The Anesthesiologists Role in Preventing Postoperative Infections
Veröffentlicht von:Allan FoxGeändert vor 9 Monaten
Präsentation zum Thema: "The Anesthesiologists Role in Preventing Postoperative Infections"— Präsentation transkript:
1 The Anesthesiologists Role in Preventing Postoperative Infections PD Dr. S. Schulz-StübnerDeutsches 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.
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 hospitalizedpatients, save lives, and enhanceresource allocation.Based on this evidence, the use of laminar air operating rooms is not recommendedBone 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 attireIs it more contaminated when you leave the OR?
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 procedureAs 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 alcohol121 airway contacts: 120 x glove usenever performed a hand disinfection after glove removal!65 blood contacts with gloved hands13 contacts with urin with gloved handsMunoz-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.FazitDie 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 glovingContaminated sites in the ORAnesth 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;114:1236–48Photo: 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 IntravenousLine: A Prospective Study on Propofol Anesthesia andImplications of Stopcock ContaminationDevon C. Cole, MD,* Tezcan Ozrazgat Baslanti, PhD,* Nikolaus L. Gravenstein, BS,† andNikolaus Gravenstein, MD*BACKGROUND: Acute care handling of IV stopcocks during anesthesia and surgery may result incontaminated IV tubing sets. In the context of widespread propofol use, a nutrient-rich hypnoticdrug, we hypothesized that propofol anesthesia increases bacterial contamination of IV stopcocksand may compromise safety of IV tubing sets when continued to be used after propofolanesthesia.METHODS: We conducted an in vitro trial by collecting IV tubing sets at the time of patient dischargefrom 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 cultured50 samples at each interval for both cohorts. Quantitative cultures were done by aspirating theIV 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 bacterialcounts 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 nonpropofolanesthesia stopcocks. There was a 100-fold increase in bacterial number in contaminated stopcockdead spaces at 48 hours after propofol anesthesia. This difference remained significantwhen comparing positive counts from stopcocks with no visible residual propofol and nonpropofolanesthesia (P = 0.034).CONCLUSIONS: There is a covert incidence and degree of IV stopcock bacterial contaminationduring anesthesia which is aggravated by propofol anesthetic. Propofol anesthesia may increaserisk for postoperative infection because of bacterial growth in IV stopcock dead spaces. (AnesthAnalg 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% ofnonpropofol anesthesia stopcocks (28/150). Growth ofall samples per respective holding times was averagedin CFU per milliliter plus 1 SD (1δ) with subset averagesfrom only positive samples analyzed (Table 1). At 6hours, we observed average values for visible propofol inthe dead space at 44 CFU/mL and no visible propofol inthe stopcock dead space from propofol-receiving patientsand nonpropofol-receiving patients at 41 and 37 CFU/mL,respectively. At 24 and 48 hours, the incidence of positivebacterial cultures remained unchanged (Table 1), but differencesin average bacterial counts were readily apparent(Figs. 3 and 4). When comparing all samples, averagebacterial counts at 48 hours for propofol and nonpropofolgroups were 472 and 4 CFU/mL, respectively. When comparingonly positive samples at 48 hours, averages fromthe visible propofol group were 5066 CFU/mL, comparedwith the nonvisible propofol group at 831 CFU/mL andnonpropofol group at 30 CFU/mL. There was no evidenceof significant differences among the 3 groups according tothe negative binomial regression model or the Kruskal–Wallis test at 6 hours, although there were significant differencesamong the groups using both methods at 24 and48 hours (Table 2).Log-linear mixed-model analysis performed to comparevisible propofol, nonvisible propofol, and nonpropofolgroups showed that group and time were significant predictorsof the number of bacteria (P values of and0.006, respectively), although there was no strong evidenceof significant interaction between group and time (P = 0.09).Multiple comparison tests using the Tukey–Kramer methodshowed that there were no significant differences amonggroups at 6 hours (P = 0.99), but number of bacteria wassignificantly higher for the visible propofol group than thenonvisible group (P = 0.03) and the nonpropofol group at 24hours (P = ). Similarly, number of bacteria observed inthe visible propofol group was significantly higher than inthe nonvisible propofol and nonpropofol groups at 48 hours(P values of 0.01 and , respectively). Table 3 shows Pvalues for differences in bacteria count in visible propofol,nonvisible propofol, and nonpropofol groups at each time point obtained using mixed-model analysis along with estimatesfor differences and 95% confidence intervals on logscale. Median and 95% confidence intervals for the ratio ofnumber of bacteria comparing pairs of groups are reportedas well.A representative set of colonies from each holding intervalwas submitted for speciation (Table 4). Review of microorganismsindicated that sources were most likely skin flora andenvironmental fomites. The bulk of bacteria recovered wereGram-positive cocci at varying levels of CFU per milliliter.Densities of slower growing bacteria, such as Micrococcus andKocuria, had only moderate growth after propofol anesthesiacompared with higher yields of Staphylococcus, Acinetobacter,and Pseudomonas after propofol anesthesia. The concentrationof Intralipid varied widely and was not evaluated in thisstudy; we noted presence or absence of visible propofol inthe IV extension set stopcock dead space of patients knownto 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% ofnonpropofol