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Merry AF, Gargiulo DA, Bissett I, Cumin D, English K, Frampton C, Hamblin R, Hannam J, Moore M, Reid P, Roberts S, Taylor E, Mitchell SJ. The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial. Trials 2019; 20:342. [PMID: 31182142 PMCID: PMC6558820 DOI: 10.1186/s13063-019-3402-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 05/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Māori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces. Methods We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental “champions”. Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle. Discussion If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12618000407291. Registered on 21 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3402-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alan F Merry
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand. .,Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand.
| | - Derryn A Gargiulo
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Ian Bissett
- Department of Surgery, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.,Department of Surgery, Auckland City Hospital, Private Bag 92019, Auckland, 1142, New Zealand
| | - David Cumin
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Kerry English
- Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand
| | - Christopher Frampton
- Department of Psychological Medicine, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Richard Hamblin
- Health Quality & Safety Commission, PO Box 25496, Wellington, 6146, New Zealand
| | - Jacqueline Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Matthew Moore
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Sally Roberts
- LabPLUS, Auckland City Hospital, PO Box 110031, Auckland, 1070, New Zealand
| | - Elsa Taylor
- Starship Children's Health, Auckland District Health Board, PO Box 9389, Auckland, 1149, New Zealand
| | - Simon J Mitchell
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.,Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand
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Zorrilla-Vaca A, Arevalo JJ, Escandón-Vargas K, Soltanifar D, Mirski MA. Infectious Disease Risk Associated with Contaminated Propofol Anesthesia, 1989-2014(1). Emerg Infect Dis 2018; 22:981-92. [PMID: 27192163 PMCID: PMC4880094 DOI: 10.3201/eid2206.150376] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Transmission of illness to 144 patients, resulting in 10 deaths, has been linked to extrinsic contamination. Administration of propofol, the most frequently used intravenous anesthetic worldwide, has been associated with several iatrogenic infections despite its relative safety. Little is known regarding the global epidemiology of propofol-related outbreaks and the effectiveness of existing preventive strategies. In this overview of the evidence of propofol as a source of infection and appraisal of preventive strategies, we identified 58 studies through a literature search in PubMed, Embase, and Lilacs for propofol-related infections during 1989–2014. Twenty propofol-related outbreaks have been reported, affecting 144 patients and resulting in 10 deaths. Related factors included reuse of syringes for multiple patients and prolonged exposure to the environment when vials were left open. The addition of antimicrobial drugs to the emulsion has been instituted in some countries, but outbreaks have still occurred. There remains a lack of comprehensive information on the effectiveness of measures to prevent future outbreaks.
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Cole DC, Baslanti TO, Gravenstein NL, Gravenstein N. Leaving more than your fingerprint on the intravenous line: a prospective study on propofol anesthesia and implications of stopcock contamination. Anesth Analg 2015; 120:861-7. [PMID: 23749446 DOI: 10.1213/ane.0b013e318292ed45] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute care handling of IV stopcocks during anesthesia and surgery may result in contaminated IV tubing sets. In the context of widespread propofol use, a nutrient-rich hypnotic drug, we hypothesized that propofol anesthesia increases bacterial contamination of IV stopcocks and may compromise safety of IV tubing sets when continued to be used after propofol anesthesia. METHODS We conducted an in vitro trial by collecting IV tubing sets at the time of patient discharge from same-day ambulatory procedures performed with and without propofol anesthesia. These extension sets were then held at room temperature for 6, 24, or 48 hours. We cultured 50 samples at each interval for both cohorts. Quantitative cultures were done by aspirating the IV stopcock dead space and plating the aspirate on blood agar for colony count and speciation. RESULTS Positive bacterial counts were recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of nonpropofol stopcocks (28/150). At 6 hours, the average bacterial counts from stopcocks with visible residual propofol was 44 colony forming units (CFU)/mL, compared with 41 CFU/mL with no visible residual propofol and 37 CFU/mL in nonpropofol anesthesia stopcocks. There was a 100-fold increase in bacterial number in contaminated stopcock dead spaces at 48 hours after propofol anesthesia. This difference remained significant when comparing positive counts from stopcocks with no visible residual propofol and nonpropofol anesthesia (P = 0.034). CONCLUSIONS There is a covert incidence and degree of IV stopcock bacterial contamination during anesthesia which is aggravated by propofol anesthetic. Propofol anesthesia may increase risk for postoperative infection because of bacterial growth in IV stopcock dead spaces.
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Affiliation(s)
- Devon C Cole
- From the *Department of Anesthesiology, University of Florida College of Medicine; and †University of Florida College of Medicine, Gainesville, Florida
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Abstract
Dexmedetomidine is a highly selective, potent α₂-adrenoceptor agonist which was approved in 2011 by the European Medicines Agency for sedation of patients in intensive care units (ICU). Dexmedetomidine exhibits sedative as well as analgesic and anxiolytic effects. Recent studies suggest that dexmedetomidine may be an alternative to midazolam in long-term ICU sedation. This review summarizes the pharmacokinetics and pharmacodynamics of dexmedetomidine particularly in ICU patients and with special regard to covariate effects. Although dexmedetomidine is currently approved only for use in adults the pharmacokinetics and pharmacodynamics in children will also be addressed as there are numerous studies on this off-label use.
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Affiliation(s)
- H Ihmsen
- Anästhesiologische Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Deutschland.
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Massari M, Petrosillo N, Ippolito G, Solforosi L, Bonazzi L, Clementi M, Manzin A. Transmission of hepatitis C virus in a gynecological surgery setting. J Clin Microbiol 2001; 39:2860-3. [PMID: 11474004 PMCID: PMC88251 DOI: 10.1128/jcm.39.8.2860-2863.2001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A cluster of hepatitis C virus (HCV) infections among gynecological patients who underwent surgical intervention in the same setting is described. An epidemiological investigation was conducted to identify the cases, the likely source of infection, and the route of transmission. Four recent HCV infections were identified. Based on molecular fingerprinting analysis and epidemiological investigation, transmission between the putative source patient (an HCV-positive woman who was the first patient of the surgical session) and outbreak patients was highly suggestive. All patients, including the source patient, were infected with HCV type 1b. Molecular characterization of HCV clones by sequence analysis of both structural envelope regions (20 clones from the source patient and 58 from the outbreak patients) and the nonstructural NS5 region of the viral genome (12 clones from the source patient and 32 from the outbreak patients) showed close homology between the viral isolates from the source and those from the outbreak patients that was higher than that observed between the viral isolates from the source and those from four unrelated, HCV type 1b-infected patients from the same geographical area (in the latter case, 33 clones were sequenced for the envelope regions and 30 were sequenced for the NS5 region). The mean percent divergence between clones was 4.69 for the envelope and 3.71 for the NS5 region in the source patient and the outbreak patients compared with 6.76 (P = 0.001) and 5.22 (P = 0.01) in the source patient and control patients, respectively. Among the risk factors investigated, only that of having undergone surgery in the morning session of the same day reached statistical significance (P = 0.003). The investigation showed that the source patient and outbreak patients shared only the administration of propofol in multidose vials. The study documents the risk of nosocomial transmission of HCV and the importance of infection control procedures in the operating room and highlights the crucial role of molecular strategies, especially sequence-based phylogenetic analysis of cloned viral isolates, in the investigation of HCV outbreaks.
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Affiliation(s)
- M Massari
- Divisione Malattie Infettive Arcispedale Santa Maria Nuova Azienda Ospedaliera, Reggio Emilia, Italy
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