Recommended Practices for Cleaning, Handling, and Processing Anesthesia Equipment



## Recommended practices
for Cleaning, Handling, and Processing Anesthesia Equipment he following recommended practices were developed by the AORN Recom-T mended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comment to members and others. These recommended practices are effective Jan 1,2005.
These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings or clinical situations that determine the degree to which the recommended practices can be implemented.
AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended to provide guidance for various practice settings, including traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed. PURPOSE. Anesthesia equipment is a potential vector in the transmission of microorganisms. Proper handling and processing of medications, supplies, and equipment can reduce the risk of infection to the patient. These recommended practices provide guidelines for the handling, cleaning, disposal, and reprocessing of anesthesia equipment and instrumentation. Medications should be stored in a clean area. Personnel should perform basic hand hygiene according to the CDC's "Guideline for hand hygiene in health-care settings,"'" before preparing medication. Vial stoppers should be cleaned with alcohol before they are punctured. Single-dose vials should be used for only one patient. Syringes of unused medication should be discarded at the end of the procedure. Propofol should be withdrawn immediately before administration.
ing medications, them, ication into multiple syringes, ication between patients, and temperature for the day.
Aseptic technique should be used when administering medications. Bacteria from hands can contaminate syringes and their Multidose vials have been found to be contaminated." Syringe contents have been found to contain blood or bloodbome pathogens after one injection or entry into IV Using a common syringe in the IV tubing ports of more than one patient has transmitted infectious Syringes and needles should be used for only one application (eg, one syringe and one needle per entry into a multidose vial). Intravenous tubing ports should be cleaned with alcohol before they are punctured with a needle.

## Recommended p r a c t i c e

## I1
Anesthesia equipment that comes in contact with mucous membranes should be sterilized or undergo high-level disinfection before use. 2. Reusable semicritical items should be cleaned as the first step in reprocessing. Removal of organic material provides optimal conditions for proper exposure of equipment to disinfectants and steril a n t~. ' ,~~,~~ Rgid laryngoscopes should be disassembled and all components cleaned, including handles. Some automated pasteurization equipment has a cleaning step within the pasteurizing cycle.

## 3.
Clean, semicritical reusable items should be processed by high-level disinfection, pasteurization, or sterilization with a US Food and Drug Administration (FDA)-approved agent, according to AORN's "Recommended practices for high-level disinfection" or "Recommended practices for sterilization in the practice ~e t t i n g . "~~,~* Written instructions from the manufacturers of reprocessing equipment, chemicals, and instruments should be followed. Items should be rinsed with sterile water after the chemical disinfection process. If sterile water is not used, the item should be rinsed first with water and then with 70% alcohol, and it should be thoroughly dried, along with its lumens and channels?'
6. Disinfected semicritical items should be stored in a clean location in a manner that prevents recontamination or damage. Storing semicritical items in a clean location minimizes the risk of contamination with pathogens before use. Endoscopes should be stored vertically with control valves, caps, and hoods removed." 7. Personnel should be trained in the reprocessing procedures and equipment. Training personnel regarding the complexities of the equipment, chemicals, and processes used minimizes the risk of human error.
8. Quality control of reprocessing procedures should be performed and documentation maintained in accordance with 0 AORN's "Recommended practices for high-level disinfection,"" 0 AORN's "Recommended practices for sterilization in the practice setting,"" and 0 manufacturers' written instructions. Quality control measures provide assurance that mechanical and chemical conditions are optimal for high-level disinfection. Documentation provides a mechanism for process improvement and investigation of adverse events.

