Anesthesiology
INFECTION CONTROL AND THE ANESTHESIA CARE TEAM
December 21, 2011.Elliott S. Greene, MD,
Educational Objectives
The goal of this program is to improve adherence to proper infection control procedures. After hearing and assimilating this program, the clinician will be better able to:
1. Identify the major questionable injection practices among health care professionals cited by the Centers for Disease Control and Prevention (CDC).
2. Implement the standard infection control precautions recommended by the CDC.
3. Take expanded safety precautions for infection control, when necessary.
4. Reduce the risk for surgical site infections.
5. Provide prophylaxis to health care professionals who have been exposed to a possible source of infection.
Summary
Infection Control and the Anesthesia Care Team
From Anesthesiology Autumn Update and Review, presented by the Department of Anesthesiology and the Office of Continuing Medical Education, Albany Medical College
Elliott S. Greene, MD, Professor, Department of Anesthesiology, Albany Medical College, Albany, NY
Educational Objectives
The goal of this program is to improve adherence to proper infection control procedures. After hearing and assimilating this program, the clinician will be better able to:
1. Identify the major questionable injection practices among health care professionals cited by the Centers for Disease Control and Prevention (CDC).
2. Implement the standard infection control precautions recommended by the CDC.
3. Take expanded safety precautions for infection control, when necessary.
4. Reduce the risk for surgical site infections.
5. Provide prophylaxis to health care professionals who have been exposed to a possible source of infection.
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Greene and the planning committee reported nothing to disclose.
Reuse of injection equipment
Background: studies from 1989 and 1995 showed high rates of syringe reuse for multiple patients among anesthesiologists; first recommendations for infection control published by American Society of Anesthesiologists (ASA) in 1992; recommended single use of syringes and other injection equipment; by 2002, reported incidence of needle or syringe reuse for multiple patients 3%; in 2003, Centers for Disease Control and Prevention (CDC) reported transmission of hepatitis B (HBV) and C (HCV) in outpatient clinics in several states, due to syringe or needle reuse by anesthesia providers; similar outbreak reported in Nevada in 2008; some health care workers still unaware that reuse dangerous (believe that changing microbore tubing alone sufficient to prevent transmission); between 1998 and 2008, 33 cases of patient-to-patient transmission of HBV or HCV reported in United States, 7 involving delivery of anesthesia care, 144 actual infections, and >55,000 patients placed at risk; outbreaks could have been prevented by adherence to aseptic technique for preparation and administration of parenteral medications, use of sterile single-use disposable needles and syringes for each injection (not each patient), and prevention of contamination of injection equipment and medication
Problematic injection practices identified by CDC: reuse of needle, cannula, or syringe for multiple patients (pathogens may linger even after flushing; suctioning effect upon removing needle may contaminate syringe); accessing medication vial or other container with used needle, cannula, or syringe (single-dose vials sometimes used as multiple-dose vials); mixing of used injection equipment with clean equipment
2010 survey of injection practices among health care professionals: 90% registered nurses; 15.1% reported reusing syringes on multidose vials; 1.1% saved vials for use on other patients (some still believed contamination limited to needle); 6% use single-dose vials on >1 patient; identified obstacles to safe injection practices — lack of awareness and failure to implement CDC recommendations; rationalization based on need to reduce waste and costs; failure to appreciate risks; mistaken beliefs about risks associated with syringe reuse and aseptic technique
Health care providers’ professional responsibility: review and monitor infection control practices of all staff under one’s supervision, and ensure use of safe practices; failure to comply increases risk for adverse patient outcomes, potential charges of professional misconduct, actions against license, or allegations of medical malpractice; New York only state to require infection control training every 4 yr as prerequisite for relicensure
New York State Society of Anesthesiologists’ Infection Control for Anesthesia Professionals: web-based continuing medical eduction course released in March 2010; fulfills state infection training requirements; access at http://nyssa-pga.org/
CDC’s standard precautions: evolved from universal precautions; health care workers should view every patient as potential risk; all blood, bodily fluids, nonintact skin, mucous membranes, secretions, and excretions (except sweat) potential vehicles of contamination, even if no visible blood present
