The Anesthesiologists Role in Preventing Postoperative Infections

Präsentation zum Thema: "The Anesthesiologists Role in Preventing Postoperative Infections"—  Präsentation transkript:

1 The Anesthesiologists Role in Preventing Postoperative Infections
PD Dr. S. Schulz-Stübner Deutsches Beratungszentrum für Hygiene (BZH GmbH), Freiburg, Germany

2 Objectives: Discuss potential chains of transmission of micro- organisms, and the anesthesiologist’s role in these chains; Organize the anesthesia workplace in order to reduce contamination and minimize transmission opportunities; Identify barriers in implementing infection control practices in the OR environment, especially the danger of a false sense of security, and how to overcome those barriers.

3 What we hope for in the OR
Drawing: Flury

4 …is not always what we get!
Drawing: Flury

5 Because there are patients…
Curr Opin Crit Care 2016, 22:347–353

6 ..and medical staff: (Particles: > 0,5 µm, with different clothing and movements) Diagramm Partikelemission (in: Reinraumtechnik, 2002)

7 Does LAF work at least for big joint replacement surgery?
12 studies involving THRs, 9 infection control strategies were identified. Conclusion: Preventing deep SSI with antibiotic prophylaxis and antibiotic-impregnated cement has shown to improve health outcomes among hospitalized patients, save lives, and enhanceresource allocation. Based on this evidence, the use of laminar air operating rooms is not recommended Bone Joint 2013;95:

8 WHO recommendations for surgical site infection prevention
Laminar airflow ventilation systems should not be used for patients undergoing total arthroplasty surgery (Conditional/low to very low) Lancet Infect Dis 2016; doi.org/ /S (16)30398-X

9 Is it more contaminated when you leave the OR?
Theatre staff attire Is it more contaminated when you leave the OR?

10 Theatre staff attire No!

11 What do Surgeons think? The American College of Surgeons (ACS) guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence. They are as follows: Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure As stewards of our profession, we must retain emphasis on key principles of our culture, including proper attire, since attention to such detail will help uphold the public perception of surgeons as highly trustworthy, attentive, professional, and compassionate. This statement will be published October 2016 in the Bulletin of the American College of Surgeons

12 A good role model is helpful to improve compliance
Figure 1: Nachahmeffekt, wenn die erste Person, die das Zimmer betritt die Hände desinfiziert. Figure 1: Effekt, wenn der Vorgesetzte sich die Hände desinfiziert. Haessler S, BMJ Qual Saf 2012; 21(6):

13 What about gloving? Observation of 40 anesthesiologists during 80 procedures: 425 iv drug applications: 19x (4,5%) hub desinfection with alcohol 121 airway contacts: 120 x glove use never performed a hand disinfection after glove removal! 65 blood contacts with gloved hands 13 contacts with urin with gloved hands Munoz-Price et al.: Randomized crossover study evaluating the effect of hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. Infect Control Hosp Epidemiol 2014; 35:

14 Is glove disinfection an answer?
The disinfection efficacy for all disinfectant/glove combinations was better with rather than without gloves. For eight combinations, the disinfection efficacy was always >5.0 log10. There were significant differences within the gloves (P=0.0021) and within the disinfectant product (P=0.0023), respectively. In detail, Nitril Blue Eco-Plus performed significantly better than Vasco Braun (P=0.0017) and Latex Med Comfort (P=0.0493). Descoderm showed a significantly worse performance than Promanum pure (P=0.043). In the check for tightness, only the Vasco Braun gloves showed no leaks in all samples. There were relevant qualitative differences pertaining to the comfort of disinfecting gloves. CONCLUSION: The disinfection efficacy for the different disinfectant/glove combinations was greater than for the ungloved hands. However, various disinfectant/glove combinations produce relevant differences as regards disinfection efficacy. Scheithauer et al. Disinfection of gloves: feasible, but pay attention to the disinfectant/glove combination. Journal of Hospital Infection 2016; 94: Die Händehygienecompliance wird oftmals durch die rasche Abfolge von Tätigkeiten, bei denen eine Händedesinfektion indiziert wäre, erschwert. Insbesondere dann, wenn aus Gründen des Personalschutzes nicht-sterile Einmalhandschuhe getragen werden, und eigentlich ein Handschuhwechsel mit Händedesinfektion erforderlich wäre, könnte eine Handschuhdesinfektion den Workflow vereinfachen und die Compliance verbessern. Scheithauer und Mitarbeiter untersuchten nun die Effektivität einer Handschuhdesinfektion an verschiedenen Handschuhtypen mit verschiedenen alkoholischen Händedesinfektionsmitteln und den Einfluss der Handschuhdesinfektion auf die Materialeigenschaften der Handschuhe. Als Kontrolle wurde die Händedesinfektion ohne Handschuhe durchgeführt. Zur Kontamination wurde eine definierte Lösung von E. coli K12 NCTC gewählt und die Reduktionsraten nach Desinfektion wurden gemäß DIN EN 1500:2013 bestimmt. Die Dichtigkeit der Handschuhe wurde anschließend nach DIN EN mittels Wasserdichtigkeitstest untersucht. Verglichen wurden drei verschiedene Handschuhtypen (Ampiri Nitril Blue Eco-Plus®, Vasco Braun® und Latex Med Comfort® mit fünf unterschiedlichen Händedesinfektionsmitteln (Sterilium®, Sensiva®, Descoderm®, Desderman pure® und Promanum pure®). Es wurden jeweils 10 Tests pro Handschuh/Desinfektionsmittelkombination durchgeführt, wobei 4 Probanden beteiligt waren. Im Ergebnis zeigten sich die durchgeführten Handschuhdesinfektionen hinsichtlich der Reduktionsrate der nativen Händedesinfektion in ihrer konstanten Wirkung überlegen (Reduktion jeweils mehr als 5,0 log10 bei der Handschuhdesinfektion verglichen mit < 2,0 bis 5,8 log10 bei der nativen Händedesinfektion). Allerdings zeigten sich statistisch signifikante Unterschiede in den Handschuhtyp/Desinfektionsmittelkombinationen, wobei die Kombination Nitril Blue Eco-Plus®/Sensiva® am besten abschnitt. Die Kombination Latex Med Comfort® und Sterilium® ergab eine unbefriedigende Desinfektionswirkung. Bei der Dichtigkeit wiesen nur die Vasco Braun®-Handschuhe keine Undichtigkeiten auf, die Latex Med Comfort®-Handschuhe hatten die meisten Undichtigkeiten. Fazit Die Autoren kommen zu dem Schluss, dass eine Handschuhdesinfektion möglich und effektiv ist, wobei Nitrilhandschuhe am geeignetsten erscheinen, auch wenn selbst innerhalb dieser Gruppe Unterschiede hinsichtlich Desinfektionswirkung und Kompatibilität zu beobachten waren. Sie betonen daher, dass ihre Ergebnisse nicht ohne weiteres auf andere Handschuh/Desinfektionsmittelkombinationen übertragbar sind und die Kompatibilität eine entscheidende Voraussetzung für die sichere Anwendung der Handschuhdesinfektion in ausgewählten Situationen ist. Journal of Hospital Infection 2016; 94:

15 Contaminated sites in the OR
Double gloving Contaminated sites in the OR Anesth Analg Apr;120(4):848-52

16 What about the iv? Anesth Analg 2012;114:1236–48 Photo: Flury
* Zentrifuge, Argarplatte (5Tage bei 35°C) Anesth Analg 2012;114:1236–48 Photo: Flury

