Association of Anaesthetists of Great Britain and Ireland. Infection control in anaesthesia

Perioperative concerns in a patient with suspected Creutzfeldt - Jakob disease: A case report and review of literature

A case of Creutzfeldt-Jakob Disease (CJD), a rare prion disease, posted for surgery is a clinically challenging scenario for an anesthesiologist. In addition to weighing in the consequences of using general versus neuraxial anesthesia for a patient of such a progressive neurodegenerative disorder, the anesthesiologist must also meticulously plan and institute a robust infection control protocol, keeping in mind that prion diseases are transmissible and highly resistant to the standard sterilization process. We hereby report the successful anesthetic management of a 57-year-old patient with suspected CJD presented with intertrochanteric fracture femur for closed reduction and internal fixation and also review the existing literature regarding the anesthetic management of a definite or suspected case of CJD.

Observance of preventive standards against COVID-19 transmission in operating rooms: A cross-sectional study

BACKGROUND

Due to the highly contagious innate of the novel coronavirus, the surgical team is exposed to the disease during surgical care of patient with confirmed covid-19. Therefore, the necessary measures should be taken to protect surgical caregivers. This study was conducted to determine the status of compliance with the preventive standards against covid-19 transmission in the operating room.

METHODS

This cross-sectional descriptive study was conducted on 183 surgical team members working in hospitals affiliated to Tabriz university of medical sciences in 2020. Participants were selected by stratified random sampling. The required data were collected by a researcher-made questionnaire according to the standard protocols of SAGES, EAES and AORN. In the first part of this questionnaire, the level of compliance with the standards of using personal protective equipment (PPE) was evaluated and in the second part, the level of compliance with the preventive strategies in the operating room was evaluated in three phases of Pre, Intra and Post-operative. The data was analyzed using SPSS16.

RESULTS

preventive standards observance against COVID-19 was in moderate (55.3 ± 10.5) level and The level of compliance with the standards of using PPE by the surgical team was favorable (61.8 ± 8.1). There was a statistically significant relationship between the level of compliance with the standards of using PPE and the type of specialty (P = 0.004).

CONCLUSION

According to the results, the level of compliance with the principles of standards in applying protective measures against covid-19 was not favorable, so the operating room personnel is exposed to COVID-19 and the necessary measures and improvements should be considered in compliance with standards in operating room.

Retrospective Analysis of COVID-19 Conversion Rate Among Anesthesiologists in Acute Care Centers

Brief description of the primary research objective

Among healthcare workers, anesthesiologists are regarded as frequently exposed frontline providers in the fight against COVID-19 due to their proximity to patient airways and involvement in aerosolized procedures. As such, the risk of contracting the COVID-19 virus as an occupational hazard is presumed to be higher. To date, in most published studies, all healthcare workers were grouped together, independent of specialty or profession. At the time that this survey was distributed, we did not find any peer-reviewed articles that differentiated COVID-19 infection rates among frontline, such as anesthesiologists vs. non-frontline healthcare workers. This retrospective survey’s primary research objective was to report the rate of COVID-19 infection among anesthesiologists compared to the general population of healthcare workers.

Methodology

A survey was sent among anesthesiology attendings and residents in Northern New Jersey and Brooklyn, New York hospitals on duty during the peak pandemic from March 2020 to May 2020. Questions in the survey focused on infection rates and adherence to standards of infection precaution and personal protective equipment (PPE) utilization.

Main Findings

This retrospective study highlights the rate of infection among anesthesiologists as a particularly vulnerable subgroup of frontline residents and physicians, as they are called to duty when emergent airway management is required. In our study, the reported rate of contracting COVID-19 among anesthesiologists was 16.7%. This statistic is higher than the infection rates published by studies by New York State and the CDC.

Conclusion

The survey sent to anesthesiologists is useful to understand the impact of COVID-19 on this subgroup of frontline providers and the importance of adhering to standards of infection protocol and the role of PPE.