## Recommended practice 111
Anesthesia equipment contacting intact skin should be clean at the time of use. 1. Items such as blood pressure cuffs, electrocardiogram (ECG) leads, and oximeter probes that contact only intact skin are con-sidered noncritical. The CDC 0 has determined that the potential for transmission of infectious agents is lower when items contact only intact skin, 0 has classified these items as noncritical, and 0 recommends low-level dismfection.' 2. Reusable items and surfaces contacting intact slun (eg, blood pressure cuffs, ECG leads, s h temperature probes) should be cleaned between use on patients. Cleaning removes organic and inorganic material, whch allows the disinfectant to contact all surfaces.',E,2h
3. Reusable laryngoscope handles should be cleaned and low-level disinfected between patients. Laryngoscope handles become contaminated during airway management.
In studies, 40% to 50% of handles tested positive for Cleaning and disinfecting these handles minimizes the risk of transmission of bloodborne pathogens. The disinfectant selected should be registered with the Environmental Protection Agency (EPA) for use as a hospital disinfectant and used according to the manufacturer's written instructions.ffi 4. Reusable noncritical items should be lowlevel disinfected between patients. Low-level disinfection with an EPA-registered hospital disinfectant kills most bacteria and some viruses and fungi but may not kill tubercle bacilli or bacterial spores.' After subjection to low-level disinfection, the device is considered safe to come in contact with intact skin.
5. Surfaces of anesthesia equipment that are touched by personnel while they are providing patient care or handling contaminated items should be cleaned and low-level disinfected between use on patients, according to manufacturers' written instructions. Surfaces of anesthesia equipment become contaminated with oral secretions and blood during surgical procedure^."^-^^ Researchers have found occult or visible blood on 29.5% to 35.5% of anesthesia machines, carts, and monitor~.~~,~* Blood also has been found on ventilator controls, flow meter knobs, vapor controls, ECG leads, oximeter probes, and blood pressure cuffs (ie, 25% to 64.3h). [bib_ref] The prevalence of visible and/or occult blood on anesthesia and monitoring equipment, S M Perry [/bib_ref] Surfaces of anesthesia carts, drawer handles, touch screens, flow meter knobs, ventilator controls, ECG leads, oximeter probes, and blood pressure cuffs should be cleaned and disinfected between use on patients. Other surfaces known to have been touched during patient care also should be cleaned and disinfected between patients.

## 6.
Exterior surfaces of anesthesia equipment (eg, anesthesia cart, machine, monitors) that are not knowingly contaminated during patient care should be terminally low-level disinfected at the end of the day according to manufacturers' written instructions. Contact with blood and body fluids is routinely associated with tasks performed by anesthesia care These surfaces may become contaminated during use, without the knowledge of the provider.Low-level disinfection with an EPA-registered hospital disinfectant renders the surfaces safe to contact intact skin.' Manufacturers recommend specific agents to clean complex electronic equipment. These instructions should be followed.

## Recommended practice i v
Single-use items (eg, breathing circuits, endotracheal tubes, filters, needles, some LMAs, stylets, suction catheters, syringes) should be used once and discarded in accordance with local, state, and federal regulations.
1. Single-use items should be used for a single patient and not reused on subsequent patients. Patient care equipment and supplies are potential vectors of microorganisms and can transmit infectious agents. Safe cleaning and reuse of single-use items has not been established. These items should be discarded after use on a single patient.
2. Single-use items should not be reprocessed unless requirements for validation testing can be met. Reuse of items designed for single use creates the potential for injury related to mechanical failure, residual bioburden, and chemical residue from the reprocessing agent. For these reasons, reprocessing of items designed for single use is regulated by the FDA. Under the Federal Food, Drug, and Cosmetic Act, facilities reprocessing single-use devices must meet all regulatory requirements of a device manufacturer, including 0 facility registration and device listing, 0 premarket clearance or approval, 0 labeling, 0 corrections and removals, 0 medical device tracking, 0 medical device reporting, and 0 quality system regulation?' These requirements exceed the capabilities of most perioperative settings.

## Recommended practice v
Anesthesia equipment should meet performance and safety criteria established by the practice setting and that is consistent with the manufacturer's written instructions. of the anesthetic circuit was identified as the likely cause of transmission of hepatitis C virus.'5 Currently, there is no consensus about the routine use of bacterial f i l t e r~. 2~,~,~* ,~~,~ For patients with known or suspected tuberculosis, the CDC, ASA, and AANA recommend using a bacterial filter between the patient and breathing circuit.2y,W,58 The Canadian Society of Anesthesiologists also recommends use of bacterial filters for patients with severe acute respiratory syndrome (SARS).'* With the increased prevalence of tuberculosis, increased numbers of immunocompromised patients, and the advent of SARS, it is prudent to consider the routine use of bacterial filters on the inspiratory and expiratory limbs of the anesthesia circuit. Some single-use circuits have a heat and moisture exchanger equipped with these filters. Reusable circuits should be cleaned and undergo high-level disinfection, pasteurization, or sterilization between use on patients.

