Infection Control Guide to Care of Inhalation Sedation

Infection Control procedures for use and care of this type of equipment are frequently misunderstood and the intention of this article is to guide and assist with provision of a suitable Infection Control Protocol.

Section 1. Inhalation Sedation Flowmeters

As defined in ‘A Conscious Decision’ published by the Department of Health in 2003 the section for Equipment for Conscious Sedation states:

“Of the various reports since 1967, the Poswillo Report made the most specific recommendation for the equipment and drugs which dental practices should have to support the practice of sedation. This included the availability and use of dedicated inhalational sedation machines capable of delivering a fixed maximum level of nitrous oxide and a fixed minimum level of oxygen when providing relative analgesia (a particular sedation technique using inhalation); the use of indwelling cannullae for intravenous sedation; and additional equipment for the resuscitation of patients who had received sedation. It is essential that all machines used for conscious sedation meet the above guidelines bearing in mind the potential for general anaesthetic machines to be used for conscious sedation. The Group recommends that all Inhalation Sedation machines should be regularly maintained and equipped to the British or European Standard applicable at the time of their purchase.” (ref 1)

The most commonly found types of Inhalation Sedation Flowmeters are currently:

Cyprane or Matrx Analogue MDM (commonly referred to as Quantiflex)

Quantiflex Mark II

Matrx Digital MDM

Porter C2000 & C3000 MXR

McKesson 882 / 883 & Mc1

Accutron Ultra & Newport

The above units are all dedicated Inhalation Sedation machines. Units still in production are:

MDM / DMDM / C3000 MXR – all manufactured by Porter Instruments Inc, USA

McKesson Mc1 – manufactured by McKesson/Cestradent, UK

Ultra / Newport – manufactured by Accutron Inc, USA

All these units have dedicated one-way valving on the fresh gas outlets. These valves also incorporate bag tees which direct some of the titrated gas flow into a reservoir bag. In units which are correctly maintained, this valving is preserved and effectively means that the inside of the IS unit and bag will never become contaminated by human breath. This protection is usually assisted by the breathing system used to deliver titrated gas mix to the patient. By the same token, use of bacterial filters, as used with G A circuits – is not necessary or desirable.

External Cleaning

It is becoming increasingly apparent that serious damage is being caused to sedation flowmeters by the overzealous use of cleaning products. This includes: tidal marks behind the flowmeter perspex cover, fluid in the oxygen & nitrous oxide flow tubes, damage to flowtube seals and also internal damage to valves and diaphragms.

This damage can be expensive to repair and in many cases, may occasion a ‘return to workshop’ as the damage can be too extensive to repair on site.

To prevent this damage occurring, staff should observe the following actions:

1) If using pre-moistened cleaning wipes, on removal from the container make sure there is no excessive moisture by wringing the wipe out.Use of Clinell and Cutan wipes are not recommended, due to excessive moisute levels/foaming.

2) Apply to the flowmeter or other equipment in a light sweeping motion, avoiding any potential openings in the equipment.

3) Never ever spray onto the flowmeter and associated equipment – only onto a cloth.

4) If any liquid is observed within the flowmeter or flowtubes then do not use the equipment and contact your service provider immediately.

Reservoir bags:

Reservoir bags are usually composed of a grey non-latex material. These are protected from internal contamination by the non-return valving of the flowmeter outlet. If required, they can be externally cleaned with a mild detergent such as Tri-Sodium Phosphate or a neutral liquid soap. The product can also be autoclaved providing the maximum temperature does not exceed 137 degrees Celsius. Lower sterilisation temperature will extend product life. It is not necessary to change the reservoir bag between patients or use disposable bags (green).

Section 2. Scavenger Breathing Systems

Cleaning and sterilisation of these will vary considerably with regard to manufacturer instructions. The most frequently seen types on the UK marketplace are:

Porter brown double mask Scavenger System

Accutron Scavenger System

Matrx ANS (Autoclavable Nitrous Scavenger) System

Note on Matrx Passive Systems: This system has been on the marketplace for approximately 40+ years and was originally designed to scavenge ‘passively’ i.e. air flow rate at the nasal mask of no more than 0.5 L/min even when connected to an AGS System (w/air break in-line). There were also infection control issues as only the blue nasal hood could be autoclaved. The Manufacturer, Porter Instruments, discontinued production in September 2009 and this system type is now considered obsolete for dental application.

Porter brown System: Porter Instruments recommend the following Protocol:

The following items are placed in an ultrasonic with water and an enzymatic instrument cleaner, manually cleaned (if necessary) with soap and water and sterilised in a steam autoclave on a low temperature cycle (121° Centigrade is recommended*):

Porter Adult Hood (grey) – 5054A

Porter Adult Liner (grey) – 5054-1

Porter Paediatric Hood (grey) – 5054B

Porter Paediatric Liner (grey) – 5054-2

Porter Coaxial Inhaler Tubing – 5056

Fresh Gas Y Connector (grey) – 5058

Vacuum Line Y Connector (grey) – 5062

Tension Slide Adjuster (grey) – 5057

Mask to Tubing Connectors -pair (grey) – 5061

Vacuum Hose (grey) – 5059

Fresh Gas Hose (cream autoclavable only) – RA2011 is rinsed with soap and water and autoclaved.