Spinal Epidural Abscess Post Spinal Anesthesia: An Uncommon Complication of a Common Procedure

Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space. Bacteria gain access to the epidural space either by hematogenous spread, contiguous spread from a neighboring infected structure, or through iatrogenic inoculation. The diagnosis of SEA is a challenge, largely because of its rarity. We present here a case of SEA of iatrogenic origin (post spinal anesthesia), which we treated at Tata Main Hospital, Jamshedpur.

Hepatitis C Contamination of Medication Vials Accessed with Sterile Needles and Syringes

BACKGROUND

Health care-associated hepatitis C virus outbreaks from contaminated medication vials continue to be reported even though most practitioners deny reusing needles or syringes. The hypothesis was that when caring for hepatitis C virus-infected patients, healthcare providers may inadvertently contaminate the medication vial diaphragm and that subsequent access with sterile needles and syringes can transfer hepatitis C virus into the medication, where it remains stable in sufficient quantities to infect subsequent patients.

METHODS

A parallel-arm lab study (n = 9) was performed in which contamination of medication vials in healthcare settings was simulated using cell culture-derived hepatitis C virus. First, surface-contaminated vials were accessed with sterile needles and syringes, and then hepatitis C virus contamination was assessed in cell culture. Second, after contaminating several medications with hepatitis C virus, viral infectivity over time was assessed. Last, surface-contaminated vial diaphragms were disinfected with 70% isopropyl alcohol to determine whether disinfection of the vial surface was sufficient to eliminate hepatitis C virus infectivity.

RESULTS

Contamination of medication vials with hepatitis C virus and subsequent access with sterile needles and syringes resulted in contamination of the vial contents in sufficient quantities to initiate an infection in cell culture. Hepatitis C virus remained viable for several days in several commonly used medications. Finally, a single or 2- to 3-s wipe of the vial diaphragm with 70% isopropyl alcohol was not sufficient to eliminate hepatitis C virus infectivity.

CONCLUSIONS

Hepatitis C virus can be transferred into commonly used medications when using sterile single-use needles and syringes where it remains viable for several days. Furthermore, cleaning the vial diaphragm with 70% isopropyl alcohol is not sufficient to eliminate the risk of hepatitis C virus infectivity. This highlights the potential risks associated with sharing medications between patients.

Environmental sustainability in veterinary anaesthesia

OBJECTIVE

Attention is drawn to the potential of global warming to influence the health and wellbeing of the human race. There is increasing public and governmental pressure on healthcare organisations to mitigate and adapt to the climate changes that are occurring. The science of anaesthetic agents such as nitrous oxide and the halogenated anaesthetic agents such as greenhouse gases and ozone-depleting agents is discussed and quantified. Additional environmental impacts of healthcare systems are explored. The role of noninhalational anaesthetic pharmaceuticals is discussed, including the environmental life-cycle analyses of their manufacture, transport, disposal and use. The significant role of anaesthetists in recycling and waste management, resource use (particularly plastics, water and energy) and engagement in sustainability are discussed. Finally, future directions for sustainability in veterinary anaesthesia are proposed.

CONCLUSIONS

Veterinary anaesthetists have a considerable opportunity to drive sustainability within their organisations through modification of their practice, research and education. The principles of sustainability may help veterinary anaesthetists to mitigate and adapt to our environmental crisis. Due to their particular impact as greenhouse gases, anaesthetic agents should be used conservatively with the lowest safe fresh gas flow possible. Technologies for reprocessing anaesthetic agents are described.