## Humidifiers should be used and cleaned
according to manufacturers' written instructions. The water in humidifiers is heated to temperatures that reduce or eliminate microbial growth.79 Tap water may contain stationary-phase forms of Legionella pneumophila, which are heat resistant.66 Sterile water should be used in h~rnidifier~.~*~~'-*' Reusable humidifying chambers should undergo sterilization or high-level disinfection between patient U S~S .~"~~ Single-use chambers should be discarded after use on one patient.

## Recommended p r a c t i c e

## Vii
Waste must be disposed of in a manner consistent with local, state, and federal regulations.
1. Biohazardous waste should be placed in a biohazardous waste bag. Some anesthetic waste poses a risk of transmission of bloodborne pathogens. Placing it in designated biohazardous containers alerts handlers to this risk. Management of biohazardous waste within the health care facility is regulated by the Occupational Safety and Health Administration (OSHA).8Z State and local laws also apply. Perioperative professionals should be aware of and act in accordance with these laws.
2. Sharps should be handled in a manner that minimizes the risk of percutaneous injury.
To minimize the risk of injury from contaminated sharps, OSHA requires that puncture-resistant sharps containers be located at the point of Placing the container next to or on the anesthesia equipment meets this expectation. Sharps should be placed directly into the container.

## 3.
Waste that is hazardous upon disposal must be managed in a way that minimizes environmental impact. Some waste poses a risk to the environment (eg, alcohol, bezoin, epinephrine, mercury). This waste is classified by the EPA as hazardous upon disposal and is regulated under the Resource Conservation and Recovery Act.The EPA requires that this waste be placed in hazardous waste containers at the point of use to alert handlers to the need to take precautions upon its disposal.84 State and local laws also may apply.

## Recommended practi ce viii
Potential hazards to perioperative personnel that are associated with handling and processing clean and contaminated anesthesia equipment (eg, exposure to infectious organisms, chemicals) should be identified, and practices should be established to reduce the risk of injury. 1. Contaminated sharps must be discarded in a puncture-resistant container at the point of use. Immediate disposal of sharps prevents injuries to people unaware of the location of the sharp and is required by OSHA.*' 2. All personnel involved with cleaning and processing anesthesia equipment should practice according to A0R"s "Recommended practices for standard and transmissionbased precautions.''85 These precautions define general measures for infection control.
3. Anesthesia equipment should be processed using methods that reduce the risk of exposure to pathogens and injury. Manual cleaning methods that minimize splashing, spraying, spattering, and generation of droplets protect personnel from exposure to blood, body fluids, and cleaning agents.
4. Personnel must be apprised of the hazards in the workplace, including chemicals used for reprocessing anesthesia equipment.
Knowledge of the hazards in the workplace, preventive measures, and exposure management minimize the risk of injury to employees and are required by OSHA."

## Personal protective equipment (ppe) must
be provided to minimize the risk of exposure to bloodbome pathogens and chemicals used in the workplace. Use of barrier protection minimizes the risk of exposure to bloodbome pathogens by personnel performing tasks likely to generate contact with blood. According to OSHA regulations, employers are required to provide PPE (eg, gloves, gown, mask, protective eyewear, face shield) for their employees.K' 6. Personnel should actively participate in the evaluation of engineering devices and work practice controls to minimize the risk of exposure to bloodbome pathogens. Active participation in the selection of PPE and practices provides the best opportunity for designing a safer workplace. According to OSHA regulations, employers are required to solicit nonmanagerial employee input during evaluation of engineering devices and work practice controls to minimize exposures to bloodbome pathogens.67

## Recommended p r a c t i c e
I X Anesthesia equipment should be handled, cleaned, processed, or discarded in the same manner in all areas of the practice setting.
1. Guidelines should be developed and approved by appropriate mechanisms and goveming bodies in the practice setting. Equipment may be located in satellite areas (eg, labor and delivery). Guidelines should be consistent throughout the practice setting because all patients are entitled to the same standard of care.88

## Recommended p r a c t i c e x
Policies and procedures on cleaning and processing anesthesia equipment should be developed, reviewed periodically, and readily available in the practice setting.
1. These recommended practices should be used as guidelines for developing policies and procedures in the practice setting. Policies and procedures establish authority, responsibility, and accountability for cleaning, handling, and processing anesthesia equipment and serve as operational guidelines. Policies and procedures also help in developing performance improvement activities.
2. Policies and procedures for cleaning and processing anesthesia equipment should include, but not be limited to, 0 disposal of single-use items, 0 equipment maintenance programs, 0 equipment quality checks, 0 personal protection, 0 personnel education, 0 processing reusable equipment, and 0 waste disposal.