17 Intraoperative contamination of stopcocks
Link to Mortality? Anesth Analg 2012;114:1236–48

18 Propofol…. Anesth Analg 2015;120:861–7
Leaving More Than Your Fingerprint on the Intravenous Line: A Prospective Study on Propofol Anesthesia and Implications of Stopcock Contamination Devon C. Cole, MD,* Tezcan Ozrazgat Baslanti, PhD,* Nikolaus L. Gravenstein, BS,† and Nikolaus Gravenstein, MD* BACKGROUND: Acute care handling of IV stopcocks during anesthesia and surgery may result in contaminated IV tubing sets. In the context of widespread propofol use, a nutrient-rich hypnotic drug, we hypothesized that propofol anesthesia increases bacterial contamination of IV stopcocks and may compromise safety of IV tubing sets when continued to be used after propofol anesthesia. METHODS: We conducted an in vitro trial by collecting IV tubing sets at the time of patient discharge from same-day ambulatory procedures performed with and without propofol anesthesia. These extension sets were then held at room temperature for 6, 24, or 48 hours. We cultured 50 samples at each interval for both cohorts. Quantitative cultures were done by aspirating the IV stopcock dead space and plating the aspirate on blood agar for colony count and speciation. RESULTS: Positive bacterial counts were recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of nonpropofol stopcocks (28/150). At 6 hours, the average bacterial counts from stopcocks with visible residual propofol was 44 colony forming units (CFU)/ mL, compared with 41 CFU/mL with no visible residual propofol and 37 CFU/mL in nonpropofol anesthesia stopcocks. There was a 100-fold increase in bacterial number in contaminated stopcock dead spaces at 48 hours after propofol anesthesia. This difference remained significant when comparing positive counts from stopcocks with no visible residual propofol and nonpropofol anesthesia (P = 0.034). CONCLUSIONS: There is a covert incidence and degree of IV stopcock bacterial contamination during anesthesia which is aggravated by propofol anesthetic. Propofol anesthesia may increase risk for postoperative infection because of bacterial growth in IV stopcock dead spaces. (Anesth Analg 2015;120:861–7) Anesth Analg 2015;120:861–7

19 …and germs Anesth Analg 2015;120:861–7
Results: Positive bacterial cultures were recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of nonpropofol anesthesia stopcocks (28/150). Growth of all samples per respective holding times was averaged in CFU per milliliter plus 1 SD (1δ) with subset averages from only positive samples analyzed (Table 1). At 6 hours, we observed average values for visible propofol in the dead space at 44 CFU/mL and no visible propofol in the stopcock dead space from propofol-receiving patients and nonpropofol-receiving patients at 41 and 37 CFU/mL, respectively. At 24 and 48 hours, the incidence of positive bacterial cultures remained unchanged (Table 1), but differences in average bacterial counts were readily apparent (Figs. 3 and 4). When comparing all samples, average bacterial counts at 48 hours for propofol and nonpropofol groups were 472 and 4 CFU/mL, respectively. When comparing only positive samples at 48 hours, averages from the visible propofol group were 5066 CFU/mL, compared with the nonvisible propofol group at 831 CFU/mL and nonpropofol group at 30 CFU/mL. There was no evidence of significant differences among the 3 groups according to the negative binomial regression model or the Kruskal– Wallis test at 6 hours, although there were significant differences among the groups using both methods at 24 and 48 hours (Table 2). Log-linear mixed-model analysis performed to compare visible propofol, nonvisible propofol, and nonpropofol groups showed that group and time were significant predictors of the number of bacteria (P values of and 0.006, respectively), although there was no strong evidence of significant interaction between group and time (P = 0.09). Multiple comparison tests using the Tukey–Kramer method showed that there were no significant differences among groups at 6 hours (P = 0.99), but number of bacteria was significantly higher for the visible propofol group than the nonvisible group (P = 0.03) and the nonpropofol group at 24 hours (P = ). Similarly, number of bacteria observed in the visible propofol group was significantly higher than in the nonvisible propofol and nonpropofol groups at 48 hours (P values of 0.01 and , respectively). Table 3 shows P values for differences in bacteria count in visible propofol, nonvisible propofol, and nonpropofol groups at each time point obtained using mixed-model analysis along with estimates for differences and 95% confidence intervals on log scale. Median and 95% confidence intervals for the ratio of number of bacteria comparing pairs of groups are reported as well. A representative set of colonies from each holding interval was submitted for speciation (Table 4). Review of microorganisms indicated that sources were most likely skin flora and environmental fomites. The bulk of bacteria recovered were Gram-positive cocci at varying levels of CFU per milliliter. Densities of slower growing bacteria, such as Micrococcus and Kocuria, had only moderate growth after propofol anesthesia compared with higher yields of Staphylococcus, Acinetobacter, and Pseudomonas after propofol anesthesia. The concentration of Intralipid varied widely and was not evaluated in this study; we noted presence or absence of visible propofol in the IV extension set stopcock dead space of patients known to have received propofol via those stopcocks. Anesth Analg 2015;120:861–7