Evaluation of a novel in-line point-of-care blood gas analyser

Point-of-care testing is becoming increasingly relevant to the practice of anaesthesia and critical care medicine, especially in terms of minimisation of sample volumes and decreased time to decision making. We performed a prospective observational study to evaluate a novel, in-line blood gas analysis device against a conventional benchtop model, and assessed it while placing the enrolled patients under extreme physiological conditions, specifically deep hypothermic circulatory arrest. Eight patients were studied, and had between seven and 11 samples analysed for seven variables (pH, pCO2 , pO2 , HCO3 (-) , base excess [BE], K(+) and haematocrit [Hct]), using the device during the process of cooling to 20 °C on cardiopulmonary bypass, and subsequent rewarming to normothermia. After Passing-Bablok analysis, the variables were evaluated for bias, limits of agreement and percentage error at above and below 30 °C. Of the measured variables, only pH (percentage error 2.4%) and potassium (19.8%) demonstrated acceptable (< 30%) percentage error over the full range of temperatures measured. Carbon dioxide, when stratified by temperature, was acceptable (< 30 °C percentage error 24.6%, > 30 °C percentage error 9.9%), but the overall percentage error of the dataset (45.8%) was excessively high. Bicarbonate and haematocrit both had an acceptable percentage error above 30 °C (25.2% and 18.5%, respectively), but similar to carbon dioxide, percentage error for the full range of temperatures exceeded 30%. These data differ from previous work examining this device, and highlights the difference between derived measures using different apparatuses when exposed to extreme physiological conditions.

Comparison of efficacy and cost-effectiveness of 0.55% ortho-phthalaldehyde and 2% glutaraldehyde for disinfection of laryngoscopes: A prospective pilot study

BACKGROUND AND AIMS

The laryngoscope is a potential source of cross-infection as it involves contact with the mucous membrane, saliva and occasionally blood. This study compared efficacy and cost-effectiveness of two Centre for Disease Control approved agents for disinfection of laryngoscope blades.

METHODS

One hundred and sixty patients requiring laryngoscopy and intubation for general anaesthesia were randomly allocated into two groups. After tracheal intubation, used laryngoscope blades were cleaned with tap water. The blades were then immersed in either 2% w/v glutaraldehyde for a contact time of 20 min or 0.55% w/v ortho-phthalaldehyde (OPA) for 10 min. The handles were wiped with 0.5% w/v chlorhexidine wipes. Samples were collected using sterile cotton swabs from the tip, flange and light bulb area of the laryngoscope blade and one from the handle. They were cultured aerobically on blood and McConkey agar.

RESULTS

In 2% glutaraldehyde group, of 240 samples sent from the blades, 2 (0.8%) showed the growth of methicillin-resistant coagulase-negative staphylococci (MRCONS) and Enterobacter. In OPA group, of 240 samples, 2 (0.8%) showed growth of MRCONS. Thus, 2% glutaraldehyde and 0.55% OPA were comparable in terms of efficacy of disinfection. Growth was seen on 4 out of 160 handles.

CONCLUSIONS

We suggest OPA for high-level disinfection of laryngoscope blades as it is equally efficacious as compared to glutaraldehyde, with a shorter contact time and available as a ready to use formulation.

Bacterial contamination of saline used for epidural procedures in an obstetric setting: a randomised comparison of two drawing-up techniques

BACKGROUND

There is little evidence to inform practice regarding the optimum aseptic technique of drawing up saline for epidural insertion. Our regional practice is to draw up saline from a non-sterile packaged plastic ampoule, therefore introducing the risk of bacterial contamination. Usually, the anaesthetist draws up saline directly from the vial held by an assistant using a needle (needle technique). Alternatively, the saline vial is emptied onto a sterile tray by an assistant and then drawn up by the anaesthetist (tray technique). We hypothesised that the latter will lead to an increase in the number of contaminated saline samples as they are exposed to the environment.

METHODS

In labour rooms and before epidural catheter insertion, 110 samples of saline 20mL were randomly drawn up using our hospital's recommended epidural aseptic precautions, using either the needle or the tray technique. Equal amounts of saline were inoculated into aerobic and anaerobic blood culture bottles.

RESULTS

Eleven percent of samples in the needle arm and 24% of samples in the tray arm grew commensal micro-organisms including coagulase-negative Staphylococcus, Micrococcus luteus and Streptococcus viridans. A two-sided Fisher's exact test for categorical unpaired data showed no statistical difference between the two arms of the trial (P=0.13).

