Healthcare-Associated Infections in Anesthesia

Joshua K. Schaffzin

L. Silvia Munoz-Price

INTRODUCTION

Dr. John Snow (1813-1858) is best known for his groundbreaking investigation to identify and mitigate the source of cholera outbreaks, the public Broad Street water pump, in London in 1853. Less known is that Snow’s primary specialty was anesthesia. His studies of the safe use of volatile agents helped the practice gain acceptance, and he administered chloroform analgesia to Queen Victoria for the birth of her eighth and ninth children.¹

Infection prevention is often difficult to practice in the modern anesthesia work area. Both fields have evolved over time and produced innovations and advances to prevent patient harm. However, not all developments in anesthesia have addressed infection prevention, and similarly, many infection prevention processes do not take anesthesia into account. Significant advances in infection prevention, such as in prevention bundles, are meant to be implemented in a clinic or inpatient room setting. The World Health Organization’s (WHO) 5 moments of hand hygiene² are difficult if not impossible to follow during anesthesia induction. As Dr. Snow did not combine his two areas of interest, so too have the respective fields not aligned practices effectively.

While numerous guidelines have been published on infection prevention in anesthesia practice,³^,⁴^,⁵^,⁶^,⁷ a lack of uniform knowledge and implementation of recommendations persists. In a recent survey of members of the American Academy of Anesthesiologist Assistants (AAAA), subsets of the American Association of Nurse Anesthetists (AANA), and the American Society of Anesthesiologists (ASA), only 87% of respondents reported always wearing gloves for airway management.⁸ In 2014, safe use of medication vials was the subject of a Joint Commission (TJC) Sentinel Event Alert⁹ after a Centers for Disease Control and Prevention (CDC) assessment of ambulatory surgery centers showed widespread deficiencies, including routine use of single-dose medication vials for multiple patients in 28% of facilities surveyed. Additionally, surveys of U.S. healthcare providers,¹⁰^,¹¹ New York State anesthesiologists,¹² New Zealand anesthesiologists,¹³ and certified nurse anesthetist students¹⁴ reported improper practices despite knowledge of associated risks and existence of guidance. Despite widespread publicity, practice gaps likely persist. In the more recent survey referenced above, 92% reported always disposing of a needle or syringe between every patient, but only 43% reported never using multidose vials for more than 1 patient.⁸

This apparent disconnect has led some authors to conclude that attention to and redesign of the anesthesia work area, through collaboration between anesthesia and prevention professionals, is necessary to align the two practices. Notably, anesthesia professionals play a crucial role in surgical site infection (SSI) prevention, such as ensuring proper dosing and timing of antimicrobial prophylaxis and maintaining normoglycemia and normothermia,¹⁵ many of which carry a risk of disease transmission. This chapter reviews the evidence for pathogen transmission in the
operating room (OR) and anesthesia work area that can occur during delivery of preventive and other cares. The available evidence and current recommendations for preventing transmission are summarized.

FIGURE 34-1 Typical anesthesia process.

DISEASE TRANSMISSION IN THE ANESTHESIA WORK AREA

The Anesthesia Process

Infection prevention professionals may not be familiar with the routine processes their anesthesia colleagues follow. Prior to discussing modes of disease transmission, it may be helpful to review some of the terms and routines in a typical procedure involving general anesthesia. This description is not meant to be comprehensive, and much variation likely exists among contexts and providers.

The anesthesia work area is defined as the space occupied by the anesthesia machines and equipment and the portion of the patient where anesthesia is managed. In a typical OR, the anesthesia work area will be located along a wall to easily connect to electrical, data, and gas sources. There will be an anesthesia machine, which includes functions such as anesthetic delivery, oxygen delivery, and vitals monitoring. Close by will be the anesthesia cart, which will have drawers filled with equipment for airway management, intravenous (IV) catheter insertion and management, anesthetic gas delivery, and medications.¹⁶ The cart has a flat working space where equipment can be staged and medication prepared. There is often more space for equipment storage above the counter space. In order to provide airway management and intravenous medication delivery, the patient’s head and at least one upper extremity will be often used for anesthesia management. Depending on the procedure and patient, the location and setup of the anesthesia work area may vary.

