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CENTRAL STERILE SUPPLY

THE evolution of central sterile supply departments(c.s.s.D.s) has been rapid; some have grown from simplesyringe services, others have begun in the operating-theatre suite, while many have been carefully planned newdevelopments. The Central and Scottish Health ServicesCouncils’ joint committee on C.S.S.D.s (the Collingwoodcommittee) has just produced a useful and timely report.!Experience gathered from c.s.s.D.s all over Britain andfrom many other sources has been examined criticallyand synthesised into an account of the aims, methods,organisation, management, and possible future of thisimportant hospital department. To those who are aboutto set up a c.s.s.D. this report will be invaluable; and tothose already shouldering this responsibility its firmstatements will be an encouragement.The declared aim of the c.s.s.D. is to provide all

hospital departments with reliably sterilised articles (withthe possible exception of operating-theatre instruments,but including disposables) as economically as possibleunder conditions which are controlled. The report deals

firmly with methods of sterilisation: we hope that neveragain will this or any other committee be forced to statethat they were disturbed to hear that water-boilers werestill in use, despite repeated warnings. Attention is alsodrawn to guidance from the Ministry of Health aboutpurchase, planned maintenance, and testing of auto-claves.2 3 Economy in c.s.s.n.s depends notably on

sufficient working size in terms of beds served and onsome standardisation of the articles sterilised. The com-mittee accepts that both large and small c.s.s.D.s have aplace: the smallest should serve about 500 beds, but 2000beds is a more economical proposition; and much largerregional services may function without loss of the essentialfeedback control between user and c.s.s.D. Standardisationof packs requires cooperation between c.s.s.D. and bothnursing and medical staff. To this end, the reportadvocates a committee of management consisting of theconsultant charged with clinical responsibility for the

c.s.s.D., the department’s superintendent, medical, sur-gical, and nursing representatives, and the hospitalpharmacist. The hospital engineer and the financeofficer might be useful members too.The importance of the C.S.S.D. superintendent in a

department that impinges on all other departments is

clearly recognised in the report. He or she must haveadministrative ability, adequate technical knowledge ofthe engineering and biological aspects of the work, andmany other qualities that will promote close liaison withmedical and nursing staff. Such qualities need adequaterecognition and reward, and a review of salary scales islong overdue.

Flexibility and the continuing evolution of c.s.s.D.s arealso important. Increased use of disposables (at presentoften an expensive luxury) and commercial supply ofother items must be continually borne in mind. Thoughindustry does not at the moment offer a complete andcheaper alternative solution for the complex demandsmade on the c.s.s.D., further standardisation mayeventually produce great changes.

It has been suggested that operating-theatre instru-ments might be sterilised in a special theatre sterile

1. Central Sterile Supply Departments. Report prepared by Joint Com-mittee of the Central and Scottish Health Services Councils. Issuedwith H.M. (67) 13 by the Ministry of Health.

2. Ministry of Health Technical Memorandum no. 10.3. Ministry of Health Technical Memorandum no. 13.

supply unit (T.S.S.U.) or, in certain circumstances, withinthe C.S.S.D.4 Centralisation must involve some stan-

dardisation and duplication of expensive instruments, withpossible loss of flexibility in surgical development, quiteapart from increased cost. Additional staff in T.S.S.U. orc.s.s.D., although relieving theatre staff of work, mightnot necessarily lead to a reduction in the number ofthose employed in the theatre, so that running costs

would be higher than in theatres which sterilise theirown instruments in high-speed autoclaves. Many peoplealso believe that removal or division of this responsibilityfrom the surgical team has both operational and economicdisadvantages. The logistics of centralised sterilisationof theatre instruments is complicated: for instance, willindustry be able to provide, on a once-and-for-all basis,the large initial supply of instruments to prime the pipe-line if this development comes rapidly in many places atonce ? Those who have seen careful plans for a C.S.S.D.frustrated by failure of instrument delivery and per-formance may be wondering about this question. If,however, the preserve of the C.S.S.D. is taken over byindustry, the plant and staff could then be used for thecentral preparation of theatre instruments-if time showsthis to be the better system.

VASOPRESSOR DRUGS

TEN years ago the main indication for giving a sym-pathomimetic drug would have been hypotension. Thisview did not take into account the interaction betweenthe circulating-blood volume and the capacity of thecirculation; and it is now recognised that adequate tissueperfusion is even more important than the maintenance ofsome arbitrary blood-pressure level. Moreover, each

organ has its own circulatory arrangements: for example,the brain’s blood-flow is subject to local adjustmentswhich maintain cerebral oxygenation and carbon-dioxideelimination at as safe a level as possible irrespective ofthe arterial blood-pressure; and a similar processoperates in the myocardium.