CONCLUSION

The difference in the saline contamination rate between the two techniques did not reach statistical significance. As bacterial contamination occurred with both techniques, we recommend using sterile saline pre-packaged in the epidural tray or individually wrapped sterile glass saline ampoules.

Bacterial and viral contamination of breathing circuits after extended use - an aspect of patient safety?

BACKGROUND

In the past, anaesthetic breathing circuits were identified as a source of pathogen transmission. It is still debated, whether breathing circuits combined with breathing system filters can be safely used for more than 1 day. The aim of this study was to evaluate the transmission risk of bacteria and also viruses via breathing circuits after extended use.

METHODS

The inner and outer surface of 102 breathing circuits used for 1 day and of 101 circuits used for 7 days were examined for bacteria and viruses. Additionally, 10 and 20 breathing circuits each were examined after use on patients with pulmonary virus infection and with multidrug-resistant organism (MDRO) colonisation/infection respectively. Bacteria were detected by standard microbiological procedures; PCR techniques were applied for herpes simplex virus, cytomegalovirus, influenza, parainfluenza and respiratory syncytial virus.

RESULTS

Endoluminal bacterial contamination of breathing circuits remained unchanged after 7-day vs. 1-day use (5.9% vs. 7.8%) [CI95%: -0.0886-0.0506, pnon-inferiority 0.0260]. Only outside surface contamination with bacteria belonging to environmental species or human flora increased (16.8 vs. 6.9%) [CI 95%: 0.0118 - 0.1876, pnon-inferiority 0.8660]. Viruses occurred on the patient side, but not in breathing circuits. No MDRO occurred in the 20 circuits after use on patients harbouring such germs.

CONCLUSION

Endoluminal contamination of breathing circuits with bacteria did not increase after extended use. No viruses were detected in the breathing circuits using filters. Based on our results, the extended use of ABC without exceptions appears safe, if a high level of anaesthesia workplace cleaning is secured.

Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016

Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.

Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Chlorhexidine to maintain cleanliness of laryngoscope handles: an audit and laboratory study

CONTEXT

Laryngoscope handles are a potential vector for infection transmission and require adequate decontamination.

OBJECTIVE

To establish an effective cleaning regimen for laryngoscope handles.

DESIGN

Three laboratory studies and an audit cycle.

SETTING

The Queen Elizabeth Hospital, King's Lynn, UK.

MATERIALS

Twenty Heine laryngoscope handles.

INTERVENTIONS

Twenty laryngoscope handles were contaminated with microbial broth and then disinfected with chemical wipes, either using Sani-Cloth CHG 2% (chlorhexidine 2%/alcohol 70%) or Tuffie 5 wipes. This was repeated with an interval of 24 h between cleaning and contamination. A further experiment repeatedly re-contaminated the handles at varying time intervals after cleaning. The audit established the current level of contamination of laryngoscope handles within the hospital, and this was repeated following a change in cleaning protocol.

MAIN OUTCOME MEASURES

Bacterial growth on agar plates was counted as the number of colony forming units.

RESULTS

Both Sani-Cloth CHG 2% and Tuffie 5 wipes were effective against microorganisms, including methicillin-resistant Staphylococcus aureus, immediately following wiping (P = 0.002). However, the chlorhexidine wipes also had a residual effect such that after wiping, the handle remained sterile following further contamination and this effect persisted for 24 h. Audit following the introduction of this practice showed significant improvements in the incidence and extent of contamination compared with the previous disinfection practice (P<0.002).

CONCLUSION

Decontamination with Sani-Cloth CHG 2% wipes confers additional advantages over routine autoclaving or handle disposal, due to a residual effect. Autoclaving handles may be desirable on a scheduled basis and if Clostridium difficile is encountered.

Safety guideline: skin antisepsis for central neuraxial blockade

Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade. The Working Party specifically considered the concentration of antiseptic agent to use and its method of application. The advice presented is based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents.