Work practice controls: barriers such as gowns and gloves; avoidance of 2-handed needle recapping (recapping before disposal unnecessary; needleless systems recommended for injections); suturing — curved needle with holder safer than straight needle (associated with lower incidence of needlesticks); do not use fingers to pull or push needle or hold tissue
Engineering controls: appropriate air-flow systems in operating rooms; needlestick safety devices and sharps control devices (required by Occupational Safety and Health Administration; eg, use of solid and leak-proof sharps disposal containers, without overfilling)
Updated precautions: published in 2007; include safe injection practices; use of masks for spinal and epidural procedures; respiratory and cough etiquette for hospital visitors
Hand hygiene: single most important practice for reducing transmission of infectious agents; use before and during handling of injection apparatus, medication, or fluid container, or before and after glove use; use soap and water on visibly soiled hands (otherwise, alcohol solutions acceptable)
Aseptic technique: use before and during handling of injection apparatus; begins with hand hygiene; clean vials with alcohol swabs; scrub needleless access ports with antiseptic; access new containers with sterile equipment; cap unused syringes and stopcocks; store unused syringes and medications in clean area; avoid cross-contamination with used items
What every health care provider should know about injection safety: needles and syringes single-use devices; do not administer medication from single-dose vial or intravenous (IV) bag to multiple patients; limit use of multidose vials and dedicate to single patient whenever possible (in anesthesiology, “whenever possible” means always); follow proper infection control practices; wear surgical mask when placing catheters during neuraxial techniques; avoid use of multidose vials in immediate patient treatment area (rooms where anesthesia administered and corresponding anesthesia carts); if medication only comes in multidose vial, treat as single-dose vial and discard after single patient use; doses safely separated only in pharmacy; many safety practices now adopted by Centers for Medicare and Medicaid Services (CMS) as conditions for coverage
Double layer of precautions: one layer concerns syringes, needles, and cannulas (use only once); second layer concerns solution containers (use on only one patient)
Safe dosing methods: draw vial contents into sterile syringe and use for sequential doses for single patient (safest method); obtain sequential doses from one vial, with use of new equipment each time
Management of infection control breaches: notify exposed individuals and source; test for bloodborne pathogens
Expanded (transmission-based) precautions
Airborne: droplet nuclei <5 µ, or dust particles (eg, tuberculosis, measles, chickenpox, smallpox, severe acute respiratory syndrome, H1N1 influenza); need frequent air changes and special ventilation, N95 respirators for health care workers, and isolation room with negative pressure; consult with hospital’s infection control specialist
Anesthesia care for patients on airborne precautions: postpone nonurgent surgical procedures until patient deemed noninfectious or not infected; if postponement not possible, schedule at end of day to minimize number of health care workers exposed and maximize time for removal of airborne contamination from room; have workers use N95 respirators; use high-efficiency particulate air (HEPA) filters at Y-piece of breathing circuit, and on bag valve mask (eg, Ambu bag, SMART BAG MO) to prevent expired air from contaminating anesthesia machine and atmosphere; ideally, have patient recover in respiratory isolation room; alternatively, have patient recover in operating room where surgery performed, while maintaining same level of respiratory precautions; keep operating room vacant until 99.9% of air turnover has occurred (at 15 air changes per hour, 28 min required)
Equipment: clean anesthesia equipment before sterilization or disinfection; highest level of safety with no reprocessing at all; reuse of disposable equipment not acceptable, including breathing circuits and sampling lines, even if HEPA filters used
Workspace: consider anesthesia workspace potential vehicle of pathogen transmission (clean knobs, buttons, and horizontal surfaces of machines between cases and at end of day)
Studies: Loftus et al (2008) — found association between contamination in anesthesia work area and likelihood of contamination of internal stopcock; IV stopcocks were contaminated in 32% of cases; use of contaminated stopcock associated with significantly higher mortality; authors concluded transmission of bacteria to work area and IV stopcocks likely due to variations in aseptic technique among hospital staff; called for better infection control practices; later study — showed contaminated hands of anesthesia providers to be significant source of operating room contamination, despite reported 90% compliance with hand hygiene procedures; challenges commonly held belief that health care workers play little or no role in bacterial transmission
