IN COLLABORATION WITH

COLLEGE OF ANAESTHESIOLOGISTSACADEMY OF MEDICINE OF MALAYSIA

MALAYSIAN SOCIETY OF ANAESTHESIOLOGISTS

K E S E LAMATAN D A L A M B I US

GUIDELINES ON INFECTIONCONTROL IN ANAESTHESIA

May 2014

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Endorsed by:Council Members, College of AnaesthesiologistsAcademy of Medicine of Malaysia2014 - 2015

President Datin Dr V SivasakthiDeputy President Dr Tan Cheng ChengHon Secretary Associate Professor Dr Raha Ab RahmanHon Treasurer Professor Dato’ Dr Wang Chew YinCouncil Members Professor Dr Lim Thiam Aun Dr Lim Wee Leong Dr Patrick Tan Dr Thohiroh Abd RazakCoopted Council Members Dr Raveenthiran Rasiah Dr Sushila Sivasubramaniam

Published byCollege of Anaesthesiologists, Academy of Medicine of Malaysia

In collaboration withMalaysian Society of Anaesthesiologists

GUIDELINES ONINFECTION CONTROL IN ANAESTHESIA

May 2014

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Contributors 1. Dr Kavita Bhojwani Senior Consultant and Head Department of Anaesthesiology and Intensive Care Hospital Raja Permaisuri Bainun Ipoh, Perak, Malaysia

2. Dr Mohd Rohisham Bin Zainal Abidin Consultant and Head Department of Anaesthesiology and Intensive Care Hospital Tengku Ampuan Rahimah Klang, Selangor, Malaysia

3. Dr Mafeitzeral Mamat AnaesthetistandSeniorLecturer AnaesthesiaandCriticalCare Faculty of Medicine UniversitiTeknologiMARA Sungai Buloh, Selangor, Malaysia

4. Dr Shahridan Fathil Consultant Department of Anaesthesia JurongHealth @ Alexandra Hospital Singapore

5. Dr Noorulhana Sukarnakadi Binti Hadzarami Specialist Anaesthesiology and Intensive Care Department of Anaesthesiology and Intensive Care HospitalKualaLumpur,KualaLumpur,Malaysia

Reviewers 1. Dr Anselm Suresh Rao Consultant Anaesthesiologist and Intensivist Gleneagles Hospital KualaLumpur,Malaysia

2. Dr Jeyaseelan P Nachiappan ConsultantInfectiousDiseasePaediatrician Hopital Raja Permaisuri Bainun Ipoh, Perak, Malaysia

3. Datin Dr Ganeswrie Rajasekaram Senior Consultant Clinical Microbiologist and Pathologist Hospital Sultanah Aminah Johor Bharu, Johor, Malaysia

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Message from the President of the College of 4Anaesthesiologists, Academy of Medicine Malaysia

Introduction 5

Recommendations for Preoperative Hand Decontamination 6

Antiseptic Agents and Skin Preparation 6

Sharps Use and Disposal 7

Theatre Wear and Codes of Practice 8

Preventing Drug Contamination 13

Anaesthetic Apparatus 14

Anaesthetic Machines 19

Infection Control Guidelines Specific to Peripheral Nerve Blocks 20

Conclusion 21

References 22

CONTENTS

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My dearest Colleagues,

It is with great pleasure that I take this opportunity to write a few lines in these latest “Guidelines on Infection Control For Anaesthesiologists”whichistheculminationofhardworkanddedicationfromaselectgroupof senior anaesthesiologists. Infection prevention and control came tothepublicawarenessaftertheriseofMRSAandC.difficile inparticularinthemiddleofthelastdecade.Thispublicationisindeedtimelyaswesee an increasingly difficult problem of resistant organisms emergingandtreatingthemhasbecomechallenging.Theguidelineshighlightstheneedforhealthcareprofessionalstounderstandandputintopracticetheprinciplesofinfectionpreventionandcontrolinordertoimprovepatientoutcomes.

The contents of these guidelines cover a spectrum of areas ranging from handwashing, antiseptics used, sharps use and disposal, theatrewear,cleaning of anaesthesia machines and other apparatus and lastly the recommendations for preoperative hand decontamination as well asperformance of peripheral nerve blocks.

