinstruments should be packaged and sterilized according tomanufacturer’s instructions before use.” When packagingpowered surgical instruments for sterilization, use appropriatecontainers and packaging materials. Some manufacturers


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include perforated cases with compartments for their poweredsurgical instruments. These can be wrapped in woven ornonwoven material. Others recommend standard cases orpans, as well as wrapping materials. The goal should be toensure that the packaging selected promotes successfulsterilization.

When packaging powered surgical instruments forsterilization, include all components in the set. To ensure thatall parts are included in the tray, a concise, easy to use,pictorial reference showing the components may be helpful.Protect delicate parts by inserting them into the appropriatecompartments in their dedicated cases or by packaging themseparately. If parts are packaged separately, keep them withthe powered instrument to avoid damage or loss. Individualparts usually are not interchangeable between differentpowered instruments. Cords and hoses should be coiledloosely for placement in the sterilization container to avoidbreakage or undue stress or tension on the cord itself and/orits internal structures.

Arrange all components so that all surfaces are directlyexposed to the sterilizing agent for the prescribed time andtemperature. When using steam sterilization, materials andcontainers should allow for adequate air removal and steampenetration. When ethylene oxide is used, the container mustallow for adequate penetration and release of gas sterilant andmoisture.

SterilizationBecause their designs vary, each type of powered instrumentshould be cared for and sterilized according to themanufacturer’s instructions or irreversible damage to thepowered instrument may result. Each manufacturer should beable to provide validated sterilization parameters for eachpowered instrument that they provide. It is critical that thesterilization process chosen sterilizes even the internalmechanisms of powered surgical instruments.

Steam Sterilization – Saturated Steam UnderPressureSaturated steam under pressure is most often used to sterilizepowered surgical instruments, unless contraindicated by themanufacturer. The device manufacturer may validate aspecific method of air removal and recommend a certain typeof steam sterilization cycle or may specify the achievementof certain cycle parameters in their written instructions for use.

Steam exposure time is very important, as are the temperature,type of sterilizer, and type of powered instrument. Follow thesterilization parameters (time, temperature, and pressure)recommended by the manufacturer of each specific poweredsurgical instrument. Optimal sterilization parameters will varyaccording to the mass, configuration, and lubrication of theparticular instrument, as well as with the type of packagingand the sterilizer used. Because of variables in the constructionand uses of powered surgical instruments, it is not unusual formanufacturers to recommend a wide range of sterilizationtimes and temperatures.

Immediate use steam sterilization is not recommended forpowered surgical instruments because it does not reliablysterilize the internal mechanisms of powered surgicalinstruments. The air in the lumens of cords and hoses isheavier than the incoming steam and may not be totallydisplaced by a gravity steam flow. If there is a lag in thetemperature within the lumen, sufficient temperature may notbe achieved. Furthermore, the internal workings of poweredsurgical instruments are complex, inhibiting steam penetrationand therefore limiting microbial kill within the inner workingsof the instrument. Unless all organisms are inactivated,pathogenic microorganisms may be propelled into the woundor onto the sterile field as the gas exhausts from either thehandpiece or the hose. These instruments should be packagedand subjected to a full sterilization cycle by central servicespersonnel.

Ethylene Oxide SterilizationEthylene oxide is an alkylating agent that, under the rightconditions (time, temperature, concentration, and humidity)can result in microbial death. It may not sterilize the internalmechanisms of powered equipment, as gas does not diffusereadily through lubricants. Use ethylene oxide to sterilizepowered surgical instruments only if specified by themanufacturer. Do not use lubricants when using ethyleneoxide sterilization, as they impede diffusion of the gas throughthe internal mechanisms. Be sure to follow the aeration timesrecommended by the manufacturer.


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Sterile StorageAfter sterilization, powered surgical instruments should bestored in a manner to ensure sterility under environmentallycontrolled conditions. unsterile

Nonsterile StorageStore all nonsterile power sources in an unsterile storage areaimmediately adjacent to the storage area for the sterileinstruments, away from the flow of traffic but close enoughfor quick access.

Nitrogen cylinders, if used, should be stored in a designatedunsterile storage location away from heat sources. Cylindersshould be secured carefully to prevent them from falling overduring storage. It is a good practice to check the remainingpressure on nitrogen cylinders before storing to ensure anadequate supply of gas for the next procedure. Gas cylindersshould not be used if their remaining pressure is less than 200psi.

Preventive MaintenanceWith proper use and care, powered surgical instruments canhave a long lifespan.

A regular program of preventive maintenance can prolong thelife of powered surgical equipment. A preventive maintenanceprogram can be coordinated within the facility or may becontracted through the manufacturer.

To ensure quick access, all instruction manuals should beplaced in a binder, along with manufacturers’ contactinformation. Records of all preventive maintenance, as wellas repairs and replacements should be logged and archived asappropriate.

CHOOSING POWERED SURGICALINSTRUMENTSNew powered surgical instruments are constantly beingintroduced into the marketplace. Perioperative nurses should

be actively involved in the product selection process.Purchasing decisions should be based on objective criteriaspecific to the function and use of the powered surgicalinstrument system, along with a clinical trial of instrumentsthat meet identified criteria. Criteria that may be used toevaluate powered surgical instrument systems include thefollowing:

• Effectiveness (including patient outcomes). Determinethe types of procedures for which the system will beused.