Vasoconstrictors, it is sometimes said, should never begiven at all, and, admittedly, their use in hypovolaemichypotension, when the body’s vasoconstrictor mechanismshave failed, is illogical 5: they reduce tissue blood-flowand increase acidosis; they often cause shutdown in therenal circulation and increase the risk of severe renalischaemia, and they may overload a heart which is alreadydoing its best with an inadequate coronary circulation.But a hypotensive patient whose vasoconstrictor mechan-ism has failed but who has a normal blood-volume maybenefit from a vasopressor-for example, when blood-pressure has fallen very low during spinal or epiduralanaesthesia.6 Indeed, during such anaesthesia, there maybe a case for giving vasopressor drugs to tide patientsover the period of maximum hypotension, for it is nowknown that some sympathomimetic agents (e.g., methox-amine, phenylephrine, and noradrenaline) act directly onthe smooth muscle of the arterial wall and not solely onthat part of the body which is unaffected by sympatheticparalysis. Similarly a small dose of a vasopressor drugwould be appropriate for a patient with very low blood-pressure caused by a ganglion-blocking agent, if rapidblood-transfusion had failed to restore blood-pressure to4. Ministry of Health Building Note no. 26.5. Bloch, J. H., Dietzman, R. H.. Pierce, C. H., Lillehei, R. C. Br. J.

Anœsth. 1966, 38, 234.6. Vickers, M. D. ibid. p. 728.

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a level likely to maintain adequate cerebral oxygenation.The use of vasopressor drugs to maintain a threatenedcoronary circulation also seems reasonable, for it is

commonly held that the coronary blood-flow is deter-mined by the arterial pressure and the metabolic needsof the myocardium rather than by the general sympathetictone. But vasopressin and angiotensin 8 are coronaryvasoconstrictors and are dangerous under these circum-stances ; and a rise in blood-pressure increases the workof the heart and demands increased coronary blood-flow,so the balance between benefit and harm may be delicate.

Although vasoconstrictors (notably noradrenaline,9 9

mephentermine,10 and metaraminol 11) have been given forthe shock of coronary thrombosis, they find few advocatestoday. Apart from the increased metabolic demand onthe heart, anoxic areas of myocardium in these patientsare particularly prone to act as foci for ectopic beats,ventricular tachycardia, or even ventricular fibrillation;and vasopressors with &bgr;-adrenergic actions would cer-tainly exaggerate these risks. Even a drug such as

methoxamine, principally a pure x-stimulator, may, in anormal person, be a partial &bgr;-blocker,12 when it can

apparently induce ectopic beats.13Whether or not to give vasopressor drugs to maintain

renal blood-flow and urinary output is even more

debatable, but plainly a mere raising of the generalblood-pressure will not necessarily improve renal function.In this sort of situation the administration of largevolumes of fluid to increase the blood-volume finds itsmain application (the choice of fluid must be dictatedby the cause of the hypotension and the length of timefor which it has persisted). In barbiturate poisoning theadministration of fluid to make the blood-volume fitthe circulatory capacity 14 is usually sufficient to raisethe blood-pressure, but when a general arterial pressurebelow 70 mm. Hg is not restored by generous fluidinfusions a vasopressor drug might be considered,particularly when urinary output was unsatisfactory. Adrug which may increase renal blood-flow,15 such as

methylamphetamine, would be preferable; but since itis mainly a &bgr;-stimulator of the myocardium, it maybe dangerous to a hypothermic patient 16 who maybe more liable to ventricular fibrillation 17 after ad-ministration of a sympathomimetic drug. Metaraminolhas also been recommended in such cases,18 thoughexperimental work suggests that it fails to increase,19 andmay indeed reduce 20 renal blood-flow.Most of the indications for giving vasopressor drugs

intravenously are acute severe hypotensive states in whichabsorption of drugs given by any other route is almostcompletely at a standstill. Tachyphylaxis often causestrouble after repeated intravenous doses, especially with7. Foster, R. W. Br. J. Anœsth. 1966, 38, 690.8. Fowler, N. D., Holmes, J. C. Circulation Res. 1964, 14, 191.9. Binder, M. J., Ryan, J. A., Marus, S., Mugler, F., Strange, D.,

Agress, C. M. Am. J. Med. 1955, 18, 622.10. Mills, L. C., Voudoukis, I. J., Moyer, J. H., Heider, C. Archs intern.