anesthesia stopcocks (28/150). Growth ofall samples per respective holding times was averagedin CFU per milliliter plus 1 SD (1δ) with subset averagesfrom only positive samples analyzed (Table 1). At 6hours, we observed average values for visible propofol inthe dead space at 44 CFU/mL and no visible propofol inthe stopcock dead space from propofol-receiving patientsand nonpropofol-receiving patients at 41 and 37 CFU/mL,respectively. At 24 and 48 hours, the incidence of positivebacterial cultures remained unchanged (Table 1), but differencesin average bacterial counts were readily apparent(Figs. 3 and 4). When comparing all samples, averagebacterial counts at 48 hours for propofol and nonpropofolgroups were 472 and 4 CFU/mL, respectively. When comparingonly positive samples at 48 hours, averages fromthe visible propofol group were 5066 CFU/mL, comparedwith the nonvisible propofol group at 831 CFU/mL andnonpropofol group at 30 CFU/mL. There was no evidenceof significant differences among the 3 groups according tothe negative binomial regression model or the Kruskal–Wallis test at 6 hours, although there were significant differencesamong the groups using both methods at 24 and48 hours (Table 2).Log-linear mixed-model analysis performed to comparevisible propofol, nonvisible propofol, and nonpropofolgroups showed that group and time were significant predictorsof the number of bacteria (P values of and0.006, respectively), although there was no strong evidenceof significant interaction between group and time (P = 0.09).Multiple comparison tests using the Tukey–Kramer methodshowed that there were no significant differences amonggroups at 6 hours (P = 0.99), but number of bacteria wassignificantly higher for the visible propofol group than thenonvisible group (P = 0.03) and the nonpropofol group at 24hours (P = ). Similarly, number of bacteria observed inthe visible propofol group was significantly higher than inthe nonvisible propofol and nonpropofol groups at 48 hours(P values of 0.01 and , respectively). Table 3 shows Pvalues for differences in bacteria count in visible propofol,nonvisible propofol, and nonpropofol groups at each time point obtained using mixed-model analysis along with estimatesfor differences and 95% confidence intervals on logscale. Median and 95% confidence intervals for the ratio ofnumber of bacteria comparing pairs of groups are reportedas well.A representative set of colonies from each holding intervalwas submitted for speciation (Table 4). Review of microorganismsindicated that sources were most likely skin flora andenvironmental fomites. The bulk of bacteria recovered wereGram-positive cocci at varying levels of CFU per milliliter.Densities of slower growing bacteria, such as Micrococcus andKocuria, had only moderate growth after propofol anesthesiacompared with higher yields of Staphylococcus, Acinetobacter,and Pseudomonas after propofol anesthesia. The concentrationof Intralipid varied widely and was not evaluated in thisstudy; we noted presence or absence of visible propofol inthe IV extension set stopcock dead space of patients knownto have received propofol via those stopcocks.Anesth Analg 2015;120:861–7
21 Drugs in general?We trapped and grew potentially pathogenic microorganismsinjected intravenously during the bolus administration ofintraoperative drugs in 6.3% of 300 cases in which patientsunderwent general anesthesia. We have no reason to doubtthe sterility of the drugs provided in ampules or vials and noreason to doubt that their subsequent contamination wasother than inadvertent. In 16% of cases, we grew microorganismsfrom the residual contents of syringes that had beenretained by the anesthesiologists, and which might potentiallyhave been used again for further intravenous injections. Collectively,the varieties of microorganism grown from the filterunits and syringes were similar, but we found little direct concordancein individual cases between microorganism isolatesfrom the filter units through which drugs were injected andresidual drug in retained syringes that had been used to injectthese drugs (tables 2 and 3). Some of this species variationmay be due to the matrix-assisted laser desorption/ionizationtime of flight identification: there may be less variation indeoxyribonucleic acid and/or bacterial resistance profile. Theprecise sources of contamination, and the aspects of practicethat need to be addressed to prevent contamination, cannotbe determined from this study. Nevertheless, these findingscorroborate our previous data5 and that of others,6–11 whichsuggest that anesthesiologists’ aseptic techniques, in relation tothe injection of drugs by bolus, may sometimes be deficient. To what extent were the isolates retrieved from the filterunits a true reflection of our patients’ actual exposure tomicroorganisms injected inadvertently with intravenousbolus drugs during anesthesia? It is difficult to completelyrule out the possibility that at least some of the culturedmicroorganisms could have been introduced during thecollection and flushing of the filter units. However, wetook considerable care to avoid introducing microorganismsin our handling of the filters and syringes. Furthermore,the data from the testing of the 38 sterile filter unitsincluded to audit this aspect of the study are reassuring.One related limitation in our development of the backflushtechnique is that only four microorganisms weretested. These were chosen to align with previous research,5to include common environmental16 and population-basedmicroorganisms17 likely to be associated with postoperativeinfections, and to include an example of a coccus, a bacillus,and a yeast. Other microorganisms, e.g., endospore-formingbacteria may behave differently. Similarly, only one type ofcommercial filter unit was studied; alternative brands withdifferent filter materials may show different characteristicswhen backflushedconvenience and the fact that the study was conductedin one center only; these results might not apply to otheranesthesiologists or other centers. On the other hand,there is no particular reason to assume