Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets

Reusable tourniquets for blood sampling as a source of multi-resistant organisms- a systematic review

Introduction

The use of reusable tourniquets is widespread around the world, and reports suggest they may be overused. Several studies have shown that reusable tourniquets can affect the spread of pathogens between patients. Based on available studies, this review aims to analyse the indirect transmission of antimicrobial-resistant pathogens present on blood collection tourniquets, which may spread infectious diseases between patients in daily clinical practice.

Methods

A systematic review of the literature was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol guidelines. The contents of PubMed, EBSCO (electronic databases), and Scopus were screened. Keywords used in the search included: "tourniquet," "cross infection," "nosocomial infection," "staphylococcus aureus," "MRO," "pathogen," "infectious disease," "anti-microbial," or a combination of these using AND or OR operators. Finally, 13 publications were included. Data were analysed both descriptively and quantitatively by calculating a balanced average for specific synthesized data.

Results

The proportional observation based on the number sampled median was 77. The genus MRSA was the type of bacteria most commonly found: on 12% of all tested tourniquets. The amount of MRSA found on tourniquets was mean ± SD 14.6 ± 45.89. A review of studies also revealed the presence of coagulase-negative staphylococci, grew Bacillus, and Staphylococcus aureus.

Conclusion

Patient safety may be at risk due to elevated contamination rates of reusable tourniquets. The microorganisms responsible for this contamination include a variety of species, the most common being the genus Staphylococcus. For this reason, we recommend the use of disposable tourniquets.

Features of modern clinical research blood analysis in the assessment of erythropoiesis in deep-premature newborns

One of the urgent problems of nursing premature babies is the timely prediction, diagnosis and treatment of anemia, the frequency of which reaches 90%. Of particular importance is the study of reticulocytic blood parameters in deep-premature newborns, since the correct assessment of hemograms is crucial in the management of this category of children. To determine the characteristics of red blood cells and reticulocyte parameters of venous blood hemogram in premature newborns 24-32 weeks of gestation in the dynamics of the neonatal period. 111 newborns were examined at 24-32 weeks of gestation in the early neonatal period (on day 3-7) and at the age of 1 month of life. Along with standard diagnostic procedures, in accordance with current clinical recommendations and standards, 28 parameters of erythrocyte and reticulocyte hemogram parameters were determined for children. Venous blood was examined using an automatic hematological analyzer ADVIA 2120i, Siemens, USA. In deep-premature newborns in the early neonatal period, there is a high activity of erythropoiesis, respectively, the severity of respiratory and metabolic disorders with rejuvenation of reticulocytic subpopulations. Negative values of Delta hemoglobin were found against the background of a decrease in the average amount of hemoglobin in reticulocytes in children 24-27 weeks of gestation, which characterizes the lowest values of iron availability for erythropoiesis in this category of newborns. It is shown that a decrease in reticulocyte counts and normochromia in all examined newborns by the age of one month are accompanied by high levels of immature reticulocyte fraction, while a third of children still have limited iron availability for erythropoiesis.

Comparison of local pain and tissue reaction between conventional pneumatic tourniquet and disposable silicone ring tourniquet during Total Knee Arthroplasty

BACKGROUND

To study the comparison of conventional pneumatic and disposable silicone ring tourniquet in Total Knee Arthroplasty.

MATERIAL AND METHODS

This is a prospective randomized control trial. We used conventional pneumatic tourniquet on one side of leg and disposable silicone ring tourniquet on the other side in consecutive 50 simultaneous bilateral TKR patients. Patients having peripheral vascular disease of the lower limb were excluded from the study. The patient demographics & characteristics are identical being the same patient with two different legs. We started the study with null hypothesis. An independent observer assessed the local tourniquet site pain (VAS score 1-10) and local tourniquet site skin reaction at 24 h and 48 h after the TKA. P value < 0.05 was considered significant.

RESULTS

There were no local skin complication with disposable tourniquet (0%). 8 out of 50 patients in whom the conventional tourniquet was applied showed local bruising, and two patients had blister formation making the local skin site complication rate 20% (statistically significant, p value0.0196, chi-squared test). The VAS score at 24 h was 4.3 ± 1.5 for disposable tourniquet group as against 5.6 ± 2.1 for conventional tourniquet group (statistically significant, p value = 0.0152, t statistic test for comparison of means). The VAS score at 48 h was 2.1 ± 1.5 and 3.3 ± 1.2 for disposable tourniquet group and conventional tourniquet group respectively (statistically significant p value = 0.003, student's t-test).