I strongly believe that if we strictly adhere to the practices in theseevidencebasedguidelines,wecollectivelycanmakeadifferencetoensurethatinfectioniscurtailedandthatthebestoutcomeforthepatientcanbe achieved!

I conclude by thanking the contributors, the panel of reviewers and the secretariat for making this possible.

Datin Dr V SivasakthiPresidentCollege of AnaesthesiologistsAcademy of Medicine of Malaysia

MESSAGE

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INTRODUCTION

Thepracticeofanaesthesiamustbemadeassafeaspossibletoallpatients,

anaesthetistsandotherhealth careproviders, thus it is absolutely vital

thatinfectionriskstoallpartiesarekepttoaminimum.Theseguidelines

on infection control are focused with particular emphasis on issues

anaesthetistswouldbefacinganddealingwithintheirdailypractice.Itis

meant to complement the Ministry of Health Malaysia book on ‘Policies

andProceduresonInfectionControl2ndEdition,preparedin2009’.

These guidelines cover hand hygiene, invasive procedures, regional

anaesthesia, the wearing of gloves, masks, gowns, movement within and

outside the operating theatre and the surgical order of patients in an

operatinglist.

We would like to thank Associate Professor Datin Dr Norsidah Abdul

Manap,PastPresidentof theCollegeofAnaesthesiologists, 2011-2013,

for initiating the development of these guidelines. A special note of

appreciation to reviewers, DatinDrGaneswrie Rajasekaram,Dr Anselm

SureshRaoandDrJeyaseelanPNachiappan.

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RECOMMENDATIONS FOR PREOPERATIVE HAND DECONTAMINATION

Agentsormethodsofskindecontaminationthatcauseskinabrasionsshouldnot be used. Using a scrubbing brush on the skin is not recommended. An approved antiseptic agent (chlorhexidine gluconate 4% or povidoneiodine7.5%)shouldbeusedforhandwashing.

‘Surgical scrub’ aseptichandwash shouldbe carriedout for aminimumdurationof twominutes. Inbetweencases, theuseofalcoholgelhandrub applied using the recommended technique is considered adequate in theoperatingtheatrewherethehandsarecleanandhavealreadybeendecontaminatedbyconventionalmethods.

ANTISEPTICS AGENTS AND SKIN PREPARATION

Alcohol based solutions are more effective and preferable to aqueoussolutions for skin preparation (chlorhexidine gluconate 0.5% in alcohol70%;povidone iodine7.5%). They shouldbeallowed todry thoroughlyafterapplicationontheskin.

Controversy still exists regarding the safest antiseptic solution to usefor regional blockade. Some of themore commonly used solutions arepovidone iodine, chlorhexidine gluconate with and without isopropyl alcohol, iodophorpreparationin isopropylalcoholandisopropylalcoholalone. Both, povidone iodine and chlorhexidine solutions, have notreceivedspecificFoodandDrugAdministrationoftheUSA(FDA)approvalforusebeforeregionalanaesthesia(spinal,epiduralandperipheralblock)becauseofalackofclinicaltesting.Atpresent,theMaterialSafetyDataSheet registered with the FDA does not describe adverse neurological or central nervous system events after recommended povidone iodine orchlorhexidine use.

Ithas,however,beenshownthat0.5%chlorhexidinein70%alcoholmaybethemosteffectiveinmaintaininganasepticstateontheskinsurface

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foraprolongedperiodoftimeandthereforereducingtheoverallriskofepiduralcathetercolonization.2,3

Fortheinsertionofacentralvenousline(CVL),2%chlorhexidinein70%alcohol is recommended. Povidone iodine should be used in infants less than two months old.

Gross contamination at the site of procedure should be subjected to aprewash using a non antimicrobial soap and thoroughly dried prior toantisepticpreparation.Applytheantisepticskinpreparationinconcentriccirclesmovingawayfromtheproposedincisionsitetotheperiphery;allowsufficientpreparedareatoaccommodateanextensiontotheincisionornew incisions or drain sites to be made or site for regional block. Allow the alcoholtodryaftertheapplicationandbeforetheuseofelectrocautery.Thetypeof theskinpreparationmayneedtobemodifiedaccording totheconditionoftheskin(e.g.burns)andthelocationoftheincisionsite(e.g.alcoholandalcoholbasedsolutionshouldnotbeusedonmucousmembranes).