that that the practicesevaluated here would be in any way unusual. Weacknowledge that relieving anesthesiologists, who were notparticipants, managed the participants’ cases for periods oftime, but we do not believe that this changes the clinicalrelevance of our finding—our study was not directed atindividual practitioners, but rather at the overall processby which intravenous drugs are administered to patientsduring anesthesia. Our rating scale for ease of use of thefilters was not formally validated, but it was similar tovisual analog scales used in many previous studies (e.g., inthe study by Merry et al.3). We assumed that the 0.2-μm filterunits performed to specifications, but we did not verify this;the filter unit was bypassed at least once in almost a third ofour cases for various reasons (table 4): these points also haveimplications for the potential utility of such filters in addressingthe problem of inadvertently injected microorganisms.The potential confounding of our data by failure ofthe filter units to trap all organisms, or failure of thebackflush method to retrieve all trapped microorganisms,could have resulted in our underestimating the exposureof patients to microorganisms by the intravenous route.In addition, although anesthesiologists were encouragedto behave “normally” in respect of their aseptic practice,the open-label nature of the study may have influencedthem to be more fastidious. Given propofol’s knownability to promote the growth of microorganisms,18 itsexclusion from injection through the filter units is also relevant.Thus, there were several potential confounders thatcould have resulted in our underestimating of the rate ofintravenous injection of microorganisms. However, the useof the filter unit on a Y-connector and the associated need toflush boluses of drug into the intravenous line using sodiumchloride involved more opportunities for contamination.Any failures in our own handling of filter units and syringesmight also have inflated our results. Therefore, it is possiblethat our data could either overestimate or underestimate thetrue incidence of intravenous injection of microorganisms.Ultimately, it is the order of magnitude of our result thatmatters, more than the exact rate. We selected 1% as thethreshold for clinical concern in our hypothesis; this was asubjective judgment, which took into account factors discussedin the following paragraph, but, arguably, the injectionof intravenous drugs should be accomplished in a sterilefashion, and in the context of processes control, it would bereasonable to expect a failure rate very close to 0 and certainlyless than 1%.The extent to which microorganisms from the bolusinjection of intravenous drugs might contribute to postoperativeinfections is not clear. Microorganisms may bepresent in the blood stream without causing harm, afterbrushing one’s teeth for example.19 In at least some patients,any injected microorganisms may be adequately dealt withby the immune system and through the use of prophylacticantibiotics (which are given routinely for many surgical procedures).However, the operative wound is an ideal environmentfor microorganisms, seeded through the bloodstream,to establish infection, particularly given that many patientsundergoing surgery and anesthesia are debilitated or ill ormay have reduced immune responses.20–22 It seems at leastplausible that injecting microorganisms in this way couldcontribute to some postoperative infections in at least somepatients. Recent research has found 18.6% of injection ports(on stopcocks) in intravenous lines used for drugs other thanpropofol and 17.3% of those used for propofol to be contaminatedwith microorganisms at 6 h after first use.23 Thispotential source of contamination may be additional to thatdemonstrated by our results or may explain some or all ofour results. A filter strategy would likely be an effective wayto reduce blood stream contamination in either case, at leastfor drugs other than propofol, because the injection port onthe filter unit is proximal to the filter membrane. In the end,the clinical relevance of these potential sources of infectionwill need to be evaluated through a randomized controlledtrial of an intervention to prevent or at least reduce them.The question arises, then, of how one might reduce thefrequency with which anesthesiologists inadvertently injectmicroorganisms while injecting intravenous drugs throughinjection ports, given that it is difficult to change embeddedclinical practices (this can be seen, e.g., in the difficultyimproving practice in relation to hand hygiene24–26).Our ease-of-use ratings confirm that it would be practicalfor anesthesiologists to routinely include 0.2-μm filterunits into their cases. It would not be possible to injectpropofol through the filter units, and, as discussed earlier,some microorganisms might pass through the filters,but the majority of bolus injections could be filtered, andthe load of injected microorganisms could be substantiallyreduced. Therefore, we plan a study in which we willtest the hypothesis that using filter units of this type willreduce subsequent postoperative infections. Our results reinforce the importance of meticulous aseptic techniquein administering intravenous injections, particularly whenusing high stakes access points, such as central venouscatheters and peripherally inserted central catheters(where the opportunity for catheter-related blood streaminfection is ever present). The routine use of an alcoholwipe of the septum before accessing drug vials may alsowarrant emphasis (data from the study by Hilliard et al.27and from our previous simulation-based study5 suggestthat the value of this may not be fully appreciated in NewZealand and elsewhere).In the meantime, we conclude that microorganisms withthe potential to cause infection are being injected into atleast some patients during the administration of intravenousbolus drugs during anesthesia. Clearly this could include anypathogen present in the OR environment.28 Strategies toreduce this potential source of infection should be developed.