CONCLUSION

Use of disposable tourniquet has better outcome than the conventional tourniquet with minimal or no local complications. The advantages of the disposable tourniquet are: 1 less local pain, 2. no local skin problems, 3. accurate tourniquet pressure at the application site, 4.0% local contamination. Hence, we recommend use of the disposable tourniquet during the Total Knee Arthroplasty.

Cellular reactions in capillary and venous blood in northerners to a short-term period in a climatic chamber

PURPOSE

The purpose is a comparative study of the cellular reactions in capillary and venous blood in northerners under general hypothermia in a climatic chamber during different photoperiods. The authors examined 108 relatively healthy people (80 women and 28 men aged 21- to 50-years old).

METHODS

The study included determining the hemogram, neutrograms, monocytograms, lymphocytograms, and phagocytic activity neutrophil granulocytes, enzyme immunoassay, flow cytometry, indirect immunoperoxidase, bioluminescence, systolic and diastolic blood pressure, and body temperature in the ear canal and on the skin of the rear left side of the right hand of volunteers before the effect of general cooling in the room at an air temperature and after 5 minutes of exposure to cold air.

RESULTS

It was established that total neutrophil count in venous blood was lower by 8.07% ± 0.41%, monocyte count by 51.32% ± 1.03%, and basophil count by 50.21% ± 1.24% than in capillary blood, but the lymphocyte count was higher by 25.23% ± 0.41% due to smaller forms that are known to be recirculating. After a 5-minute period in a climatic chamber at -25°C in 27.53% of individuals during a polar night and in 16.51% volunteers during a polar day had elevated levels of neutrophils in the venous blood due to the increase in the levels of tumor necrosis factor-α in blood and decrease in noradrenaline, adrenaline, and irisin.

CONCLUSION

The systematic effect of general cooling, especially during the polar night, leads to a reduction in reserve adaptability with the formation of neutropenia, deficiency of phagocytic defense, and functional insufficiency of T-lymphocytes.

Reduced bacterial contamination rates detected on silicone tourniquets compared to conventional tourniquets in clinical routine

Background

Tourniquets used for peripheral venous vascular access such as blood sampling are regularly contaminated in clinical routine. Although most contaminations are harmless, some pose a possible risk for infection. To improve peripheral venous access infection control standards, tourniquets with no or as few as possible bacterial burden should be used. Conventional tourniquets can be reprocessed by autoclaving or by incubating in disinfectants. However, both methods are time-consuming and not suitable for immediate use between patients. In contrast, silicone tourniquets can be quickly and simply reprocessed with wipe disinfection. In vitro studies from the manufacturer have demonstrated reduced bacterial contamination on silicone tourniquets after usage compared to conventional tourniquets. This study aims to independently investigate the bacterial load on both types of tourniquets in clinical routine.

Methods

In a first trial, new conventional and silicon tourniquets were used for blood sampling in one facility with strict guidelines for reprocessing (after each patient or not at all) for 1 day and tested for bacterial contamination. In a second trial, new tourniquets were used in four facilities while the mode and frequency of tourniquets’ reprocessing was defined individually by each facility. The number of treated patients, mode and frequency of reprocessing and other relevant handling measures were documented.

Results

Under controlled conditions, with strictly specified reprocessing, slightly fewer bacteria were found on silicone than on conventional tourniquets. In routine clinical practice the reprocessing frequency was not higher for silicone tourniquets in practice. Yet, in all four facilities, there were significantly fewer bacteria found on silicone than on conventional tourniquets.

Conclusion

Although tourniquets are classified as non-critical medical devices, results show – together with benefits of faster and easier reprocessing – that silicone tourniquets can improve infection control of venous vascular access.

