Infection Control & Hospital Epidemiology


When ORs are prepared between uses, what cleaning and disinfection of the anesthesia machine and anesthesia work area should take place?


Recommendation: To reduce the bioburden of organisms and the risk of transmitting these organisms to patients, the facility should clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area between OR uses with an EPA-approved hospital disinfectant that is compatible with the equipment and surfaces based on the manufacturers’ instruction for use. Because of challenges in consistent cleaning and disinfection between cases of the anesthesia machine and anesthesia work area, the authors sug- gest prioritizing high-touch surfaces. Inaddition, the authors suggest evaluating strategies aimed at improving the ability to clean these surfaces (eg, disposable covers, re-engineering of work surfaces). Rationale: A number of studies have demonstrated that anesthesia machines and work areas can become contaminated with a variety of potentially pathogenic microbes, and that these organisms may be transmitted to patients through direct contact with contaminated equipment, hands of anesthesia providers, or contaminated medications.20–25 However, few studies have eval- uated specific cleaning and disinfection products or practices specific to the anesthesia work area. The anesthesia work area, including the anesthesia machine,


computer keyboard, monitor and mouse, reusable patient mon- itoring equipment, anesthesia cart, and ancillary equipment (such as ultrasound machines) are physically complex and are not primarily designed and engineered to facilitate efficient and thorough cleaning. The focus on expedited OR turnover within 10–15 minutes adds to the challenge of adequate cleaning. In the future, the authors encourage engineers and manufacturers to work with human factors experts to redesign the various com- ponents of the anesthesia work area to solve this problem. The authors suggest that anesthesia machine covers may be part of the solution, but evidence is lacking to endorse their use (see the preceding recommendation). While awaiting evidence-based guidance, the authors recom-


mend that the facility prioritize cleaning of the specific compo- nents that are most likely to be contaminated. Monitoring equipment such as reusable blood pressure cuffs, pulse oximeter probes, electrocardiogram (ECG) leads, twitch monitor leads and sensors, and cables that are in physical contact with patients should receive high priority for thorough cleaning (single-use monitoring sensors may be useful for reducing the cleaning burden). The anesthesia machine work surface, gas flow controls, vaporizer dials, adjustable pressure limiting valve (APL), IV stands and fluid warmers, supply cart, and computer keyboard and mouse, are also examples of components that are particularly likely to be contaminated.


Should injection ports used by anesthesia providers in the OR be covered with isopropyl alcohol-containing caps? Should injection ports—without alcohol-containing caps—used by anesthesia providers in the OR be scrubbed with alcohol before each use?


Recommendation: Anesthesia providers should only use disin- fected ports for intravenous access. Ports may be disinfected either by scrubbing the port with a sterile alcohol-based disinfectant before each use immediately prior to each use or using sterile isopropyl alcohol containing caps that cover ports continuously. Prior to use, isopropyl alcohol–containing caps should cover the


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port for the minimum time recommended by the manufacturer. Ports should be properly disinfected prior to each individual drug injection or at the beginning of a rapid succession of injections, such as during induction of anesthesia. The authors recommend that providers consider using isopropyl alcohol containing caps, which, when in place for the recommended period, make ports immediately available for use at all times. Stopcocks should have closed injection ports installed to convert them into “closed ports,” or they should be covered with sterile caps. Rationale: Peripheral intravenous tubing stopcocks and injection ports that are used for medication administration frequently become contaminated with potentially pathogenic bacteria during intraoperative use. Lower rates of provider HH, higher numbers of intravenous medications, and greater numbers of hub inter- actions increase the probability of injection port contamination. Although the literature does not provide direct evidence of clin- ical benefit in anesthesia practice, moderate- to high-quality evidence exists that disinfecting catheter hubs, needleless con- nectors, and injection ports with a sterile alcohol-containing disinfectant reduces the risk of central-line–associated blood- stream infection (CLABSI).26 Optimally, the authors recommend disinfection of injection ports to be performed before each medication injection, consistent with recommendations in other patient care settings; however, published studies do not address the optimal frequency of injection port disinfection and the comparative effectiveness of alcohol-containing caps and alcohol wipes in anesthesia practice, and the authors acknowledge that the act of disinfecting injection ports for 10–15 seconds followed by a drying time can be challenging in anesthesia practice, par- ticularly during induction and emergence of anesthesia.27 For this reason, compared to alcohol wipes, passive disinfection using sterile alcohol-containing caps offers visual assurance of hub disinfection and may assist facilities in improving and monitoring compliance with this best practice.27


When anesthesia drugs are drawn at the point of care should vials be scrubbed with alcohol prior to puncture?


Recommendation: Anesthesia providers should wipe medication vials’ rubber stoppers and necks of ampules with 70% alcohol prior to vial access and medication withdrawal. Rationale: The caps of anesthesia medications are not sterile; therefore, it should be standard practice to disinfect the rubber stoppers and neck of ampules prior to each use.28 A study in New Zealand observed 10 anesthesia teams during 20 simulated cases.29 None of the anesthesiologists disinfected the vial septa prior to drawing intravascular solutions, and the anesthesia teams said they believed this procedure was in compliance with infec- tion prevention and control practices. These researchers isolated microorganisms from 5 of 38 collection bags (13%), 6 of 17 needles (35%), and 10 of 197 syringes (5%).28–30


Which intravenous catheters should be placed with full barrier precautions?


Recommendation: All central venous catheters (CVCs) and axil- lary and femoral arterial lines should be placed with full maximal sterile barrier precautions. Full maximal sterile barrier precau- tions include wearing mask, cap, sterile gown, and sterile gloves and using a large sterile drape during insertion. Peripheral arterial lines (eg, radial, brachial, or dorsalis pedis arterial lines) should be


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