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 2014photos: 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 recordObservation of 20 anesthesiologist over a 2 month periodGroup 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 practiceNone 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 maximalenBarrieremaßnahmen(steriler Kittel, sterileHandschuhe, steriles Feld) bei derAnlage von zentralen Venenkathetern,während bei anderen Prozeduren wieneuraxialen Anästhesien und Anlage peri‑pherer Schmerzkatheter erhebliche Un‑terschiede bei der praktischen Vorgehensweiseangegeben wurden. Alkoholplus Chlorhexidin oder Octenidin istdas bevorzugte Hautdesinfektionsmittelsowohl bei der ZVK-Anlage als auchbei neuraxialen Anästhesien ohne Unterschiedeje nach Berufserfahrung,Krankenhausgrößeoder geographischerHerkunft der Befragten. In Nordamerikanutzen 7% bei der ZVK-Anlage PVP-Jod,aber 21% bei neuraxialen Anästhesien.Der Einsatz von Alkohol/Octenidin beschränktsich auf die deutschsprachigenLänder Europas, während ansonstenausschließlich die KombinationImprovement potential: Maximal barrier precautions with regional analgesia catheters and use of alcohol/chlorhexidine skin prepAnästh Intensivmed 2017;58:8-14
35 Ultrasound useHintergrund: Trotz zahlreicher Hygiene-Empfehlungen der Fachgesellschaften er‑scheint deren Umsetzung im anästhesiologischenAlltag mitunter nur zögerlichzu erfolgen. Mit Einwilligung des ScientificCommittee der Networking WorldAnesthesia Convention (NWAC) 2015wollten wir daher mittels einer Befragungeinen Eindruck über die weltweitenHygienepraktikenin der Anästhesiegewinnen.Methodik: 60 Kongressteilnehmer wurdenals Fokusgruppe mittels Fragebogenstrukturiert befragt und die Ergebnissedeskriptiv ausgewertet.Ergebnisse: 57 Fragebögen mit Verteilungder Teilnehmenden über alle fünfKontinente konnten ausgewertet werden.Dabei zeigte sich eine 100%ige Compliancemit den maximalen Barrieremaßnahmenbei ZVK-Anlage, aber nureine sehr geringe Compliance bei derDesinfektion von (zunehmend verwendeten)nadellosen Zuspritzsystemen.Auch die Desinfektion regulärer Dreiweghähneist ebenso wenig etabliertwie die Außendesinfektion von Narkosebeatmungsschläuchenmit Filtersystembei Verwendung für mehrere Patientenoder die bewusste Einteilung des Narkosearbeitsplatzesin eine reine undunreine Zone.Diskussion: Anästhesisten kennen dieeinschlägigen Präventionsbündel undwenden sie im Falle der ZVK-Anlageauch konsequent an. Allerdings bestehenDefizite bei der Händedesinfektion vor aseptischen Tätigkeiten, und der Anästhe-siearbeitsplatzselbst und das Beatmungszubehörwerden nicht ausreichend alsmöglicherweise kontaminierte Flächenwahrgenommen. Dies sollte bei Hygiene‑schulungen in der Zukunft berücksichtigtwerden.Die meisten Befragten verwenden sterilesUltraschallgel bei Gefäßpunktionenoder Nervenblockaden. Einige setzenTransparentverbände als Schutz für dieUltraschallsonde ein und verwendenHautdesinfektionsmittel als Kontaktmedium.14% der Befragten verwendennormales, unsteriles Ultraschallgel.Sterile cover for ultrasound probe and cable and sterile gel or fluid as contact mediumAnästh Intensivmed 2017;58:8-14
36 Organizational aspects Improvement potentials:Clean and dirty areaDesinfection of iv-ports and outer surface area of breathing circuitsAnästh 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