Microbial Colonization of Pneumatic Tourniquets in the Orthopedic Operating Room

Background The rate of surgical site infections following orthopedic procedures is approximately 2% globally. Potential sources of contamination in the operating room include pneumatic tourniquets, blood pressure cuffs, and stethoscopes, among others. Our study aims to investigate microbial colonization on reusable pneumatic tourniquets stored and used in the orthopedic department of our institution and evaluate the efficacy of the cleaning protocols employed. Methods Over a course of two weeks, 26 samples were obtained. A total of 14 pneumatic tourniquets were sampled preoperatively on Monday morning following the weekly cleaning protocol of soaking the tourniquets in sodium hypochlorite for 30 minutes while 12 tourniquets were cultured immediately following the postoperative cleaning protocol of wiping the tourniquet clean with a cloth soaked in sodium hypochlorite. Samples were cultured on MacConkey and sheep blood agar and incubated at 37-degrees centigrade for a total of 48 hours. Organisms were identified and colony count was documented. The analysis was performed using the Fisher Exact test on SPSS v23 (IBM Corp., Armonk, NY, US). Results All 14 samples obtained after being soaked in sodium hypochlorite for 30 minutes cultured negative. However, four out of 12 (33%) samples obtained after simply wiping the pneumatic tourniquet with a cloth soaked in sodium hypochlorite cultured coagulase-negative Staphylococci. The difference between the two was significant (p=0.002). Conclusion Postoperative tourniquets, wiped with a cloth soaked in sodium hypochlorite and ready to be used on the next patient, were found to be contaminated with coagulase-negative Staphylococcus. This species is notorious for causing surgical site infections following implant-related surgeries potentially through direct inoculation and cross-infections intraoperatively and in storage. Efforts to identify the relationship with postoperative surgical site infections need to be made to suggest more aggressive cleaning protocols.

Improving outcomes of short peripheral vascular access in oncology and chemotherapy administration

A short peripheral intravenous catheter or cannula (PIVC) is frequently used to deliver chemotherapy in oncology practice. Although safe and easy to insert, PIVCs do fail, leading to personal discomfort for patients and adding substantially to treatment costs. As the procedure of peripheral catheterization is invasive, there is a need for greater consistency in the choice, insertion and management of short PIVCs, particularly in the oncology setting where there is a growing trend for patients to receive many different courses of IV treatment over a number of years, sometimes with only short remissions. This article reviews best practice with respect to PIVCs in cancer patients and considers the necessity for bundling these actions. Two care bundles, addressing both insertion and ongoing care and maintenance, are proposed. These have the potential to improve outcomes with the use of short PIVCs for vascular access in oncology practice.

The Sterile Elastic Exsanguination Tourniquet vs. the Pneumatic Tourniquet for Total Knee Arthroplasty

We compared the sterile elastic exsanguination tourniquet and the pneumatic tourniquet for total knee arthroplasty. 145 patients were operated on using a pneumatic tourniquet and 166 with the sterile elastic exsanguination tourniquet. Patients with the sterile elastic exsanguination tourniquet had a smaller decrease in hemoglobin on post-operative days one (P<0.028) and three (P<0.045). The amount of blood collected from drains at 24h was significantly lower in the sterile elastic exsanguination group. A trend towards a higher rate of wound complications within 3months following the operation was found in the pneumatic tourniquet group. The sterile elastic exsanguination tourniquet works at least as good as the pneumatic one.

Microbial colonisation of orthopaedic tourniquets: a potential risk for surgical site infection

Pneumatic tourniquets have been used in orthopaedic surgery to get avascular fields. Sixteen such tourniquets were analysed for microbial colonisation. Samples were taken from two inner and two outer areas of each tourniquet and cultured on sheep blood agar. Eight of these were wiped with Savlon and the rest with Sterillium solution. Post-treatment samples from the same sites were again cultured. After incubation, colonies from each site were identified and counted. It was observed that the tourniquets were colonised with coagulase-negative staphylococci, Staphylococcus aureus, Bacillus, diphtheroids, Pseudomonas, Acinetobacter, enterococci, enterobacteria, and Candida. On treating with Savlon and Sterillium, there was 92.18% and 95.70% reduction in the colony count, respectively.

The safe insertion of peripheral intravenous catheters: a mixed methods descriptive study of the availability of the equipment needed

BACKGROUND

Intravenous cannulation is undertaken in a high proportion of hospitalised patients. Much international attention has been given to the use of care bundles to reduce the incidence of infection in these patients. However, less attention has been given to the systems required to ensure availability of the equipment needed to support these care bundles. Our objectives were to assess how reliably the equipment recommended for a peripheral intravenous care bundle was available for use, and to explore factors which contributed to its non-availability.

METHODS

We studied 350 peripheral cannula insertions in three NHS hospital organisations across the UK. Staff inserting cannulae were asked to report details of all equipment problems. Key staff were then interviewed to identify the causes of problems with equipment availability, using semi-structured qualitative interviews and a standard coding frame.