Preparation of equipment and medications for a specific patient will often begin just prior to the patient’s arrival to the OR (a time point often denoted as “wheels in”). Once the patient arrives, preparation proceeds with positioning of the patient for the procedure and establishment of vascular access and monitoring. At this point, the patient is typically ready for anesthesia “induction,” which may involve any or all of preoxygenation, sedation, anesthetic delivery, muscle paralysis, and airway establishment (often through intubation). Once the patient is anesthetized and the airway is secure, they are termed “anesthesia ready,” and the surgical team can begin to prepare the site and commence with the operation. As the case progresses, the patient will require monitoring and pain and fluid management, known as anesthesia “maintenance.” As the operation nears completion, “emersion” can begin where the patient’s sedation is reversed and they are extubated. The patient then leaves the OR (“wheels out”), and room turnover (cleaning and disinfection) can begin. Once turnover is complete, setup for the next patient can commence, and the cycle restarts (Fig. 34-1).

Potential Sources of Disease Transmission

Portions of the typical anesthesia process pose substantial challenges to prevent disease transmission. During induction and emersion, the patient’s airway must often be secured while medications are given and other interventions performed. According to WHO guidelines, the exposure to patient secretions and the administration of medications should result in removal of gloves and performance of hand hygiene.² However, the anesthesia professional cannot stop the process or release the patient in order to do so. Room turnover performed by environmental services staff typically involves cleaning of the surgical bed, floors, and walls, and waste removal, but not the anesthesia machine or cart. The responsibility therefore falls to anesthesia staff, who are pressured to be ready for the next patient and may not clean the machine adequately for fear of damaging the sensitive circuitry.

Not surprisingly, the potential for, as well as proven bacterial transmission have been demonstrated due to contamination of provider hands, the anesthesia machine, and the IV apparatus and stopcock.¹⁷^,¹⁸^,¹⁹^,²⁰^,²¹^,²²^,²³^,²⁴^,²⁵^,²⁶ Finally, a lack of proper reprocessing of equipment needing high level disinfection or sterilization could potentially expose patients to pathogens.²⁷ A sample of evidence supporting disease transmission in anesthesia practice is provided in Table 34-1.

TABLE 34-1 Evidence for Disease Transmission in the Anesthesia Work Area

*Study*	*Year published*	*Setting/findings*
Indirect Evidence
Environmental Contamination/Disinfection
Munoz-Price²⁸	2012	Gram-negative bacillus recovery from OR surfaces
Biddle²⁹	2016	Simulation tracking fluorescent dye placed in mannequin mouth
Birnbach²²	2015	Simulation tracking fluorescent dye placed in mannequin mouth
Murrell³⁰	2019	Reduction of SSI rate following installation of visible-light continuous disinfection system
Stopcock/Infusion System Contamination
Fukada³¹	2007	In vitro bacterial growth in intravenous medication and intravenous systems
Mermel²⁶	2014	Bacterial contamination of catheter manifolds used during anesthesia
Koff²⁵	2009	Bacterial contamination of intravenous tubing used during anesthesia
Gargiulo²⁴	2016	Bacterial grown from syringes with remnant drug and filters used when injecting drug
Loftus²³	2008	Bacterial contamination of stopcocks and catheter manifolds used during anesthesia
Loftus¹⁷	2012	Bacterial stopcock contamination, correlated with patient mortality
Direct Evidence
Transmission Demonstrated
Loftus²⁰	2015	Bacterial transmission demonstrated comparing isolates from patient, provider hands, and anesthesia work environment
Loftus¹⁹	2015	Bacterial transmission demonstrated comparing isolates from patient, provider hands, and anesthesia work environment
Loftus¹⁸	2015	Bacterial transmission within and between cases demonstrated comparing isolates from patient, provider hands, and anesthesia work environment
Outbreaks
Rudnick³²	1996	Bacteremia following open-heart surgery; bacterial contamination of pressure-monitoring equipment by use of disinfectant spray during end-of-day cleaning; ended when equipment was assembled immediately prior to use
Sack³³	1970	Bacterial transmission during anesthesia; vial of medication used for multiple patients
CDC³⁴	1990	Candida transmission in 4 states from intravenous infusion; use of same pump syringe for multiple patients
Veber³⁵	1994	Bacteremia from contaminated medication vial used on multiple patients
Massari³⁶	2001	Hepatitis C virus transmission during anesthesia for gynecologic surgery; vial reentry and use on multiple patients
CDC³⁷	2008	Hepatitis C virus transmission during anesthesia for endoscopy; vial reentry and use on multiple patients
Samandari³⁸	2005	Hepatitis B virus transmission in private physician office; poor separation of clean and dirty, multidose vial use
Germain³⁹	2005	Hepatitis C virus transmission during general anesthesia; vial reentry and use on multiple patients
Lagging⁴⁰	2002	Cardiac catheterization procedure; vial reentry, multidose vial saline used for flush on multiple patients
Wong⁴¹	2010	Bacterial infection following joint injection; vial reentry and use on multiple patients
Gutelius⁴²	2010	Hepatitis B virus and hepatitis C virus transmission during anesthesia for endoscopy; vial reentry and use on multiple patients

