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placed with a minimum of a cap, mask, sterile gloves, and a small sterile fenestrated drape. Rationale: The authors based this recommendation on the Compendium of Strategies to Prevent Bloodstream Infections in Acute Care Hospitals26 and the 2011 Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline,31 which identify the following maximal sterile barrier precautions for CVC and axillary and femoral arterial line insertion:
1. All healthcare personnel involved in the catheter insertion procedure shouldwearmask, cap, sterilegown,andsterile gloves.
2. The provider should cover the patient with a large (“full body”) sterile drape during catheter insertion.
The provider should also follow these measures when exchanging a catheter over a guidewire. Placement of other arterial lines should follow the HICPAC recommendations to use a minimum of a cover, mask, sterile gloves, and a small sterile fenestrated drape.31 As with other standard-of-care practices, in emergency situations providers should weigh other safety considerations.
Should providers always recap a medication syringe after giving a portion of the syringe contents to the patient if the syringe and medication may be used again on that patient?
Recommendation: To reduce the risk of bacterial contamination of the syringe and syringe contents, the authors recommend that anesthesia providers cap needleless syringes that will be used to administer multiple doses of a drug to the same patient after each administered dose. Needleless syringes should be capped with a sterile cap that completely covers the Luer connector on the syringe. Rationale: Bacterial contamination of medication syringes can occur during anesthesia practice, most commonly with skin microorganisms.29 Higher rates of medication contamination have been associated with emergency procedures, compared to elective surgical procedures. Low provider HH, lack of injection port disinfection, and contact with nonsterile equipment may increase the risk of intraoperative contamination of syringe contents when used to administer multiple doses of medication to the same patient. Although research has not assessed the effec- tiveness of capping medication syringes on reducing rates of medication contamination, it is plausible that capping medication syringes will reduce the risk of inadvertent contamination of the syringe and contents from the hands or work space of the anes- thesia provider. The authors do not recommend recapping nee- dles, which is highly discouraged due to the associated occupational hazards.
What measures should be taken to protect clean supplies in the anesthesia cart from contamination? Should the anesthesia supply cart be cleaned between cases?
Recommendation: The anesthesia supply cart should have its accessible outer surfaces wiped clean between cases. To prevent contamination of communal supplies, anesthesia providers should always perform HH before opening the drawers or bins of the cart and handling the contents of the drawers or bins. Storage of supplies on the top surface of the cart should be avoided as
L. Silvia Munoz-Price et al
much as possible and any supply items on the cart top surface should be removed between cases to facilitate cleaning. The interior of the supply cart should be cleaned on a periodic basis. Future innovation and re-engineering of the storage, dispensing, and restocking of supplies in the anesthesia work area is needed to decrease the potential for bacterial cross contamination between cases. Rationale: The anesthesia work area is contaminated with potential pathogens and poses a threat for clinically significant bacterial cross transmission. Hall32 confirmed the presence of blood contamination on 33% of surfaces, including surfaces in direct contact with the patient, for example, blood pressure cuffs and pulse oximeter probes after visual inspection of anesthesia work area surfaces.32 Research has found significant anesthesia work area bioburden with both commensal and pathogenic bac- teria, including coagulase-negative staphylococci, Bacillus spp, streptococci, Staphylococcus aureus, Acinetobacter spp, and other gram-negative rods.20 Loftus et al33 studied the impact of bacterial contamination of patients, providers’ hands, and stopcocks in the OR. They found that providers’ hands and the surrounding environment were drivers of stopcock cross transmission, which was associated with increased patient 30-day mortality. Bacterial transmission in the anesthesia work area of the OR was associated with 30-day postoperative infections, which impact as many as 16% of patients undergoing surgery.34 Other studies have linked anesthesia provider hand contamination as a proximal source of both enterococcal and staphylococcal transmission in the anes- thesia work area.23,25 Although studies quantifying the impact of contamination of
anesthesia supply carts and work areas on surgical site infection (SSI) risks are lacking, a growing body of literature suggests potential contamination.20,33,35,36 Given the threat of bacterial cross transmission from the anesthesia work area, including the anesthesia machine and supply cart, the facility should take measures to minimize bioburden between all cases.
What is the expiration time for sterile injectable drugs and intravenous solutions prepared by anesthesia providers?
Recommendation: Provider-prepared sterile injectable drugs (eg, a drug drawn from a vial into a syringe) are more likely to be subject to contamination than drugs prepared in an ISO Class 5 setting, such as a pharmacy; therefore, provider-prepared sterile injectable drugs should be used as soon as practicable following preparation. The package inserts for propofol that contain a preservative typically specify that the use of propofol should commence within 12 hours of preparation. At the time of this publication, United States Pharmacopeia (USP) Chapter 797 recommends that the use of provider-prepared sterile injectable drugs commence within 1 hour of preparation; however, a draft revision of USP General Chapter 797 suggests that a drug from a single dose vial punctured or entered in environments with air less clean than ISO class 5 may be used until the end of a case.37 If available, commercially prefilled syringes or syringes prepared by the hospital pharmacy in an ISO class 5 setting have a relatively long “beyond use date.” Rationale: The USP 797 generally is considered the applicable authority for the compounding of sterile injectable solutions and drugs. At the time of this publication, USP 797 states that the use of compounded sterile provider-prepared products outside of an
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