RESULTS

47 equipment problems were recorded during 46 of 350 cannulations, corresponding to a reliability of 87%, or 94% if problems with sharps disposal were excluded. Overall reliability was similar in all three organisations, but the types of problem varied. Interviews revealed a variety of causes including issues associated with purchasing policies, storage facilities, and lack of teamwork and communication in relation to reordering. The many human factors related to the supply chain were highlighted. Often staff had adopted work-arounds to deal with these problems.

CONCLUSIONS

Overall, 87% of cannulations had the correct and functional equipment available. Different problems were identified in different organisations, suggesting that each had resolved some issues. Supply chain management principles may be useful to support best practice in care bundle delivery.

The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery

INTRODUCTION

Surgical tourniquets are commonplace in lower limb surgery. Several studies have shown that tourniquets can be a potential source of microbial contamination but have not compared the use of sterile versus non-sterile tourniquets in the same procedures.

METHODS

Patients undergoing elective orthopaedic lower limb surgery were randomised prospectively to use of non-sterile pneumatic tourniquet or sterile elastic exsanguination tourniquet (S-MART™, OHK Medical Devices, haifa, Israel). Samples were taken from the ties of the non-sterile tourniquet prior to surgery and from the sterile tourniquets at the end of the operation in a sterile fashion. These were then sealed in universal containers and immediately analysed by the microbiology department on agar plates, cultured and incubated.

RESULTS

Thirty-four non-sterile tourniquets were sampled prior to surgical application, twenty-three of which were contaminated with several different organisms including coagulase-negative Staphylococcus spp, Staphylococcus aureus, Sphingomonas paucimobilis, Bacillus spp, and coliforms. Thirty-six sterile tourniquets were used, with no associated contamination.

CONCLUSIONS

There was significant contamination of 68% of orthopaedic surgical tourniquets. These are used regularly in procedures involving the placement of prosthesis and metalwork, and can act as a potential source of infection. We recommend the use of sterile single-use disposable tourniquets where possible. The availability of an alternative should now set the new standard of care and we recommend adopting this as a current NICE guideline for control of surgical site infection.

Reusable venesection tourniquets: a potential source of hospital transmission of multiresistant organisms

OBJECTIVE

To determine the prevalence of multiresistant organism (MRO) colonisation of reusable venesection tourniquets.

DESIGN AND SETTING

A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs - methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β-lactamase-producing Enterobacteriaceae - using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010.

MAIN OUTCOME MEASURE

Prevalence of MRO colonisation of tourniquets.

RESULTS

The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19; both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets.

CONCLUSION

Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.

Horizontally-acquired HIV infection in Kenyan and Swazi children

Despite many reports of HIV-infected African children who have HIV-uninfected mothers, little is known about the extent and modes of horizontal HIV transmission in African children. We estimated the extent of horizontal HIV transmission in Swazi children by comparing child and mother HIV statuses in the 2006–2007 Swaziland Demographic and Health Survey (DHS). To identify correlates of horizontal HIV transmission, we conducted a case-control study of Kenyan children with horizontally acquired HIV infections and their uninfected siblings. Of 50 HIV-positive Swazi children in the DHS, 11 (weighted percent = 20, 95% confidence interval 11–33%) had HIV-negative mothers. These 11 children represented 0.6% of all Swazi children aged 2–12 who lived with their mothers. In the Kenyan study, children with horizontally acquired HIV infections had more kinds of blood exposures than their uninfected siblings. In particular, punctures related to health care for suspected malaria (phlebotomy, injection and infusion), injections while hospitalized and dental surgery (especially by informal providers) were more common in infected children. Horizontal HIV transmission appears to be common in some sub-Saharan African countries, and blood exposures seem to be the most likely routes of transmission. Rigorous surveillance and investigation of horizontally acquired HIV infection in children are urgently needed, along with universal public education about risks of specific blood exposures and ways to avoid them.

A study of microbial colonisation of orthopaedic tourniquets

INTRODUCTION

Tourniquets are employed widely in orthopaedic surgery. The use of the same tourniquet on a repetitive basis without a standard protocol for cleaning may be a source of cross-infection. This study examines the contamination of the tourniquets in our institution.

MATERIALS AND METHODS

Agar plates were used to take samples from 20 tourniquets employed in orthopaedic procedures. Four sites on each tourniquet were cultured and incubated at 37 degrees C for 48 h.

