New SHEA expert guidance for infection prevention in the anesthesia work area needs improvement

Abstract

To the Editor-The recent SHEA Expert Guidance article 1 addresses the following questions: "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?" SHEA recommends that intravenous "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 : : : [and that] : : : Ports should be properly disinfected prior to each individual drug injection : : : " Yet this will not provide effective disinfection of the internal surface of open-lumen stopcocks. 2 When the internal surface is contaminated, neither an alcohol pad nor a cap with alcoholimpregnated pads is effective. 2 Disinfectable, needleless, closed connectors are effectively disinfected with either treatment. 2 It is very difficult to stop contamination of open-lumen stopcocks, 2 whereas closed ports can be disinfected. 3 SHEA further recommends that "Stopcocks should have closed injection ports installed to convert them into "closed ports," or they should be covered with sterile caps." Unfortunately, this recommendation indicates an infection control equivalence to using either closed injection ports or sterile caps. The recommendation to use a sterile cap does not reduce the infectious risks of open-lumen stopcocks used commonly in anesthesia practices nationwide. Open-lumen stopcocks traditionally use sterile caps, but it is well documented that during use the cap and the stopcock's internal lumen can become contaminated by bacteria, in up to 32% of cases, and these occurrences are associated with increased patient morbidity and mortality. 3-5 Even if a new sterile cap is placed on a stopcock after each access (which is not addressed by SHEA), the cap and internal lumen can still become contaminated due to inadvertent contact with a contaminated hand, glove or other surface during cap placement. The risks are clear: "A common route to intravascular device-related bloodstream infections is bacterial contamination of the injection port, which leads to hub colonization, intraluminal migration, and distal seeding of the bloodstream." 2 The rate of catheter-related bloodstream infections (CRBSIs) is lower with central venous catheters using disinfectable needle-free connectors than with open-lumen stopcocks (0.7 vs 5.0 per 1,000 catheter days). 6 Mahida et al 7 reported that 9% of cases had bacterial contamination in intravenous extension lines connected to open-lumen

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices

“…Later studies showed that the main potential infection sources coming from the anaesthesia work area were the hands of the anaesthesia providers (gram negative bacteria, Enterococcus spp) [12][13][14], and the patients skin and hair (S. aureus) [15], and that the pathogens found on the anaesthesia provider's hands can lead to postoperative infections [16].…”