## Glossary
ANESTHESIA EaUIPMENT: Equipment used to provide anesthesia and/or monitor the patient under sedation or anesthesia.
CLEANING: A process using friction, detergent, and water to remove organic debris.
CRITICAL ITEM: An item that contacts the vascular system or enters sterile tissue, posing the hghest risk of transmission of infection.

## High-level disinfection:
A process that uses a government-registered agent that kills vegetative bacteria, tubercle bacilli, some spores, fungi, and lipid and nonlipid viruses, given appropriate concentration, submersion, and contact time.

## Low-level disinfection:
A process by which most bacteria, some viruses, and some fungi are killed. This process may not kill resistant organisms, such a s Mycobacteriurn tubercle or bacterial spores. NONCRITICAL m~: An item that comes in contact with intact skin but not with mucous membranes, sterile tissue, or the vascular system. PASTEURIZATION: A process that employs time and hot water (ie, 160" to 170" F [21.7" C to 25" C] for 30 minutes) for high-level disinfection. The intensity of heat and duration of exposure must be determined by the manufacturer of the pasteurization unit and the manufacturer of the product or device to be cleaned.
SEMICRITICAL ITEM: An item that comes in contact with mucous membranes or with skin that is not intact. The technique, which uses ultrasound along with a fine needle biopsy, determines reliably whether the lymph nodes are malignant. Traditional means of determining cancer's spread to the axilla (ie, underarm) are sentinel lymph node sampling, in which the first lymph node is identified and assessed for cancerous cells, or axillary Lymph node dissection, in which all lymph nodes in the underarm are removed and examined for cancer. If the sentinel node biopsy shows cancer, then a patient must undergo surgery to have the lymph nodes removed.
For some women, chemotherapy may be necessary before surgery. In these cases, physicians must determine whether the lymph nodes are affected before the chemotherapy begins. Rather than performing a sentinel lymph node sampling surgery, physicians can use ultrasound-guided fine needle aspiration to confirm the cancer's spread without surgery.
The technique uses ultrasound to identify the axillary lymph nodes and determine if their appearance is normal or abnormal. If they look abnormal, a 22-gauge needle is inserted into the node to extract cells to be evaluated for cancer. The technique requires only local anesthesia and involves no surgical incisions, unlike sentinel lymph node sampling and axillary node dissection, which are full surgical procedures.
Researchers used ultrasound to examine 57 women who were recently diagnosed with breast cancer. If the lymph nodes appeared abnormal on uitrasound, the researchers performed a fine needle aspiration, using ultrasound to guide the biopsy. Patients then underwent breast surgery and either sentinel lymph node sampling or axillary node dissection.
Pathology reports from surgery were compared to results from the ultrasound-guided fine needle aspiration. Of the women whose ultrasounds showed abnormal lymph nodes, 92.8% had cancerous nodes at surgery. Additionally, all the women with an abnormal ultrasound and a positive biopsy were found to have cancer in their lymph nodes at surgery.
Researchers note that the technique is not reliable to rule out the cancer's spread-it only can confirm positive lymph nodes. If a test is negative, therefore, sentinel lymph node sampling still is necessary.
New Biopsy Technique Helps Assess Breast Cancer' s Spread (news release, Ann Arbor, Mich: University of Michigan Health Center, Nov 
[fig] RECOMMENDED: PRACTICE I Anesthesia equipment that comes in contact with the vascular system or sterile body tissue should be sterile at the time of use. 1. Items such as IV catheters, tubing, and stopcocks; syringes and needles; and medication vials and ampules are considered critical items. The Centers for Disease Control and Prevention (CDC) uses Spaulding's criteria to determine the potential for transmission of infectious agents. In this classifi-856 AOKN JOURNAL cation, items contacting the vascular system or sterile tissues pose the greatest risk of infection and are classified as critical.' Using sterile items when contacting the vascular system or sterile tissues minimizes the risk of infection. Aseptic technique should be used when preparing medications. Breaks in aseptic technique have contaminated IV anesthetic agents and medications, resulting in clusters of infections.2" Good practices include 0 performing hand hygiene before prepar-0 cleaning vial stoppers before puncturing 0 using multiple needles to withdraw med-0 not transferring syringes of unused med-0 not storing syringes of propofol at room [/fig]