20 …like this: Anesth Analg 2015;120:861–7
Results: Positive bacterial cultures were recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of nonpropofol anesthesia stopcocks (28/150). Growth of all samples per respective holding times was averaged in CFU per milliliter plus 1 SD (1δ) with subset averages from only positive samples analyzed (Table 1). At 6 hours, we observed average values for visible propofol in the dead space at 44 CFU/mL and no visible propofol in the stopcock dead space from propofol-receiving patients and nonpropofol-receiving patients at 41 and 37 CFU/mL, respectively. At 24 and 48 hours, the incidence of positive bacterial cultures remained unchanged (Table 1), but differences in average bacterial counts were readily apparent (Figs. 3 and 4). When comparing all samples, average bacterial counts at 48 hours for propofol and nonpropofol groups were 472 and 4 CFU/mL, respectively. When comparing only positive samples at 48 hours, averages from the visible propofol group were 5066 CFU/mL, compared with the nonvisible propofol group at 831 CFU/mL and nonpropofol group at 30 CFU/mL. There was no evidence of significant differences among the 3 groups according to the negative binomial regression model or the Kruskal– Wallis test at 6 hours, although there were significant differences among the groups using both methods at 24 and 48 hours (Table 2). Log-linear mixed-model analysis performed to compare visible propofol, nonvisible propofol, and nonpropofol groups showed that group and time were significant predictors of the number of bacteria (P values of and 0.006, respectively), although there was no strong evidence of significant interaction between group and time (P = 0.09). Multiple comparison tests using the Tukey–Kramer method showed that there were no significant differences among groups at 6 hours (P = 0.99), but number of bacteria was significantly higher for the visible propofol group than the nonvisible group (P = 0.03) and the nonpropofol group at 24 hours (P = ). Similarly, number of bacteria observed in the visible propofol group was significantly higher than in the nonvisible propofol and nonpropofol groups at 48 hours (P values of 0.01 and , respectively). Table 3 shows P values for differences in bacteria count in visible propofol, nonvisible propofol, and nonpropofol groups at each time point obtained using mixed-model analysis along with estimates for differences and 95% confidence intervals on log scale. Median and 95% confidence intervals for the ratio of number of bacteria comparing pairs of groups are reported as well. A representative set of colonies from each holding interval was submitted for speciation (Table 4). Review of microorganisms indicated that sources were most likely skin flora and environmental fomites. The bulk of bacteria recovered were Gram-positive cocci at varying levels of CFU per milliliter. Densities of slower growing bacteria, such as Micrococcus and Kocuria, had only moderate growth after propofol anesthesia compared with higher yields of Staphylococcus, Acinetobacter, and Pseudomonas after propofol anesthesia. The concentration of Intralipid varied widely and was not evaluated in this study; we noted presence or absence of visible propofol in the IV extension set stopcock dead space of patients known to have received propofol via those stopcocks. Anesth Analg 2015;120:861–7

