Download Educational Objectives Faculty Disclosure - Audio

AUDIO-DIGEST ANESTHESIOLOGY 53:24
Volume 53, Issue 24
INFECTION CONTROL AND THE ANESTHESIA CARE TEAM
INFECTION CONTROL AND THE ANESTHESIA CARE TEAM
To test online, go to www.audiodigest.org and sign in to online services.
To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. Which problematic injection practices were identified by the Centers for Disease Control and Prevention (CDC) in a
recent survey?
1. Reuse of needles and syringes on multiple patients
2. Accessing a medication vial with a used needle or syringe
3. Mixing of contaminated and clean injection equipment
4. Using single-dose vials as multiple-dose vials
(A) 1,2,3,4
(B) 1,2,3
(C) 2,3,4
(D) 1,3
2. Failure to comply with safe infection control practices can result in actions against one’s license.
(A) True
(B) False
3. The standard precautions established by the CDC urge clinicians to view all the following as potential sources of
infectious contamination, except:
(A) Urine
(B) Tears
(C) Sweat
(D) Saliva
4. The single most important practice for reducing the transmission of infectious agents in the health care setting is:
(A) Wearing gloves, masks, and gowns
(C) Refraining from coming to work while ill
(B) Hand hygiene
(D) Use of needleless systems
5. All the following are good examples of safe injection techniques, except:
(A) Using intravenous solution from multidose bottles for several patients
(B) Limiting needles and syringes to one use
(C) Not administering medication from a single-dose bag to multiple patients
(D) Avoiding the use of multidose vials in the immediate patient treatment area
6. Which of the following precautions was not recommended for management of infection control breaches?
(A) Notifying all potentially exposed individuals
(B) Locating the source of the infection
(C) Testing potentially infected patients for bloodborne pathogens
(D) Isolating individuals who may have been exposed
7. If a patient with tuberculosis has just undergone surgery, how long should the operating room remain empty, assuming
15 air changes per hour?
(A) 17 min
(B) 28 min
(C) 39 min
(D) 54 min
8. Which of the following is not a recommended technique for infection control when preparing a patient for a neuraxial
block?
(A) Wide application of chlorhexidine gluconate and isopropyl alcohol
(B) Briskly rubbing the skin with a saturated cotton pad
(C) Starting the incision while the skin is still wet
(D) Using povidone-iodine instead of chlorhexidine on children
9. Which of the following sites of catheter insertion does not require the use of sterile gloves?
(A) Arterial
(B) Central
(C) Midline
December 21, 2011
(D) Peripheral
10. Risk for mortality has been shown to be higher with very tight control of postoperative blood glucose than with
conventional control.
(A) True
(B) False
Answers to Audio-Digest Anesthesiology Volume 53, Issue 23: 1-A, 2-C, 3-D, 4-B, 5-A, 6-B, 7-D, 8-C, 9-C, 10-D
Attention Accreditation Participants
The cutoff date for logging 2011 credits is December 31. Test forms received after that date will be accrued to 2012. You should
receive the current year’s history by the end of January 2012.
훿 2011 Audio-Digest Foundation • ISSN 0271-1265 • www.audiodigest.org
Toll-Free Service Within the U.S. and Canada: 1-800-423-2308 • Service Outside the U.S. and Canada: 1-818-240-7500
Remarks represent viewpoints of the speakers, not necessarily those of the Audio-Digest Foundation.
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
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)
Educational Objectives
Faculty Disclosure
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.
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.
AUDIO-DIGEST ANESTHESIOLOGY 53:24
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 2 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
AUDIO-DIGEST ANESTHESIOLOGY 53:24
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
Accreditation: The Audio-Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Designation: The Audio-Digest Foundation designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should
claim only the credit commensurate with the extent of their participation in
the activity.
The American Academy of Physician Assistants (AAPA) accepts certificates
of participation for educational activities designated for AMA PRA Category
1 Credit from organizations accredited by ACCME or a recognized state
medical society. Physician assistants may receive a maximum of 2 AMA PRA
Category 1 Credits for each Audio-Digest activity completed successfully.
Audio-Digest Anesthesiology programs are approved by the American
Association of Nurse Anesthetists (AANA) for a maximum of 24 CE credits for Volume 53 (Code Number 33415; Expiration Date 12/31/12) and 24
CE credits for Volume 52 (Code Number 32293; Expiration Date 12/31/11).
CRNAs must earn a score of 80% to receive credit, and are not permitted to
retest, as per the AANA.
CRNAs may earn 1 credit per issue in Volume 53 from January 1,
2011 to December 31, 2012 and in Volume 52 from January 1, 2010 to
December 31, 2011.
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 catheterrelated 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.
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 designates each activity for 2.0 CE contact hours.
Audio-Digest Foundation is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners (AANP
Approved Provider number 030904). Audio-Digest designates each activity
for 2.0 CE contact hours, including 0.5 pharmacology CE contact hours.
The California State Board of Registered Nursing (CA BRN) accepts
courses provided for AMA category 1 credit as meeting the continuing education requirements for license renewal.
Expiration: The CME activity qualifies for Category 1 credit for 3 years
from the date of publication.
