4
(1 inch) away from an ignition source. However, the incidence of fire from ABHR dispensers appears to be extremely small.12,13
Can the anesthesia provider apply ABHR on gloves that are being worn during a case, rather than removing the gloves, performing HH, and then replacing a new set of gloves if contaminated?
Recommendation: Changing gloves with HH between doffing and donning is the preferred method of disinfection. Current data are inadequate for the authors to either support or discourage the procedure of usingABHRon gloved hands or to determine whether application of foam or gel affects glove integrity. However, appli- cation ofABHRto gloved hands might be better than to not perform any HH when doffing and donning are not feasible. Rationale: The clinical practice of disinfecting latex or nitrile disposable gloves with ABHR is an interesting but currently uncommon practice (supplementary Table 4). Application of foam or gel may have unknown or unintended consequences on glove integrity; however, during the Ebola outbreak in 2014, the Centers for Disease Control and Prevention (CDC) published detailed guidance (revised in 2015) recommending that ABHR be used for disinfecting the gloves at multiple times during doffing of the personal protective equipment.14 A recent paper demon- strated that multiple ethanol-based hand-rub administrations did not show observable signs of material degradation with nitrile and latex gloves15; however, the study did not test every available glove and was predominantly evaluating tensile strength and/or per- meability, which may serve as an indicator of glove degradation. In addition, the authors reported that some types of glove material may become sticky to the touch after multiple admin- istrations of ABHR, but this was not considered problematic in clinical use. In the current, predominant approach to HH, gloved hands are usually assumed to be contaminated, whereas bare hands are assumed to be clean (following appropriate washing or ABHR application). The application of ABHR to gloves could produce the unintended consequence of making the identification of clean hands more difficult (eg, “Are these gloves contaminated or was ABHR applied?”). Nevertheless, the authors believe that application ofABHRto gloves in the anesthesia workplace is worthy of consideration and further investigation. The CDC and WHO guidelines recommend removing gloves before performing HH as standard practice; however, given the frequency of HH opportu- nities in the perioperative setting, evaluation of the effectiveness and feasibility of application of ABHR to gloves in the anesthesia workplace as an alternative practice merits further investigation. Additionally, the authors encourage glove manufacturers to per- form studies to indicate whether andhowmanyABHRapplications can occur while still maintaining the glove’s integrity.
Environmental disinfection
Should reusable laryngoscopes or video-laryngoscopes be replaced with single-use laryngoscopes/video- laryngoscopes?
Recommendation: The authors recommend that facilities ensure that standard direct laryngoscope or video-laryngoscope reusable handles and blades undergo high-level disinfection (at the mini- mum) or sterilization prior to use, or that reusable laryngoscopes are replaced with single-use standard direct laryngoscopes or video-laryngoscopes. Clean blades and handles should be stored
L. Silvia Munoz-Price et al
in packaging appropriate for semicritical items designated for “high-level” disinfection. Rationale: Researchers have found bacteria, blood, and lymphoid tissue contamination of laryngoscope blades and handles fol- lowing low-level decontamination.16 Infectious disease outbreaks have been associated with contaminated laryngoscopes.17 Lar- yngoscopes are considered “semicritical” devices and therefore should be subjected to high-level decontamination (at the mini- mum) or sterilization. The Joint Commission and other regulators require that standard direct laryngoscope reusable blades be subject to high level decontamination (at the minimum) or sterilization and that blades be packaged to maintain deconta- mination until just prior to use. Optimal processing of laryngo- scope handles has been subject to some controversy. Many reusable laryngoscope handles require disassembly prior to high- level decontamination or sterilization, making the cleaning pro- cess potentially costly. The authors recommend that handles that are not able to
undergo high-level disinfection according to manufacturer’s instructions should not be used. The State of California Health and Human Services Agency Department of Health Services recommends high-level decontamination of laryngoscope han- dles.2 A study of laryngoscope handles cleaned with bactericidal wipes containing either 70% alcohol and 2% chlorhexidine or coco alkyl dimethyl benzyl ammonium chloride found that common bacteria were effectively eliminated; however, the authors point out that C. difficile and norovirus would not be expected to be eliminated by this treatment.19 They recommend autoclaving laryngoscope handles at risk for the presence of C. difficile and also on a routine, monthly basis. Single-use laryngoscopes have evolved considerably in recent
years. Their performance may be comparable to reusable lar- yngoscopes, and their cost per use may be less than reusable laryngoscopes if the costs of high-level decontamination of reu- sable laryngoscopes are considered. Environmental issues per- taining to single-use laryngoscopes are addressed by some manufacturers with recycling programs for their products. Although the authors did not conduct a literature search
specific to supraglottic airway masks, they note the plausibility of residual contamination of these masks and suggest that facilities consider applying the same principles when deciding between reusable and single-use supraglottic airway masks.
Should anesthesia machines be partially or completely covered with disposable covers to prevent contamination?
Recommendation: Current data are inadequate for the authors to make recommendations regarding the use of disposable covers to prevent contamination of anesthesia machines. Rationale: Although several studies have demonstrated the potential for contamination of anesthesia equipment and work- spaces and possible transmission of a variety of microorganisms within the anesthesia environment, the authors did not identify studies that evaluated the impact of equipment covers on the level of environmental contamination or patient infection risk. How- ever, they suggest that facilities consider using disposable covers given the plausible reduction in contamination and facilitation of cleaning and disinfection of anesthesia machines.20–25
2“Items directly attached to instruments that contact mucous membranes, such as the handles of rigid laryngoscopes, should be considered semicritical instruments.”18
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