Practice advisory for neuraxial techniques: identify patients at risk for infectious complications; complications may occur despite use of prophylactic antibiotics; if antibiotics administered to symptomatic patient, do not perform block until symptoms diminish; use aseptic technique; remove jewelry; use cap and mask; hand hygiene —alcohol-based wash appropriate; don sterile gloves only after hands dry; widely prepare area with 2% chlorhexidine gluconate and 70% isopropyl alcohol (saturate pad; rub skin with back-and-forth motion to create friction and reach cracks in skin; let skin dry for ³2 min); povidone-iodine solution recommended instead of chlorhexidine for infants and neonates; consider removing any catheters accidentally disconnected if disconnection unwitnessed; evaluate patient daily for signs and symptoms of infection
Central venous catheter-related bloodstream infections (CRBSI): “bundles of care” — specific practices associated with decreased mortality from CRBSI; include avoiding femoral site if possible, hand hygiene, cleaning skin with chlorhexidine gluconate and alcohol, maximal barrier precautions, and removal of unnecessary catheters; in study by Pronovost et al, interventions associated with decrease in mean rate of CRBSI from 7.7 per 1000 catheter days at baseline to 1.4 at 16 to 18 mo of follow-up
Prevention of intravascular catheter-related infections: CDC guidelines include use of hand hygiene and aseptic technique; hand hygiene before and after palpating catheter insertion sites, and before and after any manipulation of catheter; use of sterile gloves for insertion of arterial, central, and midline catheters (nonsterile gloves acceptable for peripheral IV catheter insertion); maximal sterile barrier precautions recommended when placing central lines, including mask, cap, gown, gloves, and full body drape; disinfect skin before insertion of central venous or peripheral arterial catheters; use 0.5% chlorhexidine solution with alcohol; let skin dry before catheter placement (but do not blot or wipe)
Additional recommendations: non-tunneled central venous catheters — use subclavian rather than internal jugular or femoral site due to increased risk for infection and (at femoral site) thrombosis in adults (risk lower in pediatric patients); peripheral arterial catheters — cap, mask, gloves, and small drape; axillary or femoral artery catheters — maximal barrier precautions recommended; femoral and axillary arteries should never be first choice of catheter site; brachial site contraindicated in children due to risk for mechanical complications
Needleless systems: recommended over stopcocks by CDC for accessing IV tubing; closed catheter systems associated with fewer infections than open systems and should be used preferentially; scrub port with antiseptic, and access only with sterile devices
Reducing risk for surgical site infections
Antimicrobial prophylaxis: administer antibiotic 1 hr before incision to ensure bactericidal in serum and tissues; re-dose periodically to maintain therapeutic efficacy; vancomycin and fluoroquinolones have long half-lives (require 1-hr infusion; start 2 hr before incision)
Temperature regulation: hypothermia causes vasoconstriction, decreased tissue perfusion and oxygenation, and inhibits destruction of bacteria by neutrophils; also associated with adverse cardiac events, reduced drug metabolism, and altered coagulation; CMS recommends active intraoperative warming or documented perianesthetic normothermia (36o C) for all patients undergoing anesthesia for >1 hr
Glucose control: hyperglycemia associated with neutrophil dysfunction and decreased local immune response; blood glucose >200 mg/dL associated with increased risk for surgical site infections after cardiovascular surgery; good preoperative glycemic control shown to decrease infectious complications even after noncardiac surgery, but very tight glucose control associated with increased risk for mortality; recommendation — avoid perioperative hyperglycemia and hypoglycemia; maintain perioperative glucose levels at no more than 180 to 200 mg/dL
Protective measures for anesthesia professionals: annual tuberculosis screening; vaccination for HBV; work restrictions if professional has infectious illness or draining wound; protection of small breaks in skin
Postexposure procedures: immediate washing of needlestick site and evaluation by emergency or employee health department; consider administration of hepatitis B immune globulin or treatment with anti-HIV medications (effectiveness declines rapidly if taken more than several hours after exposure); file incident report; baseline and follow-up blood testing; test source whenever possible; offer counseling to affected worker
Acknowledgements
This program was recorded at Anesthesiology Autumn Update and Review, held September 9-10, 2011, in Saratoga Springs, NY, and sponsored by the Department of Anesthesiology and the Office of Continuing Medical Education, Albany Medical College, Albany, NY. For information on upcoming CME meetings at Albany Medical College, please visit their website at AMC.edu and search for Continuing Medical Education, or check our website, Audio-Digest.org, under Upcoming Meetings. The Audio-Digest Foundation thanks Dr. Greene and Albany Medical College for their cooperation in the production of this program.