[fig] NOTES 1: W A Rutala, APIC Guidelines Committee, "APIC guideline for selection and use of disinfectants," American Journal uflnfection Control 24 (August 2. Centers for Disease Control and Prevention, "Postsurgical infections associated with an extrinsically contaminated intravenous anesthetic agent-California, Illinois, Maine, and Michigan, 1990," Morbidity and Mortalify Weekly Report 39 (' June 29, 3. M J Daily, J B Dickey, K H Packo, "Endogenous Candida endophthalmitis after intravenous anesthesia with propofol," Archives of Opht\mlmology 109 4. M E Villarino et al, "Postsurgical infectious associated with an extrinsically contaminated intravenous anesthetic agent," program and abstracts of the 31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, 29 Sept-2 Oct 1991. 5. B Veber et al, "Severe sepsis after contaminated Propofol," Anestkesiology 80 (March 1994) 712-713. 6. K Kidd-Ljunggren et al, "Nosocomial transmission of hepatitis B virus infection through multipledose vials," Journal of Hospital Znfection 43 (September 1999) 57-62. 7 . M J Kuehnert et al, "Staphylococcus aureiis bloodstream infections among patients undergoing electroconvulsive therapy traced to breaks in infection control and possible extrinsic contamination by Propofol," Anesthesia and Analgesia 85 (August 8. M Massari et al, "Transmission of hepatitis C virus in a gynecological surgery setting," Journal of Clinical Microbiology 39 (August 2001) 2860-2863. 9. Centers for Disease Control and Prevention, "Transmission of hepatitis B and C viruses in outpatient settings-New York, Oklahoma, and 1997) 420-425. Nebraska, 2000-2002," Morbidity and Mortality Weekly Report 52 (Sept 26,2003) 901-906. 10. J M Boyce, D Pittet, "Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC /SHEA / APIC/ISAD Hand Hygiene Taskforce," Morbidity and Mortality Weekly Report 51 (Oct 25, 2002) 11. C E Blogg, M A Ramsey, J D Jarvis, "Infection hazard from s ringes," British Journal of Anaesthesia 46 (April 19747260-262. 12. M R Lessard et al, "A microbiological study of the contamination of the syringes used in anaesthesia practice," Canadian Journal of Anaesthesia 35 (November 1988) 567-569. 13, C T Lutz et al, "Allergy testing of multiple patients should no longer be performed with a common syringe," The New England Journal of Medicine 310 (May 17,1984) 1335-1337. 14. J W Koepke, J C Selner, "Allergy testing of multiple patients with a common syringe," The New England Journal Medicine 311 (Nov 1,1984) 1188-1189. 15. D J Shulan et al, "Contamination of intradermal skin test syringes," Journal of Allergy and Clinical bnnzunology 76 (August 1985) 226-227. 16. J W Koepke et al, "Viral contamination of intradermal skin test syringes," Annals of Allergy 55 (December 1985) 776-778. 17. A Carbonne et al, "Patient to patient transmission of hepatitis C in surgery clinic through multidose vials," abstract presented at the 13th annual meeting of the Society for Healthcare Epidemiology of America, Arlington Va, 5-8 April 2003. 18. A Fleming, A C Ogilvie, "Syringe needles and mass inoculation technique," British Medical Journal 1 (March 17,1951) 543-546. 19. R R Hughes, "Post-penicillin jaundice," British Medical Journal2 (Nov 9, 1946) 685-688. 20. R Uren, C Commens, R Howman-Giles, "Intradermal injections: A potential health hazard?" Medical Journal of Australia 161 (August 994) 226. 21. H A Hein et al, "Recapping needles in anesthesia-Is it safe?" Anesthesiology 67 (September 1987) A161. 22. C A Trepanier et al, "Risk of cross-infection related to the multiple use of disposable syringes," Canadian Journal of Anaesthesia 37 (March 1990) 156-159. 23. J L Parlow, "Blood contamination of drug syringes used in anaesthesia," Canadian Journal of Anaesthesia 36 suppl (1989) S61-S62. 24. B Meier, "Reuse of needle at hospital infects 50 with hepatitis C," New York Times, Oct 10,2002. [/fig]