Ideally,antisepticsshouldbeavailableasready-for-usedilutionsinsmall,single-use containers. Multi-use containers are liable to contaminationeachtimetheyareopened.Multi-useantisepticsolutions,ifused,shouldbelabelledwiththedateitwasopenedandusedwithinthe‘usebydate’.Itshouldnevertoberefilledandmustbediscardedaftertheexpirydate.

SHARPS USE AND DISPOSAL

Useanappropriatesizeandtypeof‘sharps’bin/boxfortheanticipatedprocedure and volume of usage. Do not place ‘sharps’ bins / boxes inareas where there may be an obstacle to environmental cleaning. Avoid overfilling; the sharps containersmust be closed securely when three-quartersfull.Usedneedlesmustnotberesheathed/recapped.Surfacecontaminationbybloodorbodyfluidsshouldbedealtwithpromptly,asstatedperthe“PoliciesandProcedureonInfectionControl”,MinistryofHealth).Policiestousesafetydevicesoughttobephasedin.StaffsinOTought to be familiar with local protocol following sharps injury.

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THEATRE WEAR AND CODES OF PRACTICE

GlovesSterile gloves have to be worn for invasive procedures such as CVLinsertions, arterial line insertions, nerve blocks (neuraxial, peripheral,ultrasound guided), fibreoptic intubation and endotracheal suction.The addition of a second pair of surgical gloves significantly reducesperforationstotheinnermostglove,reducehandcontaminationandalsoreduces the risk of transmission of blood borne pathogens.

Cannulationofcentralveinsistobeperformedusingfullaseptictechniqueincluding the wearing of facemask, sterile gown and gloves, and the use of asterilefieldborderedbysteriledrapesisrequired.1

GownsThe purpose of theatre gowns and drapes is to prevent bacteria from the healthcareworkerorthenonsterileareaofthepatientpassingthroughthe material directly into the surgical wound or into the air.

Face MasksAsingle3plysurgicalmask(filtersize<1.1microns)istobewornbyallmembers of the scrub team. There is insignificant evidence to supportthecontinuedwearingofmasksfornon-scrubbedstafftopreventwoundinfection.1 It does however provide a barrier for airborne organisms and alsoprotects thehealthcareworkeragainstblood,bodyfluidsplashes,smoke and laser plumes. Masks should not be worn outside theatre areas orlefttiedaroundtheneck.Aftersurgery,themaskshouldberemovedanddisposedappropriately.Afreshmaskshouldbewornforeachoperation.Inverticallaminarflowtheatres,amaskshouldbewornduringprostheticimplant surgery.

Performance of aerosol generating procedures such as endotrachealintubation,bronchoscopyandendotracheal suctioning forpatientswhohavehighlyinfectiousrespiratoryinfections(e.g.Severeacuterespiratorysyndrome (SARS), avian influenza,H1N1 influenza) require theuseof aPoweredAirPurifyingRespirator(PAPR)bythehealthcareworker.

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Theatre CapsTheatre personnel should wear disposable headgear even though there islittleevidencefortheeffectivenessofthispracticetheexceptionbeingthe scrub staff because of their close proximity to the operating field.Headgearsarestillrecommendedasithelpstokeephairoutofthewayanddifferentcoloursareusetoindicatethepositionofpersonnel.Afteruse,headgearsmustbedisposedoffandnotwornoutsidetheoperatingtheatre. Cloth caps, if used, must be washed daily.