Description of a new non-injectable connector to reduce the complications of arterial blood sampling

Arterial cannulation is associated with complications including bacterial contamination, accidental intra-arterial injection and blood spillage. We performed a series of audits and experiments to gauge the potential for these, as well as assess the possible contribution of a new device, the Needle-Free Arterial Non-Injectable Connector (NIC), in reducing these risks. The NIC comprises a needle-free connector that prevents blood spillage and a one-way valve allowing aspiration only; once screwed onto the side port of a three-way tap, the device can only be removed with difficulty. We performed a clinical audit of arterial monitoring systems in our intensive care unit, which showed an incidence of bacterial colonisation of five in 86 (6%) three-way tap ports. We constructed a manikin simulation experiment of the management of acute bradycardia, in which trainee doctors were required to inject atropine intravenously. Ten of 15 (66%) doctors injected the drug into the three-way tap of the arterial monitoring system rather than into the intravenous cannula or the central venous catheter. In a laboratory study, we replicated the arterial blood sampling and flushing sequence from a three-way tap, with the syringes attached either directly to the three-way tap port or to a NIC attached to the port. The first (discard) syringe attached to the three-way tap was contaminated with bacteria. Bacterial growth was found in 17 of 20 (85%) downstream flushed samples (corresponding to the patient's circulation) when the three-way tap was accessed directly, compared to none of 20 accessed via the NIC (p < 0.0001). Growth was found on all of 20 (100%) ports accessed directly compared to none of 20 accessed via the NIC (p < 0.0001). The NIC effectively prevents bacteria from contaminating sampling lines. As its design also prevents accidental intra-arterial injection, we suggest that it can reduce complications of arterial monitoring.

The management of central venous catheters and infection control: is it time to change our approach?

Catheter related bloodstream infections (CR-BSIs) can lead to a number of serious conditions for the patient, including death. There is much recent evidence both in the UK and abroad which identifies the sources of CR-BSIs, yet they continue to occur. This article seeks to review some of the current evidence in relation to the prevention of CR-BSIs at insertion point.

Cleaning and sterilisation of anaesthetic equipment

The main purpose of this review article is to bring up what has been known (practiced) about decontamination, disinfection, and sterilisation of anaesthetic equipment. It also discusses how this evidence-based information on infection prevention and control impacts care of patient in routine anaesthesia practice. This review underscores the role played by us, anaesthetists in formulating guidelines, implementing the same, monitoring the outcome and training post-graduate trainees and coworkers in this regard. The article re-emphasises that certain guidelines when followed strictly will go a long way in reducing transmission of hospital acquired infection between patient and anaesthetist or between patients. Anaesthetists do not restrict their work to operating room but are involved in disaster management, interventional radiological procedures and in trauma care. They should ensure that the patients are cared for in clean and safe environment so as to reduce healthcare associated infections (HCAIs) simultaneously taking preventive measures against the various health hazards associated with clinical practice. They should ensure that the coworkers too adopt all the preventive measures while delivering their duties. For this review, we conducted literature searches in Medline (PubMed) and also searched for relevant abstracts and full texts of related articles that we came across. There is much to be learned from the western world where, health care organisations now have legal responsibility to implement changes in accordance with the newer technology to reduce health care associated infection. There is a need to develop evidence-based infection prevention and control programs and set national guidelines for disinfection and sterilisation of anaesthesia equipment which all the institutions should comply with.

Diagnostic Lumbar Puncture

Diagnostic Lumbar Puncture is one of the most commonly performed invasive tests in clinical medicine. Evaluation of an acute headache and investigation of inflammatory or infectious disease of the nervous system are the most common indications. Serious complications are rare, and correct technique will minimise diagnostic error and maximise patient comfort. We review the technique of diagnostic Lumbar Puncture including anatomy, needle selection, needle insertion, measurement of opening pressure, Cerebrospinal Fluid (CSF) specimen handling and after care. We also make some quality improvement suggestions for those designing services incorporating diagnostic Lumbar Puncture.