Suggested Reading
American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques: Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010 Mar;112(3):530-45; Loftus RW at al: Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008 Sep;109(3):399-407; Loftus RW et al: Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg 2011 Jan;112(1):98-105; Melling AC et al: Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001 Sep 15;358(9285):876-80; O’Grady NP et al: Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011 May;52(9):e162-93; Patel PR et al: Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control 2008 Dec;36(10):685-90; Pronovost P et al: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32; Pugliese G et al: Injection practices among clinicians in United States health care settings. Am J Infect Control 2010 Dec;38(10):789-98; Siegel JD et al: 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007 Dec;35(10 Suppl 2):S65-164; Thompson ND et al: Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009 Jan 6;150(1):33-9; Traynor K: CDC pushes for elimination of catheter-related infections. Am J Health Syst Pharm 2011 Jun 1;68(11):962-3; Voelker R: Updated guidelines target reductions in catheter-related bloodstream infections. JAMA 2011 May 4;305(17):1753-4.
Readings
Suggested Reading
American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques: Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010 Mar;112(3):530-45; Loftus RW at al: Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008 Sep;109(3):399-407; Loftus RW et al: Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg 2011 Jan;112(1):98-105; Melling AC et al: Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001 Sep 15;358(9285):876-80; O’Grady NP et al: Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011 May;52(9):e162-93; Patel PR et al: Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control 2008 Dec;36(10):685-90; Pronovost P et al: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32; Pugliese G et al: Injection practices among clinicians in United States health care settings. Am J Infect Control 2010 Dec;38(10):789-98; Siegel JD et al: 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007 Dec;35(10 Suppl 2):S65-164; Thompson ND et al: Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009 Jan 6;150(1):33-9; Traynor K: CDC pushes for elimination of catheter-related infections. Am J Health Syst Pharm 2011 Jun 1;68(11):962-3; Voelker R: Updated guidelines target reductions in catheter-related bloodstream infections. JAMA 2011 May 4;305(17):1753-4.
Disclosures
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Greene and the planning committee reported nothing to disclose.