Theatre FootwearWellfittingfootwearwithimpervioussolesshouldbewornandshouldberegularlycleanedtoremovesplashesofbloodandbodyfluid.Proceduresshould be in place to ensure that this is done regularly. Studies of bacterial contamination of the Operating Theatre (OT) corridor floors indicatea change of footwear should occur as far from theOT as possible.5 OTfootwearisforbiddenoutsidetheoperatingtheatrecomplex.Overshoesleadtoasignificantincreaseinfloorcolonyandmayalsocontaminatethehands when they are put on or removed.7

JewelleryWearing of rings or other jewellery during procedures are strongly discouraged. If religious or cultural influences strongly condition thepersonnel’sattitude,simpleandpracticalsolutionallowingeffectivehandhygieneisforthepersonneltowearthering(s)aroundtheneckonachainas a pendant.8

Artificial fingernails are not allowed and nails to be kept short, lessthan0.5cms.Removingnailpolish fromoperating room(OR)personnelprior to scrubbing and frompatients prior to surgery on their hands isrecommended.Thereareconcernsthatmicro-organismscanproliferatein chipped, peeled nails because they remain relatively protected fromantimicrobialeffectofsoaporalcoholscrubsandcanactasavehicleforthetransferofinfectiveagents.9,10

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VisitorsFor parents accompanying children, they are required to wear an overcoat andachangeoffootwear.Theywillneedtoleavetheoperatingroomafterthe induction. If visitors are to enter theORand stayon for theentireduration of surgery (e.g. husbands accompanying wives for Caesareansections),theyshouldchangeintotheatreattire.

Attire on Leaving Operating TheatreTheatrestaffshouldwearanovercoatwhen leaving theOTandchangetheir footwear. Surgical masks and caps must be removed. If an overcoat is notworn, theymust change into newOT attire on return to theOT.WearingOTattireinpublicareascangivetheimpressionthatdisciplineis lax.Although there is insufficientevidence to support thewearingofovercoatsoversurgicalattiretopreventinfection,thepracticeisdesirableaesthetically.11

Movement in OT and OT LayoutThedoorstotheOTandORshouldbekeptclosedexceptwhennecessaryforpassageofthepatient,personnel,suppliesandequipment.DisruptedpressurisationcausesamixtureofthecleanairoftheOTwiththecorridorair which has a higher microbial count. Cabinet doors should remain closed.12

Roomtemperaturemustbemaintainedbetween18 -210Catalltimes.Humidityshouldbemaintainedat50-60%.TheORshouldbe10C cooler than the outer area. This aids in the outward movement of air. A thermostat andhumidistatsuitablefortheORapplicationoughttobemadeavailable,properlypositionedandcalibrated.

Operatingroomdoorsneedtobekeptclosedduringprocedurestooptimisetheefficiencyoftheventilationsystem.Aconventionallyventilatedtheatreshouldhaveanairchangerateof15-20airchanges/houroratleastthreeexchangeoffreshair(1airchangeevery3minutes).Eachairchangewill,assuming perfect mixing, reduce airborne contamination to 37% of itsformer level.

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Operation Theatres are designed to have gradients of cleanliness fromgeneral areas at the periphery of the suite (changing rooms, rest area,corridors and disposal rooms), through intermediate areas (scrub,anaesthetic)tothecleanestareas(theatreandlay-up).Giventhisconceptof gradients, measures such as red lines (over which non-theatre feetmustnottread)arearbitrary.Whilsttheymayenforcediscipline,theyareunlikelyinthemselvestohaveanyeffectonpatientinfection.

Use of either one (one trolley fromward to OT table) or two transfertrolleys(onefromwardtotransferzoneandanotherfromtransferzoneto OT table) does not seem to affect number of airborne bacteria intheatre.13 The use of two trolleys does have a lower bacterial counts on floorsbutthecontributiontoairborneinfectionisnegligible.14 If beds are usedtotransportpatientsfromwardsintotheatre,thebeddingshouldberemoved and be replaced with clean, fresh linen.

PersonalitemsarenotencouragedtobebroughtintoOTsbutshouldbekept in lockers provided.

Despitethelackofevidence,adhesivematsareusedatair-locksasstickysurface that collects debris from trolley wheels and footwear. However there is a concern that it may become a reservoir and a source of contamination.Therefore,itshouldbereplaceddaily.15

Listing of Biohazard PatientsMostmicrobesfoundinthecirculatingairoftheoperatingtheatreoriginatefromthestaffandverylittleoriginatefromthepatient.However,iftheatreventilationiseffectiveairshouldnotbeasourceofinfectionregardlessofwhether theprocedure isdirtyor clean.Surfacecontamination ismorelikelytoposeariskoftransmissionofinfectionthanair.Theonlypracticalwayofreductionofmicrobes isbycleaninganddisinfectionofrelevantsurfaces.Therefore,theoperatingtable,surfaceanditemsofequipmentin direct contactwith the patient should be cleaned between patients.Traditionally ‘dirty’casesor infectivecasesareputlast inthelistasthis

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wouldfacilitatetheprocessofadequatedecontamination.Howeverthisisnot necessary provided the cleaning of surfaces is done adequately during a list.