RESULTS

All sampled tourniquets were contaminated with colony counts varying from 9 to > 385. Coagulase-negative Staphylococcus spp. were the most commonly grown organisms from the tourniquets (96%). Some tourniquets had growths of important pathogens including methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas spp., and S. aureus. On cleaning five tourniquets with Clinell (detergent and disinfectant) wipes (GAMA Healthcare Ltd, London, UK), there was a 99.2% reduction in contamination of the tourniquets 5 min after cleaning.

CONCLUSIONS

In addition to the manufacturers' guidelines, we recommend the cleaning of tourniquets with a disinfectant wipe before every case.

Pneumatic tourniquet use in the perioperative environment

Pneumatic tourniquets are routinely used in operating theatres worldwide. Generally, tourniquets are viewed as a relatively safe instrument with minimal complications. Nevertheless, Klenerman (2003) and Golder et al (2000) both suggest that caution should be exercised in tourniquet use. Furthermore Phillips (2004, p532) claims that, 'a tourniquet is dangerous to apply, to leave on and to remove'. This article will inform perioperative practitioners of the current research pertaining to the routine procedure of using pneumatic tourniquets to achieve a bloodless surgical field.

Pre-sterilisation cleaning of re-usable instruments in general dental practice

OBJECTIVE

This study examined the policies, procedures, environment and equipment used for the cleaning of dental instruments in general dental practice.

MATERIALS AND METHODS

A total of 179 surgeries were surveyed. This was an observational based study in which the cleaning processes were viewed directly by a trained surveyor. Information relating to surgery policies and equipment was also collected by interview and viewing of records. Data were recorded onto a standardised data collection form prepared for automated reading.

RESULTS

The BDA advice sheet A12 was available in 79% of surgeries visited. The most common method for cleaning dental instruments was manual washing, with or without the use of an ultrasonic bath. Automated washer disinfectors were not used by any surgery visited. The manual wash process was poorly controlled, with 41% of practices using no cleaning agent other than water. Only 2% of surgeries used a detergent formulated for manual washing of instruments. When using ultrasonic baths, the interval that elapsed between changes of the ultrasonic bath cleaning solution ranged from two to 504 hours (median nine hours). Fifty-eight percent of surgeries claimed to have a dedicated area for instrument cleaning, of which 80% were within the patient treatment area. However, in 69% of surgeries the clean and dirty areas were not clearly defined. Virtually all cleaning of dental instruments was undertaken by dental nurses. Training for this was provided mainly by demonstration and observed practice of a colleague. There was little documentation associated with training. Whilst most staff wore gloves when undertaking manual cleaning, 51% of staff did not use eye protection, 57% did not use a mask and 7% used waterproof overalls.

CONCLUSIONS

In many dental practices, the cleaning of re-usable dental instruments is undertaken using poorly controlled processes and procedures, which increase the risk of cross infection. Clear and unambiguous advice must be provided to the dental team, especially dental nurses, on appropriate equipment, chemicals and environment for cleaning dental instruments. This should be facilitated by appropriate training programmes and the implementation of quality assurance procedures at each stage of the cleaning process.

Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets

BACKGROUND

Hospital-acquired infection often occurs because of lapses in accepted standards of practice on the part of health care personnel. The aim of this study is to attract attention on poor hospital infection control practice in venepuncture and use of tourniquets and emphasize the importance of hand hygiene.

METHODS

Overall compliance with hygiene during usage of tourniquets and routine patient care before and after implementation of a hospital infection control measures was evaluated.

RESULTS

According to the questionnaire, only 26.9% of respondents always washed their hands both before and after venepuncture. In the second step of the study, based on direct observation, hands were washed both before and after venepuncture on only 41 (45.1%) occasions. Failure to remove gloves after patient contact was observed on 23.1% occasions.

CONCLUSION

Our survey reveals poor infection control practice in hand hygiene, glove utilization, and usage of tourniquets and the implementation of infection control measures produced a moderate improvement in compliance with them.