21 Drugs in general? We trapped and grew potentially pathogenic microorganisms injected intravenously during the bolus administration of intraoperative drugs in 6.3% of 300 cases in which patients underwent general anesthesia. We have no reason to doubt the sterility of the drugs provided in ampules or vials and no reason to doubt that their subsequent contamination was other than inadvertent. In 16% of cases, we grew microorganisms from the residual contents of syringes that had been retained by the anesthesiologists, and which might potentially have been used again for further intravenous injections. Collectively, the varieties of microorganism grown from the filter units and syringes were similar, but we found little direct concordance in individual cases between microorganism isolates from the filter units through which drugs were injected and residual drug in retained syringes that had been used to inject these drugs (tables 2 and 3). Some of this species variation may be due to the matrix-assisted laser desorption/ionization time of flight identification: there may be less variation in deoxyribonucleic acid and/or bacterial resistance profile. The precise sources of contamination, and the aspects of practice that need to be addressed to prevent contamination, cannot be determined from this study. Nevertheless, these findings corroborate our previous data5 and that of others,6–11 which suggest that anesthesiologists’ aseptic techniques, in relation to the injection of drugs by bolus, may sometimes be deficient. To what extent were the isolates retrieved from the filter units a true reflection of our patients’ actual exposure to microorganisms injected inadvertently with intravenous bolus drugs during anesthesia? It is difficult to completely rule out the possibility that at least some of the cultured microorganisms could have been introduced during the collection and flushing of the filter units. However, we took considerable care to avoid introducing microorganisms in our handling of the filters and syringes. Furthermore, the data from the testing of the 38 sterile filter units included to audit this aspect of the study are reassuring. One related limitation in our development of the backflush technique is that only four microorganisms were tested. These were chosen to align with previous research,5 to include common environmental16 and population-based microorganisms17 likely to be associated with postoperative infections, and to include an example of a coccus, a bacillus, and a yeast. Other microorganisms, e.g., endospore-forming bacteria may behave differently. Similarly, only one type of commercial filter unit was studied; alternative brands with different filter materials may show different characteristics when backflushedconvenience and the fact that the study was conducted in one center only; these results might not apply to other anesthesiologists or other centers. On the other hand, there is no particular reason to assume that that the practices evaluated here would be in any way unusual. We acknowledge that relieving anesthesiologists, who were not participants, managed the participants’ cases for periods of time, but we do not believe that this changes the clinical relevance of our finding—our study was not directed at individual practitioners, but rather at the overall process by which intravenous drugs are administered to patients during anesthesia. Our rating scale for ease of use of the filters was not formally validated, but it was similar to visual analog scales used in many previous studies (e.g., in the study by Merry et al.3). We assumed that the 0.2-μm filter units performed to specifications, but we did not verify this; the filter unit was bypassed at least once in almost a third of our cases for various reasons (table 4): these points also have implications for the potential utility of such filters in addressing the problem of inadvertently injected microorganisms. The potential confounding of our data by failure of the filter units to trap all organisms, or failure of the backflush method to retrieve all trapped microorganisms, could have resulted in our underestimating the exposure of patients to microorganisms by the intravenous route. In addition, although anesthesiologists were encouraged to behave “normally” in respect of their aseptic practice, the open-label nature of the study may have influenced them to be more fastidious. Given propofol’s known ability to promote the growth of microorganisms,18 its exclusion from injection through the filter units is also relevant. Thus, there were several potential confounders that could have resulted in our underestimating of the rate of intravenous injection of microorganisms. However, the use of the filter unit on a Y-connector and the associated need to flush boluses of drug into the intravenous line using sodium chloride involved more opportunities for contamination. Any failures in our own handling of filter units and syringes might also have inflated our results. Therefore, it is possible that our data could either overestimate or underestimate the true incidence of intravenous injection of microorganisms. Ultimately, it is the order of magnitude of our result that matters, more than the exact rate. We selected 1% as the threshold for clinical concern in our hypothesis; this was a subjective judgment, which took into account factors discussed in the following paragraph, but, arguably, the injection of intravenous drugs should be accomplished in a sterile fashion, and in the context of processes control, it would be reasonable to expect a failure rate very close to 0 and certainly less than 1%. The extent to which microorganisms from the bolus injection of intravenous drugs might contribute to postoperative infections is not clear. Microorganisms may be present in the blood stream without causing harm, after brushing one’s teeth for example.19 In at least some patients, any injected microorganisms may be adequately dealt with by the immune system and through the use of prophylactic antibiotics (which are given routinely for many surgical procedures). However, the operative wound is an ideal environment for microorganisms, seeded through the bloodstream, to establish infection, particularly given that many patients undergoing surgery and anesthesia are debilitated or ill or may have reduced immune responses.20–22 It seems at least plausible that injecting microorganisms in this way could contribute to some postoperative infections in at least some patients. Recent research has found 18.6% of injection ports (on stopcocks) in intravenous lines used for drugs other than propofol and 17.3% of those used for propofol to be contaminated with microorganisms at 6 h after first use.23 This potential source of contamination may be additional to that demonstrated by our results or may explain some or all of our results. A filter strategy would likely be an effective way to reduce blood stream contamination in either case, at least for drugs other than propofol, because the injection port on the filter unit is proximal to the filter membrane. In the end, the clinical relevance of these potential sources of infection will need to be evaluated through a randomized controlled trial of an intervention to prevent or at least reduce them. The question arises, then, of how one might reduce the frequency with which anesthesiologists inadvertently inject microorganisms while injecting intravenous drugs through injection ports, given that it is difficult to change embedded clinical practices (this can be seen, e.g., in the difficulty improving practice in relation to hand hygiene24–26). Our ease-of-use ratings confirm that it would be practical for anesthesiologists to routinely include 0.2-μm filter units into their cases. It would not be possible to inject propofol through the filter units, and, as discussed earlier, some microorganisms might pass through the filters, but the majority of bolus injections could be filtered, and the load of injected microorganisms could be substantially reduced. Therefore, we plan a study in which we will test the hypothesis that using filter units of this type will reduce subsequent postoperative infections. Our results reinforce the importance of meticulous aseptic technique in administering intravenous injections, particularly when using high stakes access points, such as central venous catheters and peripherally inserted central catheters (where the opportunity for catheter-related blood stream infection is ever present). The routine use of an alcohol wipe of the septum before accessing drug vials may also warrant emphasis (data from the study by Hilliard et al.27 and from our previous simulation-based study5 suggest that the value of this may not be fully appreciated in New Zealand and elsewhere). In the meantime, we conclude that microorganisms with the potential to cause infection are being injected into at least some patients during the administration of intravenous bolus drugs during anesthesia. Clearly this could include any pathogen present in the OR environment.28 Strategies to reduce this potential source of infection should be developed.