AconventionallyventilatedORdoesnotneedtolieidleformorethan15minutesbeforeacleanprocedureisperformedfollowingadirtyoperation.VerticallaminarflowORneedonly5minutestoreplacethefullvolumeofair in the theatre.

Use standard precautions for all patients. Take extra care with sharpsand ensure that all measures are in place to minimise the risk of needle stick injuryorcontaminationwithblood.Theoperatingteamshouldbeexperiencedandtheprocedureunhurried.Theadditionofasecondpairofsurgicalglovessignificantlyreducesperforationstotheinnermostgloves.16 Gowns and drapes that are waterproof and disposable are recommended astheyofferbetterprotection.17

Cleaning the OR in-between PatientsAfter the patient has left and before the next patient enters the OR,surfacessuchastheoperatingtableandanyequipmentindirectcontactwith the patient should be cleaned with a detergent and allow to airdry.15minutes is sufficient forconventionallyventilated theatres to liefallowafterdirty cases andbefore thenext case. Floors should alsobecleaned with detergent and dried. Disinfectants are unnecessary apart fromtheiruseintheremovalofbodyfluidspillage.Wallsandceilingsarerarelyheavilycontaminated;cleaningthemtwiceayear isareasonablepractice.11

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PREVENTING DRUG CONTAMINATION

Syringes and NeedlesSyringes and needles are sterile, single-use items and after entry orconnection to a patient’s vascular systemor attachment to infusions, asyringe and needle should be considered contaminated and used only for thatpatient.

Before use, prepared syringes and needles should be stored in a clean containerandsyringescappedtoavoidcontamination.Itispreferabletousea singledrug tray foreachpatient tominimizecross-contaminationandtoreducetheneedtorecaptheneedle.Afteruseorattheendoftheanaesthetic, all used syringeswithneedles shouldbediscarded into anapproved sharps container.

Presentation of Drugs for InjectionBecause of the potential for cross infection, the use of the contentsof multiple dose vials and ampoules for more than one patient is notrecommendedexceptinadispensingsituationwheredifferentdosesaredrawnupbefore administrationof first dose to a patient. Likewise it isrecommended that any infusion should be prepared and used for one patientonly.

Intravenous Drip SetAll infusions, administration sets or items in contact with the vascularsystem or other sterile body compartments are for single-patient use.Connectionsandinjectionportsinintravenouslinesshouldbekepttoaminimum.Injectionportsshouldbemaintainedwithasteriletechnique,kept free of blood and covered with a cap when not in use.

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ANAESTHETIC APPARATUS

Itemsofanaestheticequipmentmaybecomecontaminatedeitherdirectlyor indirectly. Contamination is not always visible and all usedpiecesofequipment must be assumed to be contaminated and disposed off or,if reusable, undergo a process of decontamination. There is a need todesignate a person who is responsible for ensuring equipment cleanliness. The following measures are intended to minimise the risk of transmission ofinfectionintherespiratorytractviaanaestheticequipment.

Single-use EquipmentThe balance between single-use items and re-usable equipment willrequirelocaldeterminationbasedonanassessmentofpatientsafety,theavailable facilities and cost. Packaging should not be removeduntil thepointofuseforinfectioncontrol,identification,traceabilityinthecaseofamanufacturer’srecall,andsafety.

DecontaminationDecontamination is a combination of processes including cleaning,disinfection and/or sterilisation used to make a re-usable item safeto be handled by staff and safe for further use on patients. Effectivedecontaminationof reusabledevices is essential in reducing the riskofinfection.

Decontamination Processes Cleaning - removal of foreign material from an item. This usually involveswashingwithadetergenttoremovecontaminationfollowed by rinsing and drying. All organic debris, e.g. blood, tissue or body fluids, must be removed before disinfection or sterilisation, as its presencewillinhibitdisinfectantorsterilantfromcontactingmicrobial cells.Cleaningbeforesterilisation isoftheutmost importance inthe effectivenessofdecontaminationproceduresandinreducingtherisk of transmission of pathogens and prions.

