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breathing system bags, adjustable pressure-limiting valves, and monitoring control buttons. They detected the same types of bacteria as Maslyk et al. Loftus et al assessed22 transmission of potentially pathogenic
bacteria in the anesthesia work area by culturing intravenous stopcock sets and adjustable pressure-limiting valve complex and agent dials prior to the start of surgical procedures and after completion of the case. They noted a significant increase in the number of bacterial colonies per surface area sampled at case conclusion and found bacterial contamination of intravenous stopcock sets in 32% of cases, as well as an association between the risk of stopcock contamination and degree of anesthesia work space contamination. In a series of follow-up studies, they eval- uated the dynamics of transmission of enterococci, S. aureus, and gram-negative organisms by comparing isolates found on patient screening cultures, anesthesia providers’ hands, and the adjustable pressure-limiting valves and agent dials of the anesthesia machines during the first and second operative cases (case pairs) performed on a given day at 3 academic medical centers. Isolate relatedness was based on species, antimicrobial susceptibility results, and temporal association.23–25,34 For all 3 organism types, possible transmission events were common and appeared to involve both environmental and anesthesia provider hand con- tamination reservoirs. Mahida et al107 performed swab cultures of the external surface of syringe tips and syringe contents in addition to surface swabs of ventilator machines and found that the same bacterial species was cultured from both the ventilator and the syringe tip in 13% of cases, as well as in the intravenous fluid administration set in 4% of cases, suggesting the potential for environmental contamination leading to contamination of intravenously administered medications.107 Gonzalez et al122 compared different disinfectant wipes, find-
ing S. aureus, Bacillus atrophaeus spores, and Clostridium spor- ogenes spores on the surface of an anesthesia machine, sterile flat caps, and ridged caps (used to simulate the actual knobs on anesthesia machines) and cleaned with 5 commercially available disinfectant wipes containing: (1) diisobutylphenoxyethoxyethyl dimethyl benzyl ammonium chloride, (2) citric acid, (3) sodium hypochlorite, (4) hydrogen peroxide, and (5) o-phenylphenol/o- benzyl-p-chlorophenol as well as sterile gauze soaked in water or 5% bleach diluted 1:10 in water.122 All wipes cleaned the surfaces significantly better than the no-wipe control. Removal of S. aureus from the machine surface by the commercial wipes was not better than gauze with bleach and water but outperformed gauze and water when cleaning the flat and ridged caps. Bacillus atrophaeus and C. sporogenes spores were more difficult to clean from the machine surface and caps compared to S. aureus. Gauze with bleach and water removed 99% of spores from the machine’s surface, and only the sodium hypochlorite wipe significantly outperformed gauze and bleach and water. No commercial disinfectant wipe performed significantly better than gauze and bleach water when cleaning spores from the caps. Gonzalez et al122 found that all 3 organism types maintained viability after being dried on these surfaces after a month. The investigators concluded that these results emphasized the importance of physical removal of bacteria from anesthesia device surfaces between uses. Rutala et al123 found that novel touchless disinfection tech-
nologies (eg, ultraviolet-C light and hydrogen peroxide cleaning systems) are effective in further reducing bioburden after a standard cleaning and may be considered by facilities for terminal cleaning of ORs. However, the clinical efficacy on reduction of
L. Silvia Munoz-Price et al
device-associated infections and SSIs has not been studied, and the intervention has not been subjected to a cost–benefit analysis.123
Airway management
Although few articles have been published reporting outbreaks directly linked to contaminated laryngoscopes,124,125 multiple studies have demonstrated the high frequency with which blood and bacteria can be found on both laryngoscope blades and handles, even after reprocessing.16,126–129 One study found viable bacterial contamination in up to 57% of blades and 86% of handles from laryngoscopes that were disinfected and ready for use on the next patient.16 Bhatt et al130 also found bacterial contamination of flexible fiber-optic laryngoscopes. Several stu- dies have noted the theoretical risk of transmitting Creutzfeldt- Jakob Disease (CJD) from contaminated reusable laryngoscopes. CJD proteins have been identified in lymphoid tissue from patients with variant CJD (vCJD) but not other prion diseases,131 and Hirsch et al132 found that 30% of laryngoscope blades con- tained lymphocytes after a single use. Although there are no published reports of prion transmission via laryngoscopy, the long latency period between exposure and onset of disease makes identification of transmissions difficult. Based on the potential, though unproven, risk of vCJD transmission and the extreme difficulty of eradicating prion proteins from equipment, the authors suggest that facilities consider single-use laryngoscope blades.131,132 The literature search identified a number of studies that
compare the cost and function of single-use laryngoscopes or video-laryngoscopes, but no studies were identified that used clinical infection outcomes. Using direct patient care and simu- lated patient studies, the search identified >30 articles that compared devices based largely on indirect patient related out- comes, such as user experience, ease of visualization of larynx during intubation, efficiency of use during rapid sequence intu- bation, duration of laryngoscopy, peak force applied to tissues, and quality of light. The various studies compared different products and used different outcomes. Overall providers showed a preference toward reusable direct laryngoscopes/video-lar- yngoscopes over the single-use devices; however, older studies do not reflect the current state of single-use laryngoscope technology. The authors identified unpublished, anecdotal reports from a
number of hospitals that switched from reusable to single-use laryngoscopes. These facilities cited lower cost of new generation single-use laryngoscopes compared to previously tested models, especially when the cost of high-level disinfection or sterilization of reusable laryngoscope handles was included. Additionally, the function of single-use laryngoscopes was reportedly improved compared to earlier models and compared favorably with reusable equipment, especially considering that reusable laryngoscope function may degrade over time due to wear and tear. In addition, single-use laryngoscope batteries hypothetically are fresh, whereas reusable laryngoscope batteries discharge variably with repeated use. Anesthesia providers’ hands may become contaminated with upper-airway secretions while providing airway management and endotracheal intubation resulting in cross contamination of the anesthetizing area.3,8,9,117 Two studies were identified in the literature search related to “double gloving” during airway man- agement.8,9 In these studies, conducted in a simulation setting, a
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