22 Ways to reduce stoppcock-contamination

23 The anesthesiologist in the centre of attention?
Anesth Analg 2015;120:853–60

24 An evidence-based multimodal approach for improvements in intraoperative infection control
Anesth Analg 2015;120:853–60

25 Perhaps we should let him do it…
What do we know? Perhaps we should let him do it… Fernandez et al. Hand Hygiene Knowledge and Perceptions Among Anesthesia Providers, Anesth Analg 2014 photos: Anesth Analg 2013; 116:

26 Good Compliance is key…
Anesth Analg 2015;120:853–60

27 Even unspecific visual reminders are helpful?
Visual reminder „Hand disinfection“ q 15 minutes via electronic anesthesia record Observation of 20 anesthesiologist over a 2 month period Group 1 (Start without reminder) 0,2/h -> 2,1/h (p = 0,05) Group 2 (Start with reminder) 2,3/h -> 2,1/h (n.s.) Significant increase of hand disinfection rate (from very bad baseline) and minimal washout effect. Questions remaining: What kind of reminder, how often, how long? Infect Control Hosp Epidemiol 2016; 37:

28 The ventilatory circuit of the anesthesa machine
Acta Anaesthesiologica Scandinavica 2016 doi: /aas.12768, Photo: Schulz-Stübner, Intensive Care Med 2013; 39: 975–6.

29 Skilled and motivated cleaning staff is helpful!
Anesth Analg. 2016;122(5):1444-7

30 Organize your work space
Photos: Schulz-Stübner

31 WHO recommendations for surgical site infection prevention
In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the operating room (Strong/moderate) Administration of surgical antibiotic prophylaxis (SAP) should be before the surgical incision when indicated (Strong recommendation/low) SAP should be administered within 120 min before incision, while considering the half-life of the antibiotic (Strong/moderate) Lancet Infect Dis 2016; doi.org/ /S (16)30398-X

32 WHO recommendations for surgical site infection prevention
Adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2–6 h (strong/moderate). Warming devices are suggested for use in the operating room and during the surgical procedure for patient body warming (Conditional/moderate). Protocols are suggested to be used for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures (Conditional/low) Goal-directed fluid therapy is suggested for use intraoperatively (Conditional/low) ???