Enzymatic detergents can aid in the cleaning of difficult to remove organic matter. It is intended for use in soaking or pre-cleaning instrumentsasafirststepinthedisinfectionorsterilizationcycle.

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Ultrasonic cleaner or washer converts high frequency sound waves into mechanicalvibrationinsolution.Thisequipmentaidsinlooseningand “liftingoff”organic soil fromhard to reachareasofmedicaldevices such as biopsy forceps of endoscope.

Low Level Disinfection - kills most vegetative bacteria (except M.tuberculosis and bacterial spores), some fungi and some viruses. Examplesofsuchdisinfectantsaresodiumhypochlorite,70%alcohol and chlorhexidine.

High Level Disinfection-killsvegetativebacteria(notallspores),fungi andviruses.Withsufficientcontacttime(oftenseveralhours), these high level disinfectants may produce sterilisation, e.g. the use of aldehydes,peraceticacidandchlorinedioxide.

Sterilisation - A process used to render an object free from viable micro-organisms,includingallbacteria,spores,fungiandviruses,with techniquessuchasautoclaving(butseeprionslater).

Risk AssessmentThechoiceofequipmentand⁄orthelevelofcleanliness⁄disinfection⁄sterility required of reusable items may be assessed against the risk posed topatientsoftransmissionofinfectionduringanyprocedureinwhichtheequipment is employed. It has been proposed that medical devices be classifiedintothreegroups:

1. Criticaldevices-thedevicewillpenetrateskinormucousmembranes enterthevascularsystemorasterilespace-thesedevicesrequire sterilisation.

2. Semicriticaldevices-thedevicewillbeincontactwithintactmucous membranes or may become contaminated with readily transmissible organisms - these devices require high-level disinfection or sterilisation.

3. Non critical devices - the device contacts intact skin or does not contactpatientdirectly-thesedevicesrequirelow-leveldisinfection or cleaning.

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INFECTION CONTROL RECOMMENDATION FOR ANAESTHETIC APPARATUS

Anaesthetic FacemasksAlthough normally in contact with intact skin, these items are frequently contaminated by secretions from patients and have been implicated incausingcross-infection;localdisinfectionisnotnormallyeffective18. These items shouldpreferablybe single-use itemsor tobe sterilisedbetweenpatientsbyanauditedSterileSuppliesDepartment (SSD) inaccordancewiththemanufacturer’sinstructions.

Airways and TubesOralairways,nasalairwaysandtrachealtubesshouldbeofsingle-usetypesince they readily become contaminated with transmissible organisms and blood.19,20Ideally,supraglotticairwaysshouldbeofthesingle-patientusetypebutsupraglotticairwaydesignedforrepeateduseshouldbesterilisednomoreoftenthanthemanufacturerrecommends.Asupraglotticairwayused for tonsillectomy or adenoidectomy should not be used again. We recommendsingle-usesupraglotticairways.

Catheter Mounts and Angle PiecesItisrecommendedthattheseitemsaresingle-patientusetypeorsterilisedif it is to be reused.

Anaesthetic Breathing SystemsItwaspreviously recommended“anappropriatefilter shouldbeplacedbetween the patient and the breathing circuit (a new filter for eachpatient)”. Although it appears that pleated hydrophobic filters have abetter filtration performance thanmost electrostatic filters, the clinicalrelevance of this has yet to be established.21,22

Thedisposableanaestheticbreathingcircuitsaresuppliedasnon-reusableitems. Inpractice,mostdepartmentsofanaesthesiaused thesecircuitsfor more than one patient or for more than one operating session inconjunctionwiththeuseofanewfilterforeachpatient.

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We recommend that anaesthetic circuits to be routinely changed on adailybasis.Ifvisiblycontaminatedorusedforhighlyinfectiouscases,e.g.tuberculosis,thecircuitsshouldbechangedbetweenpatientsandsafelydiscarded.Noattemptshouldbemadetoreprocesstheseitems.