Cultural and linguistic resources: In compliance with California Assembly Bill 1195, Audio-Digest Foundation offers selected cultural and linguistic resources on its website. Please visit this site: www.audiodigest.org/
CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST ANESTHESIOLOGY 53:24
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 2 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
AUDIO-DIGEST ANESTHESIOLOGY 53:24
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
Accreditation: The Audio-Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Designation: The Audio-Digest Foundation designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should
claim only the credit commensurate with the extent of their participation in
the activity.
The American Academy of Physician Assistants (AAPA) accepts certificates
of participation for educational activities designated for AMA PRA Category
1 Credit from organizations accredited by ACCME or a recognized state
medical society. Physician assistants may receive a maximum of 2 AMA PRA
Category 1 Credits for each Audio-Digest activity completed successfully.
Audio-Digest Anesthesiology programs are approved by the American
Association of Nurse Anesthetists (AANA) for a maximum of 24 CE credits for Volume 53 (Code Number 33415; Expiration Date 12/31/12) and 24
CE credits for Volume 52 (Code Number 32293; Expiration Date 12/31/11).
CRNAs must earn a score of 80% to receive credit, and are not permitted to
retest, as per the AANA.
CRNAs may earn 1 credit per issue in Volume 53 from January 1,
2011 to December 31, 2012 and in Volume 52 from January 1, 2010 to
December 31, 2011.
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 catheterrelated 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.
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 designates each activity for 2.0 CE contact hours.
Audio-Digest Foundation is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners (AANP
Approved Provider number 030904). Audio-Digest designates each activity
for 2.0 CE contact hours, including 0.5 pharmacology CE contact hours.
The California State Board of Registered Nursing (CA BRN) accepts
courses provided for AMA category 1 credit as meeting the continuing education requirements for license renewal.
Expiration: The CME activity qualifies for Category 1 credit for 3 years
from the date of publication.
Cultural and linguistic resources: In compliance with California Assembly Bill 1195, Audio-Digest Foundation offers selected cultural and linguistic resources on its website. Please visit this site: www.audiodigest.org/
CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST ANESTHESIOLOGY 53:24
Volume 53, Issue 24
INFECTION CONTROL AND THE ANESTHESIA CARE TEAM
INFECTION CONTROL AND THE ANESTHESIA CARE TEAM
To test online, go to www.audiodigest.org and sign in to online services.
To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. Which problematic injection practices were identified by the Centers for Disease Control and Prevention (CDC) in a
recent survey?
1. Reuse of needles and syringes on multiple patients
2. Accessing a medication vial with a used needle or syringe
3. Mixing of contaminated and clean injection equipment
4. Using single-dose vials as multiple-dose vials
(A) 1,2,3,4
(B) 1,2,3
(C) 2,3,4
(D) 1,3
2. Failure to comply with safe infection control practices can result in actions against one’s license.
(A) True
(B) False
3. The standard precautions established by the CDC urge clinicians to view all the following as potential sources of
infectious contamination, except:
(A) Urine
(B) Tears
(C) Sweat
(D) Saliva
4. The single most important practice for reducing the transmission of infectious agents in the health care setting is:
(A) Wearing gloves, masks, and gowns
(C) Refraining from coming to work while ill
(B) Hand hygiene
(D) Use of needleless systems
5. All the following are good examples of safe injection techniques, except:
(A) Using intravenous solution from multidose bottles for several patients
(B) Limiting needles and syringes to one use
(C) Not administering medication from a single-dose bag to multiple patients
(D) Avoiding the use of multidose vials in the immediate patient treatment area
6. Which of the following precautions was not recommended for management of infection control breaches?
(A) Notifying all potentially exposed individuals
(B) Locating the source of the infection
(C) Testing potentially infected patients for bloodborne pathogens
(D) Isolating individuals who may have been exposed
7. If a patient with tuberculosis has just undergone surgery, how long should the operating room remain empty, assuming
15 air changes per hour?
(A) 17 min
(B) 28 min
(C) 39 min
(D) 54 min
8. Which of the following is not a recommended technique for infection control when preparing a patient for a neuraxial
block?
(A) Wide application of chlorhexidine gluconate and isopropyl alcohol
(B) Briskly rubbing the skin with a saturated cotton pad
(C) Starting the incision while the skin is still wet
(D) Using povidone-iodine instead of chlorhexidine on children
9. Which of the following sites of catheter insertion does not require the use of sterile gloves?
(A) Arterial
(B) Central
(C) Midline
December 21, 2011
(D) Peripheral
10. Risk for mortality has been shown to be higher with very tight control of postoperative blood glucose than with
conventional control.
(A) True
(B) False
Answers to Audio-Digest Anesthesiology Volume 53, Issue 23: 1-A, 2-C, 3-D, 4-B, 5-A, 6-B, 7-D, 8-C, 9-C, 10-D
Attention Accreditation Participants
The cutoff date for logging 2011 credits is December 31. Test forms received after that date will be accrued to 2012. You should
receive the current year’s history by the end of January 2012.
훿 2011 Audio-Digest Foundation • ISSN 0271-1265 • www.audiodigest.org
Toll-Free Service Within the U.S. and Canada: 1-800-423-2308 • Service Outside the U.S. and Canada: 1-818-240-7500
Remarks represent viewpoints of the speakers, not necessarily those of the Audio-Digest Foundation.
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
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)
Educational Objectives
Faculty Disclosure
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.
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.