INFECTION PREVENTION IN THE ANESTHESIA WORK AREA

Infection prevention in the anesthesia work area should focus on the sources of disease transmission (hand hygiene, environmental disinfection, and medication safety) and incorporate healthcare-associated infection (HAI) prevention efforts from outside the OR (such as prevention of SSIs, catheter-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated respiratory infection (VARI) into routine practice) (Table 34-2).

Hand Hygiene

As described above, anesthesia professionals are challenged to follow the 5 moments of hand hygiene as defined in WHO guidelines.² Unfortunately, this may have inadvertently made anesthesia professionals less likely to perform hand hygiene. Fewer than half of professionals surveyed reported always performing hand hygiene upon entry

to or upon exit from the OR. Only 58% and 61% reported always performing hand hygiene before and after patient contact, respectively.⁸ When using the WHO 5 moments to evaluate adherence, anesthesia professionals performed poorly, with ˜1% of opportunities during induction and 2% during maintenance, resulting in poor hand hygiene performance.⁴³

TABLE 34-2 Summary of Recommendations, Society of Healthcare Epidemiology of America Expert Guidance: Infection Prevention in the Anesthesia Work Area⁸

Hand Hygiene

Performed at the minimum:

Before aseptic tasks
After removing gloves
When hands are soiled or contaminated
Before touching anesthesia cart contents
When entering and exiting the OR

Consider double gloves during airway management

Remove outer gloves immediately after airway manipulation
Remove inner gloves and perform hand hygiene as soon as possible

Locate alcohol-based hand rub dispensers at OR entrance and near anesthesia providers in the OR

Insufficient evidence for use of alcohol-based hand rub on gloves

Changing gloves with hand hygiene between donning and doffing is preferred

Environmental Disinfection

Laryngoscopes/video-laryngoscopes

Standard direct laryngoscope and video-laryngoscope reusable handles and blades—complete high-level disinfection
Consider replacement with single-use devices

Anesthesia machine and cart

Insufficient evidence for disposable cover use
Wipe accessible outer surfaces between cases
Perform hand hygiene before opening and handling drawer contents
Avoid storing supplies on top of cart

OR preparation between uses

Clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area between OR uses

Injection ports

Only use disinfected ports for intravenous access
Port disinfection

○ Scrubbing with a sterile alcohol-based disinfectant immediately prior to each use

○ Cover ports continuously with sterile isopropyl alcohol containing caps

○ Disinfect before individual drug injection or at the beginning of a rapid succession of injections (eg, anesthesia induction)

Medication vials

Wipe rubber stopper and ampule neck with 70% alcohol prior to each access
Use single-dose vials and flushes whenever possible
Multidose vials should be used for 1 patient, use sterile needle and syringe for each entry
Never reuse syringes or needles for another patient

Full barrier precautions

Use of cap, sterile gown, mask, sterile gloves, and large sterile drape
Use for insertion of all CVCs and femoral and axillary arterial catheters

Needleless syringes

Recap if administering multiple doses to same patient from same syringe

Provider prepared sterile injectables

Use as soon as practicable following preparation

Spiked intravenous fluid bags

Minimize the time between spiking and administration

Keyboards and touchscreens

Clean and disinfect after each case

Contact isolation

Follow all institution-specific policies for hand hygiene, personal protective equipment, and environmental cleaning

Implementation

Conduct regular evaluation and monitoring of practice, hand hygiene, and environmental cleaning and disinfection
Encourage collaboration of frontline providers and leadership
Insufficient evidence to recommend technology-based monitoring

OR, operating room; CVC, central venous catheter.

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