LaryngoscopesAs with anaesthetic facemasks, laryngoscopes are known to becomecontaminated during use. Current practices for decontamination anddisinfectionbetweenpatientsarefrequentlyineffective,leavingresidualcontaminationthathasbeenimplicatedasasourceofcross-infection.23,25 Bladesarealsoregularlycontaminatedwithbloodindicatingpenetrationof mucous membranes, which places these items into a high-riskcategory.25 Proper cleaning of laryngoscope blades is of great importance beforedecontamination⁄sterilisation,particularlyofresiduearoundlightsourcesorarticulatedsections.Newpurchasesshouldbeofadesignthatiseasy toclean.Although repeatedautoclavingmayaffect the functionof laryngoscopes, re-usable laryngoscope blades should be sterilisedby an audited SSD between patients, following the manufacturers’instructions.26Plasticsheathsmaybeusedtocoverbladesandhandlestoreducecontaminationbutithasbeennoted,especiallywithbladecovers,thatthesehavecreateddifficultiesduringtrachealintubation.

Therearean increasingnumberof inexpensive,single-use laryngoscopeblades and handles of improving design available, and their use is to be encouraged. The choice of blade must be dictated by Departments of Anaesthesia. Traditional blades should be available at all times in casedifficultyisencountered.

Laryngoscopehandlesalsobecomecontaminatedwithmicro-organismsand blood during use, and they should bewashed ⁄ disinfected and, ifsuitable, sterilised by SSDs after every use. The knurled handles oflaryngoscopes cannot be cleaned reliably manually if covered in blood or bodyfluids.

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Anaesthetistsshouldshowgreatcarewhenhandlinglaryngoscopes:weargloves during intubation and place used instruments in a designatedreceptacletopreventcontaminationofsurfaces,pillowsanddrapes.

Fibreoptic BronchoscopesTheseareexpensiveitemswhichcannotbeautoclaved.Decontaminationis dependent on sufficient contact timewith high level disinfectants. Itis important that the washing and cleaning process removes all organic soilfromallsurfacesofthescope.Decontaminationisbestachievedwithan automated endoscope reprocessor. With the uncertainty of the future implicationsofvariantCreutzfeldJakobDisease(CJD),theseitemsshouldhaveauniqueidentifierwhichshouldberecordedateveryusetopermitfuture tracing.

BougiesRe-use of these items has been associated with cross-infection.27 Manufacturersrecommendthatagumelasticbougiemaybedisinfectedup to five times between patients and stored in a sealed packet. It ispreferablethatalternativesingle-useintubationaidsareemployedwhenpossible.

Resuscitation EquipmentSingle-patient use equipment should be kept in a sealed package orshouldbere-sterilisedbetweenpatientsaccordingtothemanufacturer’sinstructions.Alltrainingequipmentshouldbehandledsimilarly.

HumidifierSterilewater isusedtofillhumidifiers.Hotwaterbathtypehumidifiersshould be disinfected between uses.

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Routinedaily sterilisationor disinfectionof internal components of theanaestheticmachine is not necessary if a bacterial / viral filter is usedbetween patient and circuit. However, manufacturers’ cleaning andmaintenance policies should be followed, and bellows, unidirectionalvalves and carbon dioxide absorbers should be cleaned and disinfected periodically.Allthesurfacesofanaestheticmachinesandmonitorsshouldbe cleaned on a daily basis with an appropriate disinfectant or immediately if visibly contaminated.

Sampling Lines for Side Stream Gas Analysis Theseneednotordinarilybesterilisedbeforereusebecauseoftheone-wayflowofgasthroughthem.Sampledgasfromacapnographorothersuch measurement device should not be returned to the anaestheticcircuitunlessitisfirstpassedthroughaviralfilter.

Carbon Dioxide AbsorbersWhenafilterisusedinthecircuitasdescribesinabove,sterilisationofthecarbon dioxide absorber prior to every case is not necessary nor with most modelsisitpracticablealthoughdisposableversionsandmodelscapableofbeing sterilisedare available. Thedevice including theunidirectionalvalves should be disinfected regularly.