[table] 1: Written mformation regarding safety and testing methods, warranties, and a manual for maintenance and inspections should be obtained from the manufacturer for all anesthesia equipment. These manuals help in developing operational, safety, and maintenance guidelines. Recommendations vary by manufacturer and equipment model. Manuals should be maintained for each.2. Anesthesia equipment should be assigned an identification number. Identification numbers allow for documentation of inspections, safety checks, preventive maintenance, repairs, and tracking in the event of a patient or equipment problem.3.Before placing anesthesia equipment into service, the safety features of the equipment should be tested by qualified, trained personnel, according to manufacturers' written instructions. These tests should be specific to the type and model of equipment involved AORN JOURNAL 86 1 and include, but not be limited to, calibrations and alarms. Testing the equipment before initial use minimizes the risk of patient injury resulting from faulty equipment. [/table]
[table] 25: Association for the Advancement of Medical Instrumentation, "Safe handling and biological decontamination of reusable medical devices in health care facilities and in nonclinical settings; Anesthesiologists, http://www.asahq.org/Publications 55. B Abraham et al, "Malignant hyperthermia susceftibflity;,Anaesthetic implications and risk strati ication. Ouarterlu lournal of Medicine 90 56. "Medical FAQs," Mali ant Hyperthermia .org/index.cfmlfuseaction/Con ten t. Display/lagePK /MedicalAQs.cfm (accessed 24 Sept 2004). 57. "Reducing mercury use in healthcare: Promoting a healthier environment: A how-to manual." US Environmental Protection Aeencv. htb: Association of the United ! ? tates, http://www.mhaus //wwzu.epa.gov/gInpo/bnsdocs/merchealth~ (acGessid 24 Sevt 2004). 58. Centers for Disease Control and Prevention, "Guidelines for prevention of nosocomial pneumonia, 2003," Morbidity and Mortality Weekly Report 53 (March 26,2004) (RR03) 1-36. 59. G E Dryden, "Risk of contamination from the anesthesia circle absorber: An evaluation," Anesthesia and Analgesia 48 (November/December 60. J R Jenkins, W M Edgar, "Sterilization of anaesthetic equipment," Anaesthesia 19 (April 84. "Identification and listing of hazardous waste," in Electronic Code of Federal Regulations (e-CFR) 40 Protection of Environment, Part 261, http://zmmo .epa.gou/~nhoine/c~40.htm (accessed 25 Sept 2004). 85. "Recommended practices for standard and transmission-based precautions," in Standards, Recornmended Prncticcs, and Gii idelines (Denver: 86. "Hazard communication in the 21st century workplace," US Department of Labor, Occupational Safety and Health Administration, http://zoziw .os~ia.~ou/dsh./h~zco~~i~~in/nisdsr~port./~tni/ (accessed 25 Sept 2004). 87. "Bloodborne pathogens and needlestick prevention," Occupational Safety and Health Administration, Iittp://z~uzii.osha.~ou/S LTChlood-bovize~atho~etis/inde.u.1ztml (accessed 25 Sept 2004). 88. Joint Commission on Accreditation of Health-care Organizations, "Crosswalk of 2003 standards for hospitals to 2004 leadership standards for hos itals," in 2004 Comprehensive Accreditation Manual $r Hospitals: The Official Handbook (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 2003) LD.3.20. Originally published June 1977, AORN Journal, as A 0 R " s "Recommended practices for cleaning and processing anesthesia equipment." Revised March 1978; July 1982; March 1991. Published as proposed recommended practices September 1994. Revised; published November 1999, AORN Joiirnal. Reformatted July 2000. Revised November 2004; scheduled for pubIication in the AORN Journnl in 2005. New Biopsy Technique Reduces Need for Surgery esearchers have found a new, nonsurgical tech-R nique that can help physicians determine when breast cancer has spread to the lymph nodes, according to a Nov 29, 2004, news release from the University of Michigan Health System, Ann Arbor, Mich. The technique may spare some women an extra trip to the OR. [/table]