Med. 1960, 106, 816.11. Besterman, E. M. M. Br. med. J. 1959, i, 1081.12. Karim, S. M. M. Br. J. Pharmac. Chemother. 1965, 24, 365.13. Maling, H. M., Moran, N. C. Circulation Res. 1957, 5, 409.14. Shubin, H., Weil, M. H. Am. J. Med. 1965, 138, 853. See Lancet,

Jan. 28, 1967, p. 200.15. Churchill-Davidson, H. C., Wylie, W. D., Miles, B. E., de Wardener,

H. E. Lancet, 1951, ii, 803.16. Lee, H. A., Ames, A. C. Br. med. J. 1965, i, 1217.17. Linton, A. C., Ledingham, I. M. Lancet, 1966, i, 24.18. Matthews, H., Lawson, A. A. H. Q. Jl Med. 1966, 35, 539.19. Livesay, W. R., Moyer, J. H., Chapman, D. W. Am. Heart J. 1954,

47, 745.20. Aviado, D. M., Wnuck, A. L., de Beer, E. J. J. Pharmac. exp. Ther.

1958, 122, 406.

indirectly acting agents, and the results of intravenousdrip (particularly with noradrenaline, when maintenanceof blood-pressure soon comes to depend entirely on thedrug) have evoked the title " embalming fluid ". Vaso-constrictors are for tiding the patient over an emergency-not for the continuing treatment of peripheral vascularfailure.

CANCRUM ORIS

IT is a sad commentary on the maldistribution of thenecessities of life that cancrum oris, virtually unknown fortwo generations in Britain, Europe, and North America,is still rife in many parts of Africa and Asia. Tempest,! forexample, was able to study in detail 250 cases in onehospital in Nigeria during 1962-65: this must reflect avery high incidence, since the immediate mortality inuntreated cases is great. Cancrum oris is a disease of

young children, most of whom are under five years of age,and it is very rare in adults. The exact cause is still un-

certain, but three main factors are known: malnutrition;an acute antecedent illness; and bacterial invasion of thetissues of the cheek, lips, and jaws.

Malnutrition is almost invariable; in Tempest’s seriesonly 18 of the 250 patients had no evidence of under-nourishment, and in half of them malnutrition was

severe. Reynaud et al.,2 reporting 47 cases from Senegal,noted reversal of the albumin/globulin ratio, anaemia, andabnormal serum-electrolytes in many. In Western Nigeriathe disease is significantly commoner during the dryhungry months of January to May. At best, the childreneat a diet which is mainly carbohydrate. During the firsttwo years of life, when the children are breast-fed, cancrumoris is negligible, but weaning removes their only source offirst-class protein, and the disease mounts to its highestpeak in the third year of life.Cancrum oris can arise without a predisposing illness,

but this is uncommon. Measles, a severely debilitatingdisease in the West African, was by far the commonestprecipitating cause in Tempest’s series, but many otherdisorders can equally lower the child’s resistance: scarletfever, typhoid, whooping-cough, typhus, syphilis, tuber-culosis, smallpox, kala-azar, and leukaemia have all beenblamed.3-5The organisms which have been found most often in the

early stages of noma are those of Vincent’s disease,Borrelia vincenti and Fusiformis fusiformis,6 but Bac-teroides melaninogenicus, an actively proteolytic organismindigenous in the mouth, has also been cultured. Theorganisms of Vincent’s disease are probably causative andnot merely contaminants, but this is by no means proven.Tempest emphasises the sudden onset of the gangrenousprocess and the rapidity with which it becomes definedand established, suggesting a vascular rather than a

bacterial determinant. On the other hand, Vincent’s

organisms are known to be prevalent in Nigerian chil-dren,’ 9 10, and periodontal disease with ulceration of the1. Tempest, M. N. Br. J. Surg. 1966, 53, 949.2. Reynaud, J., Diop, L., Sanokho, A., Nouhaiy, A. Bull. Soc. méd. Afr.

noire Lang. fr. 1965, 10, 434.3. Stones, H. H., Farmer, E. J., Lawton, F. E. Oral and Dental Diseases;

p. 638. Edinburgh, 1954.4. Fu-Tang-Chu, Chuan-Fan. Chin. med. J. 1936, 50, 303.5. Fan, P. L., Scott, A. V. ibid. 1934, 48, 1046.6. Eckstein, A. Am. J. dis. Child. 1940, 59, 219.7. Emslie, R. D. Dent. Practnr dent. Rec. 1963, 13, 481.8. MacDonald, J. B. Ann. R. Coll. Surg. 1962, 31, 361.9. Nicol, D. S. H. Report on Second Inter-African Conference on Nutri-

tion; p. 74. H.M. Stationery Office, 1954.10. Balfe, J. Medical Report (Dental Section), St. Luke’s Hospital, Anua,

Eastern Region, Nigeria, 1962-63. 1964.