SurfacesThesurfacesofanaestheticmachinesandmonitoringequipment,especiallythose areas which are likely to have been touched by the gloved hand thathasbeenincontactwithbloodorsecretions,shouldberegardedascontaminated and should be cleaned at the earliest opportunity, probably between patients. Local policies should be in place to ensure that allequipmentthattouchesintactskin,ordoesnotordinarilytouchthepatientat all, is cleaned with a detergent at the end of the day or whenever visibly contaminated.Thisincludesnon-invasivebloodpressurecuffsandtubing,pulse oxymeter probes and cables, stethoscopes, electrocardiographic cables,bloodwarmersetc,andtheexteriorofanaestheticmachinesandmonitors.Itemssuchastemperatureprobesshouldbeforsinglepatientuseorsterilizedformultipleuse.

ANAESTHETIC MACHINES

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IntroductionInfectious complications associated with regional anesthesia are rare.However, the complications associated central neuraxial techniquesincludingmeningitis,paralysis,anddeatharepotentiallymoredevastating.Fortunately,thereportedfrequencyofsuchcomplicationsislow27.

The frequencyof infectionassociatedwith continuousperipheralnerveblocks (PNBs) remains more undefined. Cases of localized infection,bacteremia and abcess formation have been reported after continuousperipheral nerve blocks (CPNBs).28 Increased risk factors for the developmentofcatheterinflammation/infectionincludes;IntensiveCareUnitstay,traumapopulation,prolonged(>48hours)durationofcatheteruse, absence of perioperative antibiotic prophylaxis, axillary or femoralcatheters,contaminationoflocalanestheticsolutionandthefrequencyofcatheter dressing changes27,28.

Althoughsingle-shotPNBsisbelievedtohavealowerinfectiousriskwhencompared with CPNBs, severe complications have been reported withsingle-shottechniquesaswell.Nseirhadreportedtheonlyfatalcaseofsingle-shotPNB(axillaryblock)complicatedbystreptococcalnecrotizingfasciitis inanelderlypatientundergoingcarpal tunneldecompression.29 However,more reportsof such complicationmayemergeas theuseofPNBsincreases.

Disinfectant SolutionChlorhexidinegluconateinanalcohol-basedsolutionshouldbeconsideredtheantisepticofchoicepriortotheperformanceofallPNBs.Chlorhexidinegluconate mixed with isopropyl alcohol is more effective compared topovidoneiodineinpreventingepiduralcathetercolonization.3

Sterility of Ultrasound ProbesThe usage of ultrasound machine in performing these procedures adds another factor to possible risk of infection. Unlike the single usedisposablekitsandneedles,ultrasoundmachineisamulti-userplatformfor multiple patients. The placement of protective sterile covers e.g.adhesivetransparentdressingsonthetransducerwhileperformingPNBsisessentialforinfectioncontrolpurposes.

INFECTION CONTROL GUIDELINES SPECIFIC TO PERIPHERAL NERVE BLOCKS

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These guidelines should be followed along with the Ministry of Health Malaysiabookon‘PoliciesandProceduresonInfectionControl2ndEdition,2009’.Thisshallminimise infectionrisks topatientsaswellashealthcareworkers.

Itistheresponsibilityofalltheatreandclinicalstafftoensurestandardsarecomplied toand that theseguidelinesaredisseminatedeffectively toall.Safeworkprocedurestogetherwithproperriskidentificationandassessmentshouldbedevelopedandcarriedout.TheOTcommitteeofeachhospitalshouldbeinvolvedalongwiththeInfectioncontrolcommitteetoachievegoodinfectioncontrolandsafepracticesleadingtobetterpatientcare.

CONCLUSION

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1. Guidelines on Infection Control in Anaesthesia, Australian and New Zealand CollegeofAnaesthetistsReviewPS282005.

2. Sakuragi T, YanagisawaK,DanK.BactericidalActivityof SkinDisinfectantson Methicillin-ResistantStaphylococcusaureus.Anesth Analg1995;81:555-8.

3. KinironsBetal.Chlorhexidineversuspovidoneiodineinpreventingcolonization of continuous epidural catheters in children; A randomised, controlled trial, Anesthesiology2001;94(2):239-244.

4. MitchellNJ,HuntS.Surgical facemasks inmodernoperatingrooms-acostly and unnecessary ritual? J Hosp Infect1991;18:230-42.

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