Reuse of injection equipment
Background: studies from 1989 and 1995 showed high rates of syringe reuse for multiple patients among anesthesiologists; first recommendations for infection control published by American Society of Anesthesiologists (ASA) in 1992; recommended single use of syringes and other injection equipment; by 2002, reported incidence of needle or syringe reuse for multiple patients 3%; in 2003, Centers for Disease Control and Prevention (CDC) reported transmission of hepatitis B (HBV) and C (HCV) in outpatient clinics in several states, due to syringe or needle reuse by anesthesia providers; similar outbreak reported in Nevada in 2008; some health care workers still unaware that reuse dangerous (believe that changing microbore tubing alone sufficient to prevent transmission); between 1998 and 2008, 33 cases of patient-to-patient transmission of HBV or HCV reported in United States, 7 involving delivery of anesthesia care, 144 actual infections, and >55,000 patients placed at risk; outbreaks could have been prevented by adherence to aseptic technique for preparation and administration of parenteral medications, use of sterile single-use disposable needles and syringes for each injection (not each patient), and prevention of contamination of injection equipment and medication
Problematic injection practices identified by CDC: reuse of needle, cannula, or syringe for multiple patients (pathogens may linger even after flushing; suctioning effect upon removing needle may contaminate syringe); accessing medication vial or other container with used needle, cannula, or syringe (single-dose vials sometimes used as multiple-dose vials); mixing of used injection equipment with clean equipment
2010 survey of injection practices among health care professionals: 90% registered nurses; 15.1% reported reusing syringes on multidose vials; 1.1% saved vials for use on other patients (some still believed contamination limited to needle); 6% use single-dose vials on >1 patient; identified obstacles to safe injection practices — lack of awareness and failure to implement CDC recommendations; rationalization based on need to reduce waste and costs; failure to appreciate risks; mistaken beliefs about risks associated with syringe reuse and aseptic technique
Health care providers’ professional responsibility: review and monitor infection control practices of all staff under one’s supervision, and ensure use of safe practices; failure to comply increases risk for adverse patient outcomes, potential charges of professional misconduct, actions against license, or allegations of medical malpractice; New York only state to require infection control training every 4 yr as prerequisite for relicensure
New York State Society of Anesthesiologists’ Infection Control for Anesthesia Professionals: web-based continuing medical eduction course released in March 2010; fulfills state infection training requirements; access at http://nyssa-pga.org/
CDC’s standard precautions: evolved from universal precautions; health care workers should view every patient as potential risk; all blood, bodily fluids, nonintact skin, mucous membranes, secretions, and excretions (except sweat) potential vehicles of contamination, even if no visible blood present
Work practice controls: barriers such as gowns and gloves; avoidance of 2-handed needle recapping (recapping before disposal unnecessary; needleless systems recommended for injections); suturing — curved needle with holder safer than straight needle (associated with lower incidence of needlesticks); do not use fingers to pull or push needle or hold tissue
Engineering controls: appropriate air-flow systems in operating rooms; needlestick safety devices and sharps control devices (required by Occupational Safety and Health Administration; eg, use of solid and leak-proof sharps disposal containers, without overfilling)
Updated precautions: published in 2007; include safe injection practices; use of masks for spinal and epidural procedures; respiratory and cough etiquette for hospital visitors
Hand hygiene: single most important practice for reducing transmission of infectious agents; use before and during handling of injection apparatus, medication, or fluid container, or before and after glove use; use soap and water on visibly soiled hands (otherwise, alcohol solutions acceptable)
Aseptic technique: use before and during handling of injection apparatus; begins with hand hygiene; clean vials with alcohol swabs; scrub needleless access ports with antiseptic; access new containers with sterile equipment; cap unused syringes and stopcocks; store unused syringes and medications in clean area; avoid cross-contamination with used items
What every health care provider should know about injection safety: needles and syringes single-use devices; do not administer medication from single-dose vial or intravenous (IV) bag to multiple patients; limit use of multidose vials and dedicate to single patient whenever possible (in anesthesiology, “whenever possible” means always); follow proper infection control practices; wear surgical mask when placing catheters during neuraxial techniques; avoid use of multidose vials in immediate patient treatment area (rooms where anesthesia administered and corresponding anesthesia carts); if medication only comes in multidose vial, treat as single-dose vial and discard after single patient use; doses safely separated only in pharmacy; many safety practices now adopted by Centers for Medicare and Medicaid Services (CMS) as conditions for coverage