The Vacuum Control Block 5501-RK and Vacuum Tube Holder 5065 can be wiped down with a disinfectant-type wipe. Do not autoclave or immerse in liquid.

* Please note this lower sterilisation temperature 121° C vs. 134° C requires a longer cycle time but gives same assurance of sterilization and is kinder, helping to extend the life of the product.

Warning: Chemical Disinfectants: It is recommended that these are not used. Disinfectants do not provide the same reduction in microbial contamination levels as sterilization. These techniques can leave a residue on the mask and liner that can irritate or even chemically burn the patient’s skin or mucous membranes if the mask/liners is not rinsed thoroughly with clean water.

Accutron Scavenger System: Similar in appearance to the Porter brown system except tubing is white instead of grey. However, the main differences are:

The vacuum control block is placed in-line with the vacuum hose and the system uses autoclavable or scented single patient use nasal hoods with a clear collector cap or a double mask such as the Clearview. For reusable components, the manufacturer states:

• Must be thoroughly cleaned before reuse
• The spiral vacuum tubing containing the vacuum flow gauge is not autoclavable and do not submerse in liquid solutions
• Single use PIP+ or Clearview nasal hoods may not be reprocessed

Reprocessing of reusable scavenging circuit components according to ISO 17664:2004
Preparation for	Detach spiral vacuum tubing containing vacuum flow gauge.
Decontamination	Disinfection of this component is normally unnecessary, however if
	internal contamination or fluid is observed it must be replaced.
	Do not attempt to disassemble or clean the vacuum gauge.
	Detach nasal hood – autoclave if grey. If coloured, dispose.
	Detach White or grey corrugated fresh gas hose – do not autoclave.
	All remaining components may now be reprocessed.
Cleaning/	Load Washer Disinfector according to manufacturer’s instruction
Disinfection:	Processing should include a) cold water rinse, b) circulation wash with
Automated	detergent, c) warm water rinse and d) disinfection cycle. Accutron
	recommends a 93°C – 10 minute disinfection cycle.
Cleaning:	Submerge/soak the reusable components in an enzymatic detergent
Manual	solution (as per manufacturer instructions). Scrub using a soft bristled
	nylon brush until all visible soil removed
	Rinse components in clean warm tap water for minimum of 3 mins.
	Flush all internal lumens and difficult to reach areas to ensure removal
	of all residuals. Remove excess moisture with clean absorbent lint-free
	wipes.
Sterilisation	Standard packing material may be used but ensure that it is large enough
	to prevent stressing or kinking of tubing or other components.
	Accutron recommends gravity autoclave steam sterilisation for a
	minimum of 24 minutes at a temperature of 134°C. Dry time 30 mins.
	No particular requirements for storage

Matrx ANS) Autoclavable Nitrous Scavenger System: The manual states that ‘Most A.N.S. components are autoclavable. CAUTION: When autoclaving A.N.S. components, Matrx recommends following the specific protocol of the using service or the steriliser manufacturer. Temperatures consistent with silicone, Ultem (polyetherimide) and polysulfone, in the range of 120 degrees Celsius to 134 degrees Celsius can be used.’ The system should be disassembled, each tube and the scavenging cone system washed with a mild alkali detergent and all parts not precluded, autoclaved. Precluded parts include: white single-use nasal hoods and the scavenger control valve.

Note: This system can be used with blue (autoclavable) nasal hoods and white (Dynomite single patient use) nasal Hoods. Components latex free.

Section 3. General Observations

The HTM 01-05 Decontamination in primary care dental practices does not mention R A (or I.S.) Sedation equipment. However, the Audit Tool; ‘Assessing Implementation of HTM 01-05: Decontamination in Primary Care Dental Practices and related infection prevention and control issues’ does contain the following:

Section 5 Management of Dental Medical Devices – equipment and dental instrumentsHeading: Inhalation Sedation Machines (ISM) (ref 3)contains the following questions:

27. Are IS Flowmeters used and maintained in accordance with OEM (Original Equipment Manufacturer) or Suppliers instructions?
28. Are IS breathing systems (mask and tubing’s) used in accordance with Manufacturer’s or Suppliers instructions (Also please refer to Q14).

Q14 comes under the sub-heading of Other Medical Devices and asks: ‘Are single-use items only used for single treatment episode and disposed of following use?

Comment on Disposable Breathing Components: Most breathing systems are designed to be autoclaved, but with the option of using disposable, single patient use components. These range from nasal hoods and inner liners (for use with autoclavable double masks) to coaxial hoses.

From 2012 a fully disposable ‘End Change’ Set comprising: Pair of green coaxial hose, clear slide adjuster, clear hood/hose connectors and a Clearview double mask became available. These components are designed to be combined with the Porter brown vacuum hose and vacuum control block, Vacuum Y connector, Fresh Gas Y connector and fresh gas hose, the addition of which completes the breathing system circuit. This effectively means that all components of the breathing system which come into contact with the patient, can be changed and disposed of following use.

References:

Ref 1: ‘A Conscious Decision’ Department of Health 2003

Ref 2: The Revised Healthcare Cleaning Manual www.npsa.nhs.uk/cleaning

Ref 3: Local Self-Assessment Audit for Assessing Implementation of HTM 01-05. I.P.S. 2009

Mrs J E Pickles

Issue 3 Rev: 9/16 Tel: 01535 652444

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