Bougie-related airway trauma: dangers of the hold-up sign

The bougie is a popular tool in difficult intubations. The hold-up sign is used to confirm tracheal placement of a bougie. This study aimed to establish the potential for airway trauma when using this sign with an Eschmann re-usable bougie or a Frova single-use bougie. Airways were simulated using a manikin (hold-up force) and porcine lung model (airway perforation force). Mean (SD) hold-up force (for airway lengths over the range 25-45 cm) of 1.0 (0.4) and 5.2 (1.1) N were recorded with the Eschmann and Frova bougies, respectively (p < 0.001). The mean (SD) force required to produce airway perforation was 0.9 (0.2) N with the Eschmann bougie and 1.1 (0.3) N with the Frova bougie (p = 0.11). It is possible to apply a force at least five times greater than the force required to produce significant trauma with a Frova single-use bougie. We recommend that the hold-up sign should no longer be used with single-use bougies. Clinicians should be cautious when eliciting this sign using the Eschmann re-usable bougie.

Superiority of chlorhexidine 2%/alcohol 70% wipes in decontaminating ultrasound equipment

Ultrasound equipment is known to act as a reservoir for potentially pathogenic organisms. The aims of these studies were to establish current cleaning practices, to review the extent of bacterial contamination of ultrasound equipment in our hospital, to establish an effective cleaning regimen and to ensure that cleaning does not cause damage. A questionnaire was sent to all acute NHS hospitals in England to establish current cleaning practices. A review of our current practice was performed to establish the extent of bacterial contamination of ultrasound equipment currently in use. Laboratory studies compared cleaning the probes with soap and water with decontaminating with a chlorhexidine 2% and alcohol 70% wipe, including quantifying the residual effect. Accelerated aging was performed on the probe and staff surveyed to establish potential problems with using the wipes on the probe. The survey revealed that a variety of cleaning methods were used to decontaminate ultrasound probes; 57% of our ultrasound machines were contaminated with bacteria. The laboratory studies showed superiority of the chlorhexidine and alcohol wipes over soap and water due to a residual effect, both immediately after cleaning and after 24 hours. The staff survey demonstrated no apparent change in function of the probe after cleaning with the chlorhexidine wipes. Cleaning ultrasound probes with chlorhexidine and alcohol wipes is effective and provides additional protection against bacterial contamination due to its residual effect, and appears in the short term to have no detrimental effect on the probe.

A survey of aseptic precautions and needle type for paediatric caudal block in Australia and New Zealand

This cross-sectional survey was designed to evaluate the current practice of anaesthetists in Australia and New Zealand with regard to aseptic technique and needle type during the performance of single-shot caudal blocks. Professional bodies suggest that full aseptic precautions be taken during the administration of caudal or epidural blocks. It has been suggested that using an intravenous cannula or a styletted needle may obviate the occurrence of epidermoid tumours. A total of 202 members of the Society for Paediatric Anaesthesia in New Zealand and Australia were invited to participate in this internet-based survey. Eighty-four responses were received. Most respondents used some form of antiseptic handwash (81%), wore sterile gloves (85.7%), used antiseptic skin preparation (100%) and draped the site (57.1%). When performing caudal blocks, 43.1% used unstyletted needles, 27.2% used styletted spinal needles and 29.6% used intravenous cannulas. However, 11.9% did not wash hands, 10.7% did not wear gloves and 42.9% did not drape the site. Three respondents reported neither handwashing, wearing gloves or draping, instead only using an alcohol swab for skin preparation. The majority of respondents in our region appear to use some level of aseptic precautions, albeit to a variable degree. Published recommendations may either be perceived as overly cautious or as ambiguous in that they do not specify caudal practice as distinct from other epidural blocks. There is a need for clearer professional guidance to support a minimum level of aseptic precaution for single-shot caudal epidural blocks.