Double layer of precautions: one layer concerns syringes, needles, and cannulas (use only once); second layer concerns solution containers (use on only one patient)
Safe dosing methods: draw vial contents into sterile syringe and use for sequential doses for single patient (safest method); obtain sequential doses from one vial, with use of new equipment each time
Management of infection control breaches: notify exposed individuals and source; test for bloodborne pathogens
Expanded (transmission-based) precautions
Airborne: droplet nuclei <5 µ, or dust particles (eg, tuberculosis, measles, chickenpox, smallpox, severe acute respiratory syndrome, H1N1 influenza); need frequent air changes and special ventilation, N95 respirators for health care workers, and isolation room with negative pressure; consult with hospital’s infection control specialist
Anesthesia care for patients on airborne precautions: postpone nonurgent surgical procedures until patient deemed noninfectious or not infected; if postponement not possible, schedule at end of day to minimize number of health care workers exposed and maximize time for removal of airborne contamination from room; have workers use N95 respirators; use high-efficiency particulate air (HEPA) filters at Y-piece of breathing circuit, and on bag valve mask (eg, Ambu bag, SMART BAG MO) to prevent expired air from contaminating anesthesia machine and atmosphere; ideally, have patient recover in respiratory isolation room; alternatively, have patient recover in operating room where surgery performed, while maintaining same level of respiratory precautions; keep operating room vacant until 99.9% of air turnover has occurred (at 15 air changes per hour, 28 min required)
Equipment: clean anesthesia equipment before sterilization or disinfection; highest level of safety with no reprocessing at all; reuse of disposable equipment not acceptable, including breathing circuits and sampling lines, even if HEPA filters used
Workspace: consider anesthesia workspace potential vehicle of pathogen transmission (clean knobs, buttons, and horizontal surfaces of machines between cases and at end of day)
Studies: Loftus et al (2008) — found association between contamination in anesthesia work area and likelihood of contamination of internal stopcock; IV stopcocks were contaminated in 32% of cases; use of contaminated stopcock associated with significantly higher mortality; authors concluded transmission of bacteria to work area and IV stopcocks likely due to variations in aseptic technique among hospital staff; called for better infection control practices; later study — showed contaminated hands of anesthesia providers to be significant source of operating room contamination, despite reported 90% compliance with hand hygiene procedures; challenges commonly held belief that health care workers play little or no role in bacterial transmission
Practice advisory for neuraxial techniques: identify patients at risk for infectious complications; complications may occur despite use of prophylactic antibiotics; if antibiotics administered to symptomatic patient, do not perform block until symptoms diminish; use aseptic technique; remove jewelry; use cap and mask; hand hygiene —alcohol-based wash appropriate; don sterile gloves only after hands dry; widely prepare area with 2% chlorhexidine gluconate and 70% isopropyl alcohol (saturate pad; rub skin with back-and-forth motion to create friction and reach cracks in skin; let skin dry for ³2 min); povidone-iodine solution recommended instead of chlorhexidine for infants and neonates; consider removing any catheters accidentally disconnected if disconnection unwitnessed; evaluate patient daily for signs and symptoms of infection
Central venous catheter-related bloodstream infections (CRBSI): “bundles of care” — specific practices associated with decreased mortality from CRBSI; include avoiding femoral site if possible, hand hygiene, cleaning skin with chlorhexidine gluconate and alcohol, maximal barrier precautions, and removal of unnecessary catheters; in study by Pronovost et al, interventions associated with decrease in mean rate of CRBSI from 7.7 per 1000 catheter days at baseline to 1.4 at 16 to 18 mo of follow-up
Prevention of intravascular catheter-related infections: CDC guidelines include use of hand hygiene and aseptic technique; hand hygiene before and after palpating catheter insertion sites, and before and after any manipulation of catheter; use of sterile gloves for insertion of arterial, central, and midline catheters (nonsterile gloves acceptable for peripheral IV catheter insertion); maximal sterile barrier precautions recommended when placing central lines, including mask, cap, gown, gloves, and full body drape; disinfect skin before insertion of central venous or peripheral arterial catheters; use 0.5% chlorhexidine solution with alcohol; let skin dry before catheter placement (but do not blot or wipe)
