HEAD START Enzymes help break down bioburden before instruments arrive in central sterile.

You spray enzymatic cleaners on your soiled instruments, but do you know how these protein-based detergents work and the role they play in your fight against bioburden? Enzymatic cleaners help prepare instruments and endoscopes for cleaning and sterilization or high-level disinfection by removing bodily fluids and tissue. They can be used as presoaks, during manual cleaning or in the first stage of automatic cleaning (as in ultrasonic washers or automated endoscope reprocessors).

By pre-cleaning, you're already exposing proteins, lipids and starches to enzymes that can start breaking them down. Before an instrument arrives in central sterile, an enzymatic solution should already be in use. If not, gross soil could dry on the instrument, which then requires rehydration before cleaning, a time-consuming process that limits enzyme-soil contact time.

Instead, have staffers spray the instruments at the point of use with a non-aerosol enzymatic solution. For an endoscope, staff must flush lumens with an enzymatic solution at the point of use, as well as wipe away gross soil with a single-use enzymatic sponge. Make sure employees use the correct concentrations of the detergent, or use pre-moistened options that already include the precise amount. For longer procedures, you may even want to consider new pre-cleaning enzymatic formulas that promise to keep instruments wet for up to 72 hours.

The right enzymes for the job
Enzymes are a protein that can clean heavily soiled surgical items by breaking down large organic molecules — like blood — to facilitate easier removal. There are several different types of enzymes, with 3 especially important for surgical cleaning.

• Protease. This family of enzymes breaks down proteins like blood, mucus, feces and albumin. They take large, insoluble molecules and break them down into smaller, more water-soluble ones that are easier to clean and rinse away.

• Lipase. These enzymes break down fatty deposits and lipids. Though the fat and oil molecules they attack aren't as large as proteins, they tend to be insoluble in water. Lipase can make these more water-soluble for better removal.
• Amylase. These enzymes catalyze starches. While they are less common in enzymatic detergents used on surgical instruments, they can be found in ones marketed for "heavy-duty" cleaning.

THE BIG EXCEPTION
Don't Use Enzymatic Detergents For Ophthalmic Instruments

BAD IDEA Ophthalmic groups recommend not using enzymatic solutions on your eye instruments.

Enzymatic cleaners are likely to do more harm than good when used to clean ophthalmic instruments, according to 3 major ophthalmic groups.

Though some ophthalmic instrument manufacturers recommend using enzymatic cleaners, detergents often contain exotoxins that aren't denatured by autoclave sterilization, the American Society for Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology (AAO) and the Ophthalmic Outpatient Surgery Society (OOSS) said last month in a statement. They say that corneal endothelial toxicity and TASS (toxic anterior segment syndrome) have both been associated with the use of enzymatic detergents.

Because intraocular instruments acquire little bioburden during surgery, prompt manual rinsing and cleansing after surgery should be sufficient to remove bioburden, the groups say. They also caution those who continue to use enzymatic detergents to carefully follow instructions for proper dilution, and to use sterile distilled or sterile deionized water for the final instrument rinse.

Bottom line? Based on documented risk of TASS, and with no proven benefit for endophthalmitis prevention, don't use enzymatic detergent to routinely decontaminate intraocular instruments.

— Jim Burger

Before using an enzymatic cleaner, determine the most suitable enzyme by evaluating what kind of instrument you're using. Surgical soils typically contain a variety of substances, though the most common are proteins and lipids.

Protein-based soils, such as blood, are found in most surgeries, while lipids are often discovered on instruments used in orthopedic surgeries, since there are lipid-based solutions around the joints, as well as in abdominal procedures. Because of this, you'll most likely want an enzymatic detergent that offers both protease and lipase, though triple enzymatic solutions are great for hard-to-remove soils and are often used on flexible endoscopes, since their lumens can be tricky to clean. Your manufacturer's instructions for use will often specify which enzymes you should use. Once you've figured out the type of enzymes you're looking for, don't just go on the manufacturer's word that the proteins in it will successfully remove bioburden. Ask for proof or research showing their effectiveness.

Cleaner compatibility
You'll want to read the manufacturers' instructions for use (IFU) for both your instruments and the prospective cleaners to ensure that the instrument and the cleaner are compatible with one another.

First, obtain the IFU for the instruments you're planning on cleaning with the enzymatic detergents. Check to see if the IFU list a specific enzymatic solution. If they do, you must use this solution to ensure proper cleaning of the medical device.

It's not only about the instruments — you must look at anything the detergent will come into contact with during reprocessing. Make sure that the solution is compatible with materials found in your ultrasonic washers and automated endoscope reprocessors. This can include stainless steel, soft metals like aluminum and a variety of plastics.

A BETTER CLEAN Ensure you're using the right enzymatic cleaner on your delicate flexible endoscopes to minimize risk of deterioration.

Finally, review the enzymatic solution's IFU to check for things like storage instructions and water quality. For example, some solutions require specific temperatures for storage in order to work effectively, while others are more stable over a larger temperature range. Look for cleaners that won't deteriorate pricey instruments and scopes. Don't hesitate to ask for research backing these claims.

Most solutions require pure water, so if you have hard or soft water you may need to buy filters or treatments. The IFU will specify temperature. To make this job easier, consider a system that lets techs, with the push of a button, fill the sink with the proper amount of detergent and water, at the correct temperature.

Weigh the contributing factors
While the way enzymes work to clean instruments is a crucial part of your purchasing decision, there are a few other factors to consider.

• Staff safety. Your techs will be using these solutions, so make sure that they can do so correctly and safely. Since these detergents are protein-based, they must be rinsed thoroughly and shouldn't be left to dry on items that could cause an allergic reaction if they come into contact with bare skin. To reduce the risk of allergic reactions, consider formulas designed without scents or dyes. If you're using a spray solution, make sure it's non-aerosolizing to reduce the risk of inhalation. Employees must also wear the appropriate personal protective equipment based on the cleaner's IFU.
• Low foam. Look for low-foaming solutions, since foam can make rinsing more difficult and reduce the effectiveness of automatic washers.
• Expiration date. Enzymes are proteins, and enzymes can break down proteins, so they can become less effective over time.
• Bottles or pre-moistened? While most cleaners come in large bottles that require proper dilution for use, you can buy sponges or brushes that are pre-moistened with the correct concentration for cleaning an instrument. Though pricey, these can help ensure techs are using the proper concentration.
• Price. I know there are budget constraints, especially in central sterile departments, but you should work to minimize the impact this has on selecting a suitable and effective solution. Prices can vary greatly, so work with your vendor to narrow down the best options that fit your budget. Patient safety should always come first and should always be your top interest. Enzymatic cleaners are the gold standard for removing blood, tissue and other bodily matter to prepare the instrument for high-level disinfection or sterilization. They're your first line of defense, and therefore worth the investment. OSM