33 And what are we doing? In order to assess the current infection control practice among anesthesiologists from 5 different continents we conducted focus group interviews with delegates during the Networking World Anesthesia Convention (NWAC 2015) in Vancouver, Canada. 60 congress delegates were presented with a questionnaire and were asked to reflect on their own practice None of the randomly approached delegates declined to participate. Participants were asked to describe the standard practice at their institution and not personal preferences or assumed impression of practice in their part of the world. 57 data sets were included in the final analysis. Anästh Intensivmed 2017;58:8-14

34 Ein wesentliches Ergebnis war die nahezu
100%ige Compliance mit maximalen Barrieremaßnahmen (steriler Kittel, sterile Handschuhe, steriles Feld) bei der Anlage von zentralen Venenkathetern, während bei anderen Prozeduren wie neuraxialen Anästhesien und Anlage peri‑ pherer Schmerzkatheter erhebliche Un‑ terschiede bei der praktischen Vorgehensweise angegeben wurden. Alkohol plus Chlorhexidin oder Octenidin ist das bevorzugte Hautdesinfektionsmittel sowohl bei der ZVK-Anlage als auch bei neuraxialen Anästhesien ohne Unterschiede je nach Berufserfahrung, Krankenhausgröße oder geographischer Herkunft der Befragten. In Nordamerika nutzen 7% bei der ZVK-Anlage PVP-Jod, aber 21% bei neuraxialen Anästhesien. Der Einsatz von Alkohol/Octenidin beschränkt sich auf die deutschsprachigen Länder Europas, während ansonsten ausschließlich die Kombination Improvement potential: Maximal barrier precautions with regional analgesia catheters and use of alcohol/chlorhexidine skin prep Anästh Intensivmed 2017;58:8-14

35 Ultrasound use Hintergrund: Trotz zahlreicher Hygiene- Empfehlungen der Fachgesellschaften er‑ scheint deren Umsetzung im anästhesiologischen Alltag mitunter nur zögerlich zu erfolgen. Mit Einwilligung des Scientific Committee der Networking World Anesthesia Convention (NWAC) 2015 wollten wir daher mittels einer Befragung einen Eindruck über die weltweiten Hygienepraktiken in der Anästhesie gewinnen. Methodik: 60 Kongressteilnehmer wurden als Fokusgruppe mittels Fragebogen strukturiert befragt und die Ergebnisse deskriptiv ausgewertet. Ergebnisse: 57 Fragebögen mit Verteilung der Teilnehmenden über alle fünf Kontinente konnten ausgewertet werden. Dabei zeigte sich eine 100%ige Compliance mit den maximalen Barrieremaßnahmen bei ZVK-Anlage, aber nur eine sehr geringe Compliance bei der Desinfektion von (zunehmend verwendeten) nadellosen Zuspritzsystemen. Auch die Desinfektion regulärer Dreiweghähne ist ebenso wenig etabliert wie die Außendesinfektion von Narkosebeatmungsschläuchen mit Filtersystem bei Verwendung für mehrere Patienten oder die bewusste Einteilung des Narkosearbeitsplatzes in eine reine und unreine Zone. Diskussion: Anästhesisten kennen die einschlägigen Präventionsbündel und wenden sie im Falle der ZVK-Anlage auch konsequent an. Allerdings bestehen Defizite bei der Händedesinfektion vor aseptischen Tätigkeiten, und der Anästhe- siearbeitsplatz selbst und das Beatmungszubehör werden nicht ausreichend als möglicherweise kontaminierte Flächen wahrgenommen. Dies sollte bei Hygiene‑ schulungen in der Zukunft berücksichtigt werden. Die meisten Befragten verwenden steriles Ultraschallgel bei Gefäßpunktionen oder Nervenblockaden. Einige setzen Transparentverbände als Schutz für die Ultraschallsonde ein und verwenden Hautdesinfektionsmittel als Kontaktmedium. 14% der Befragten verwenden normales, unsteriles Ultraschallgel. Sterile cover for ultrasound probe and cable and sterile gel or fluid as contact medium Anästh Intensivmed 2017;58:8-14

36 Organizational aspects
Improvement potentials: Clean and dirty area Desinfection of iv-ports and outer surface area of breathing circuits Anästh Intensivmed 2017;58:8-14

37 Self-reported indications for intraoperative hand disinfection in % of total respondents
Anästh Intensivmed 2017;58:8-14

38 Number of self-reported intraoperative hand disinfections per hour in % of total respondents
Anästh Intensivmed 2017;58:8-14

39 Infection control is literally at our fingertips
Drawing: Flury