Additional recommendations: non-tunneled central venous catheters — use subclavian rather than internal jugular or femoral site due to increased risk for infection and (at femoral site) thrombosis in adults (risk lower in pediatric patients); peripheral arterial catheters — cap, mask, gloves, and small drape; axillary or femoral artery catheters — maximal barrier precautions recommended; femoral and axillary arteries should never be first choice of catheter site; brachial site contraindicated in children due to risk for mechanical complications
Needleless systems: recommended over stopcocks by CDC for accessing IV tubing; closed catheter systems associated with fewer infections than open systems and should be used preferentially; scrub port with antiseptic, and access only with sterile devices
Reducing risk for surgical site infections
Antimicrobial prophylaxis: administer antibiotic 1 hr before incision to ensure bactericidal in serum and tissues; re-dose periodically to maintain therapeutic efficacy; vancomycin and fluoroquinolones have long half-lives (require 1-hr infusion; start 2 hr before incision)
Temperature regulation: hypothermia causes vasoconstriction, decreased tissue perfusion and oxygenation, and inhibits destruction of bacteria by neutrophils; also associated with adverse cardiac events, reduced drug metabolism, and altered coagulation; CMS recommends active intraoperative warming or documented perianesthetic normothermia (36o C) for all patients undergoing anesthesia for >1 hr
Glucose control: hyperglycemia associated with neutrophil dysfunction and decreased local immune response; blood glucose >200 mg/dL associated with increased risk for surgical site infections after cardiovascular surgery; good preoperative glycemic control shown to decrease infectious complications even after noncardiac surgery, but very tight glucose control associated with increased risk for mortality; recommendation — avoid perioperative hyperglycemia and hypoglycemia; maintain perioperative glucose levels at no more than 180 to 200 mg/dL
Protective measures for anesthesia professionals: annual tuberculosis screening; vaccination for HBV; work restrictions if professional has infectious illness or draining wound; protection of small breaks in skin
Postexposure procedures: immediate washing of needlestick site and evaluation by emergency or employee health department; consider administration of hepatitis B immune globulin or treatment with anti-HIV medications (effectiveness declines rapidly if taken more than several hours after exposure); file incident report; baseline and follow-up blood testing; test source whenever possible; offer counseling to affected worker
Acknowledgements
This program was recorded at Anesthesiology Autumn Update and Review, held September 9-10, 2011, in Saratoga Springs, NY, and sponsored by the Department of Anesthesiology and the Office of Continuing Medical Education, Albany Medical College, Albany, NY. For information on upcoming CME meetings at Albany Medical College, please visit their website at AMC.edu and search for Continuing Medical Education, or check our website, Audio-Digest.org, under Upcoming Meetings. The Audio-Digest Foundation thanks Dr. Greene and Albany Medical College for their cooperation in the production of this program.
Suggested Reading
American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques: Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010 Mar;112(3):530-45; Loftus RW at al: Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008 Sep;109(3):399-407; Loftus RW et al: Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg 2011 Jan;112(1):98-105; Melling AC et al: Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001 Sep 15;358(9285):876-80; O’Grady NP et al: Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011 May;52(9):e162-93; Patel PR et al: Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control 2008 Dec;36(10):685-90; Pronovost P et al: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32; Pugliese G et al: Injection practices among clinicians in United States health care settings. Am J Infect Control 2010 Dec;38(10):789-98; Siegel JD et al: 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007 Dec;35(10 Suppl 2):S65-164; Thompson ND et al: Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009 Jan 6;150(1):33-9; Traynor K: CDC pushes for elimination of catheter-related infections. Am J Health Syst Pharm 2011 Jun 1;68(11):962-3; Voelker R: Updated guidelines target reductions in catheter-related bloodstream infections. JAMA 2011 May 4;305(17):1753-4.
Acknowledgements
Dr. Greene and Albany Medical College for their cooperation in the production of this program.
CME/CE INFO
Accreditation:
The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.
Lecture ID:
AN532401
Expiration:
This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.
Instructions:
To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.
Estimated time to complete this CME/CE course:
Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.
More Details - Certification & Accreditation