Do anaesthetists need to wear surgical masks in the operating theatre? A literature review with evidence-based recommendations

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices

OBJECTIVE

Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

METHODS

We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

RESULTS

We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

CONCLUSION

Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Leadership in surgery for public sector hospitals in Jamaica: strategies for the operating room

The barriers to health care delivery in developing nations are many: underfunding, limited support services, scarce resources, suboptimal health care worker attitudes, and deficient health care policies are some of the challenges. The literature contains little information about health care leadership in developing nations. This discursive paper examines the impact of leadership on the delivery of operating room (OR) services in public sector hospitals in Jamaica.Delivery of OR services in Jamaica is hindered by many unique cultural, financial, political, and environmental barriers. We identify six leadership goals adapted to this environment to achieve change. Effective leadership must adapt to the environment. Delivery of OR services in Jamaica may be improved by addressing leadership training, workplace safety, interpersonal communication, and work environment and by revising existing policies. Additionally, there should be regular practice audits and quality control surveys.

Respiratory and facial protection: a critical review of recent literature

Infectious micro-organisms may be transmitted by a variety of routes. This is dependent on the particular pathogen and includes bloodborne, droplet, airborne, and contact transmission. Some micro-organisms are spread by more than one route. Respiratory and facial protection is required for those organisms which are usually transmitted via the droplet and/or airborne routes or when airborne particles have been created during 'aerosol-generating procedures'. This article presents a critical review of the recently published literature in this area that was undertaken by Health Protection Scotland and the Healthcare Infection Society and which informed the development of guidance on the use of respiratory and facial protection equipment by healthcare workers.

Use of face masks by non-scrubbed operating room staff: a randomized controlled trial

BACKGROUND

Ambiguity remains about the effectiveness of wearing surgical face masks. The purpose of this study was to assess the impact on surgical site infections (SSIs) when non-scrubbed operating room staff did not wear surgical face masks.

METHODS

Eight hundred twenty-seven participants undergoing elective or emergency obstetric, gynecological, general, orthopaedic, breast or urological surgery in an Australian tertiary hospital were enrolled. Complete follow-up data were available for 811 patients (98.1%). Operating room lists were randomly allocated to a 'Mask group' (all non-scrubbed staff wore a mask) or 'No Mask group' (none of the non-scrubbed staff wore masks). The primary end point, SSI was identified using in-patient surveillance; post discharge follow-up and chart reviews. The patient was followed for up to six weeks.

RESULTS

Overall, 83 (10.2%) surgical site infections were recorded; 46/401 (11.5%) in the Masked group and 37/410 (9.0%) in the No Mask group; odds ratio (OR) 0.77 (95% confidence interval (CI) 0.49 to 1.21), p = 0.151. Independent risk factors for surgical site infection included: any pre-operative stay (adjusted odds ratio [aOR], 0.43 (95% CI, 0.20; 0.95), high BMI aOR, 0.38 (95% CI, 0.17; 0.87), and any previous surgical site infection aOR, 0.40 (95% CI, 0.17; 0.89).

CONCLUSION

Surgical site infection rates did not increase when non-scrubbed operating room personnel did not wear a face mask.

The "six sigma approach" to the operating room environment and infection

The patient's external environment plays a significant, and in some cases dominant, role in his or her infection risk. The use of ultraclean air for certain procedures, as well as avoidance of hypothermia have been proven to reduce the risk of infection. There is no data to support the routine use of surgical masks (by surgeons or staff), ventilating helmets, or routine cleaning of all environmental surfaces in between cases. More research needs to be done in order to determine whether OR design changes, in addition to increasing OR efficiency and thus reducing case times, can also reduce infection rates. Further research is also needed to determine whether or not double gloves and/or the use of antiseptic scrubbing in addition to painting are efficacious.

Nosocomial infections and infection control in regional anesthesia

BACKGROUND

Although rare, infectious complications from regional anesthesia and analgesia can be devastating. The literature on this topic consists primarily of surveys, case reports, case series, and studies in which used supplies were cultured. We derived infection control recommendations from the existing literature and compared these recommendations with existing guidelines.

METHODS

Structured literature search of the Cochrane Central Register of Controlled Trials, MEDLINE, including old MEDLINE and EMBASE until 2005. Descriptive statistics were cited when applicable.

MAIN RESULTS

Incidence rates for infectious complications vary substantially between studies and range from 3.7 to 7.2/100,000 for spinal anesthesia-associated meningitis and from 0.2 to 83/100,000 for epidural anesthesia-associated epidural abscesses. Few comprehensive prospective trials have been conducted and most case reports do not provide complete information about infection control practices.

CONCLUSION

Studies using more robust methods are necessary to define the rates of infection after different regional anesthesia procedures and to identify risk factors for infections. Data on risk factors would allow anesthesiologists to develop evidence-based guidelines for placement and care of catheters used for regional anesthesia. A multicenter surveillance system may help anesthesiologists address some of the unanswered questions and to develop evidence-based infection control recommendations.

Neurological infections after neuraxial anesthesia

Infection is the commonest cause of serious neurologic sequelae of neuraxial anesthesia. The incidence depends on operator skill and patient population. Meningitis, a complication of dural puncture, is usually caused by viridans streptococci. The risk factors are dural puncture during labor, no mask and poor aseptic technique, vaginal infection and bacteremia. Epidural abscess is a complication of epidural catheterization, route of entry the catheter track and the organism usually the staphylococcus. Principal risk factors are prolonged catheterization, poor aseptic technique and traumatic insertion. Prevention includes wearing a mask, using a full sterile technique, avoiding prolonged catheterization and prescribing antibiotics in a high-risk situation.

The use of surgical facemasks during cataract surgery: is it necessary?

AIM

To assess whether facemask utilisation by the surgeon during cataract surgery has any effect on the bacterial load falling onto the operative site.

METHOD

Prospective randomised masked study. Consent was obtained from 221 patients. Cases were randomised to wearing a new mask or not wearing any mask throughout the procedure. Blood agar settle plates were placed adjacent to the patient's head in the operative field. Duration of procedure was noted. Plates were incubated and read at 48 hours. Colony forming bacteria were counted and identified.

RESULTS

There were significantly fewer organisms cultured when the surgeon used a facemask (p=0.0006). The majority of organisms were Staphylococcus epidermidis, Bacillus spp, and Diphtheroid spp; however Staphylococcus aureus and Pseudomonas aeruginosa were cultured on several occasions. There were no cases of infective complication.

CONCLUSIONS

The main purpose of an operating mask is to prevent bacteria falling on to the operative site from the surgeon's oropharynx or nasopharynx with the concomitant theoretical risk of infective complication. Operating masks were shown to have a significant effect on the volume of bacterial organisms falling to the operative site; however, whether this is clinically significant is unknown.