• Reliability, including frequency of repairs anddowntime. To determine functionality, you may wantto check with other perioperative nurses who haveused the.

• Durability. Are attachments durable or do they needto be replaced frequently? This will increase theoperating cost of the system.

• Cost. Cost includes both original purchase price andlong-term operating costs (e.g., the cost ofreplacement attachments or single-use accessoriesrequired).

• Comfort. The handpiece should be lightweight andeasy to hold, and the cord, hose, or battery should belightweight.

• Convenience. The instrument should be easy toassemble and disassemble. Attachments should beeasy and quick to change.

• Power. The device should be powerful enough toaccomplish the task for which it was designed, andoperate smoothly.

• Versatility. Can one handpiece accommodate a varietyof attachments?

• Ease of maintenance and sterilization. Choosepractical powered surgical instruments that can beeasily cared for and sterilized in your practice setting.

• Availability of training. Does the manufacturerprovide training on this product?

SUMMARYAs a part of the surgical team, perioperative nurses can helpensure that every patient receives safe patient care by workingcollaboratively with the OR administration, surgical andmedical staff, and central services personnel to choose high-quality powered surgical instruments and to ensure that allpowered instruments are cared for and handled according tothe instructions supplied by the manufacturer.


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REFERENCES1. Messer EJ, Carlson RS, O’Keefe JS, Bill TJ, Luce CA, Thacker JG, Edlich RF. Evolution of powered surgical

instruments. J Long Term Eff Med Implants. 1995;5(2):129-146.2. Rothrock JC. Alexander’s Care of the Patient in Surgery. 14th ed. St. Louis, MO: Mosby;2011: 741.3. Cryer M. The spiral osteotome driven by a surgical engine in craniotomy. JAMA. 1908; LI(14):1150-1152.

doi:10.1001/jama.1908.25410140032004.4. OSHA’s Bloodborne Pathogens Standard. Occupational Safety and Health Administration.

http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf Accessed November 16, 2012.5. Phillips NM, ed. Berry & Kohn’s Operating Room Technique. 11th ed. St. Louis, MO: Mosby-Elsevier; 2007: 325,

328.6. AORN guidance statement: sharps injury prevention in the perioperative setting. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc;2012:711-716.7. Gruendemann BJ, Fernsebner B, eds. Comprehensive Perioperative Nursing. Volume 2: Practice. Boston, MA:

Jones and Bartlett; 1995.8. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative

Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 513 - 536.9. AORN’s recommended practices for sterilization in the perioperative setting. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2011. 547 - 569.10. AORN. Sterilization in the Perioperative Setting [video]. Woodbury, CT: Cine-Med, Inc;2010.


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1. Compared to conventional hand-held instruments,powered surgical instrumentsa. enable the surgeon to work more quickly.b. cause less trauma to surrounding tissues.c. decrease surgical time.d. all of the above.

2. Powered surgical instruments are used for all of thefollowing excepta. cutting and fixation of bone.b. splitting the sternum.c. harvesting skin for grafting.d. suturing tissue.

3. All of the following have a rotary action excepta. femoral reamers.b. automatic screwdrivers.c. bone rasps.d. K-wire drivers.

4. Direct current is the source of power fora. pneumatic instruments.b. battery-operated instruments.c. instruments that plug into wall current.d. all of the above.

5. When regulating the gas flow for pneumatic a.instruments, the correct pressure should be set a. by the manufacturer.b. before the instrument is activated.c. while the instrument is activated.d. before attaching the hose.

6. When not in use, powered surgical instruments a.should be placeda. on the patient.b. on a nonsterile table.c. on a Mayo stand or a sterile table that is separate

from the sterile field.d. any of the above.

7. When decontaminating and cleaning apneumatically powered surgical instrument,a. the gas hose should remain attached to the

handpiece.b. a detergent/disinfectant solution should be used.c. the outside should be dried with lint free towels.d. all of the above.

8. When packaging powered surgical instruments forsterilization, small, delicate parts should bea. protected by placing in appropriate section of

container or packaged separately.b. left unpackaged.c. placed under the instrument to prevent

movement during sterilization.d. placed loosely in the container to prevent stress

and tension on the parts.

9. Criteria for choosing powered surgical instrumentsincludea. effectiveness and power.b. cost and ease of sterilization.c. versatility and durability.d. all of the above.

10. The earliest applications of powered surgicalinstruments were in the field ofa. neurosurgery.b. ophthalmology.c. dentistry.d. orthopedics.


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POST-TEST


Multiple choice. Please choose the word or phrase that best completes the following statements.

11. Powered surgical instrument systems typically havethe following basic components.a. A power source, a hose or cord that connects the

power source to the handpiece, and thehandpiece.

b. A power source, a hose or cord that connects thepower source to the handpiece, the handpiece,a hand or foot control, and accessoryattachments.

c. A power source, a hose or cord that connects thepower source to the handpiece, and accessoryattachments.

d. A power source, the handpiece, and accessoryattachments.

12. To protect health care workers from exposure toblood and other potentially infectious material, theOccupational Safety and Health Administrationbloodborne pathogens standard requires thatemployers supplya. masks that have eye protection devices.b. goggles.c. glasses with solid side shields.d. all of the above.


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POST-TEST ANSWERS


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