Reducing the potential for phlebotomy tourniquets to act as a reservoir for meticillin-resistant Staphylococcus aureus

The contamination rate of phlebotomy tourniquets with meticillin-resistant Staphylococcus aureus (MRSA) was assessed, and it was determined whether this could be reduced by changes in practice or by the use of a physical barrier. Initially, the tourniquets of both preregistration house officers and phlebotomists were investigated, but as phlebotomists reported significantly more venepunctures daily, the trial continued solely with phlebotomists. Each day, the phlebotomists were supplied with a fresh sterile tourniquet, and after use, the tourniquets were swabbed and cultured. The rate of contamination with MRSA was 32 of 131 (25%) tourniquets. An audit of hand hygiene practice was undertaken and revealed that phlebotomists were performing hand decontamination inadequately between patients and wore wristwatches while working. Education comprising standard infection control methods to encourage good practice was given. After this, a polythene strip was used as a barrier by half of the phlebotomists during all venepunctures. Tourniquets were cultured and replaced daily as before. During this stage of the trial, the rates of contamination were 1 of 46 tourniquets (using a polythene strip) and 1 of 42 tourniquets (without using a polythene strip). In conclusion, phlebotomy tourniquets may be potential vectors for transferring bacteria, including MRSA. Contamination rates, and hence potential risk, can be reduced if hand decontamination is performed. This suggests that contamination of tourniquets is via phlebotomists' hands, not directly from patients' skin. Hand hygiene should be regarded as the most important method by which the spread of organisms can be reduced.

Risk of hepatitis C after immunoadsorption

An episode of acute hepatitis in a patient with hemophilia during immunoadsorption therapy initially was misinterpreted as a reactivated hepatitis C virus (HCV) infection, but ultimately was shown to be an exogenous reinfection during cohort treatment with another HCV-positive patient. This incident illustrates that policies for the prevention of nosocomial transmission of blood-borne pathogens, especially in cohort treatment units, may need to be reassessed.

Bacterial colonisation of Doppler probes on vascular surgical wards

AIM

hospital acquired infections cost the NHS 1 pound sterling billion each year and medical equipment may act both as source and vector of nosocomial infection. This study examined bacterial contamination of Doppler ultrasound probes (USP) in routine use on vascular surgical wards in six hospitals and the knowledge of staff about the potential for cross infection from contaminated probes.

METHODS

probe head impressions and swab cultures of probe holders were plated on mannitol salt agar before and after cleaning with a paper towel. Putative S. aureus isolates were identified to species level and susceptibility to selected antimicrobials tested. Concurrently, junior medical staff were surveyed about probe cleaning protocols.

RESULTS

methicillin susceptible S. aureus was isolated from 2/21 (10%) with near confluent bacterial growth from six others (28%). The latter may have obscured low numbers of S. aureus. Further since swabs were plated without prior enrichment culture, it is likely that contamination with S. aureus might have been underestimated. No positive cultures were obtained after wiping the USP with a paper towel. 22/23 (95%) junior doctors failed to clean the USP prior to use.

CONCLUSION

USP contamination with pathogenic bacteria occurs under "in-use" conditions and junior medical staff are unaware of simple measures to prevent this. Strict guidelines for USP cleaning between patient use should, therefore, be adopted particularly when monitoring postoperative graft patency.

Poor hospital infection control practice in venepuncture and use of tourniquets

Previous studies have indicated that tourniquets may act as reservoirs of pathogenic organisms and could therefore pose a risk to patients through cross-infection. In this study, 200 tourniquets were sampled from health professionals working in a large teaching hospital. A parallel survey of control of infection was also undertaken. Staphylococcus aureus was isolated from 10 (5%) of the tourniquets sampled. Methicillin-resistant S. aureus was not isolated. Seventy-five (37.5%) of the tourniquets sampled had visible blood stains; house officers (72.7%) and laboratory phlebotomists (69.2%) had the highest proportion of blood-stained tourniquets. Tourniquets were owned on average for 1.86 years, with most respondents only obtaining a new tourniquet when the old tourniquet was lost. Three percent of respondents used a separate tourniquet for patients with known infective risk factors, e.g. HIV, MRSA. Twenty-seven percent of respondents did not wear gloves for venepuncture or did so only occasionally. Only 42% washed their hands both before and after venepuncture. Our survey reveals poor infection control practice, but a relatively low frequency of S. aureus contamination of tourniquets.

The arterial tourniquet: pathophysiological consequences and anaesthetic implications

The arterial tourniquet is widely used in upper and lower extremity surgery and in intravenous regional anaesthesia. The local and systemic physiological effects and the anaesthetic implications are reviewed. Localised complications result from either tissue compression beneath the cuff or tissue ischaemia distal to the tourniquet. Systemic effects are related to the inflation or deflation of the tourniquet. Safe working guidelines for the application of an arterial tourniquet have not been clearly defined.