oren bernstein, md 10/4/2015. i’ll try not to bore you. i’ll probably fail. but this stuff...

Infection Control In the Operating Room-

Recognizing Our RoleOren Bernstein, MD

10/4/2015

I’ll try not to bore you. I’ll probably fail. But this stuff matters!

Welcome Back From Lunch!

•One or more knowledge deficits occurred with 81.6% of survey respondents.

•Failure of providers to recognize prior contact with the environment and prior contact with the patient as hand hygiene opportunities contributed to the low mean.

Contamination with our own bugs from our hands

Contamination with bugs from other patients/the environment

Prophylactic antibiotics

Environmental contamination in the anesthesia workspace is probably grossly underestimated!

Aspects of Periop Infection Control

Device contamination Infusate contaminationHematogenous infectionSkin organisms at the insertion site

Catheter hub contamination

CLABSI

We probably don’t give antibiotics correctly, even though we’ve been doing it for decades.

Our role in contaminating the anesthesia workspace is an unrecognized problem.

We should be cleaning our hands more. Much more.

It isn’t enough to just give the Ancef and relax.

We Aren’t That Good At This.

Contamination probably far more pervasive than we realize.

Recent studies shed light on just how much. Take home message: clean your hands after

touching… pretty much anything.

So Let’s Talk About Our Workspace

Researchers put 0.5cc fluorescent dye in the mouth of a mannequin used for anesthesia resident training.

Conducted a 6 minute exercise involving intubation. Residents not told what study really was for.

Analyzed 40 different areas of the workspace.

Simulation Study

Contaminated in 100% of Simulations

Other Sites of Contamination

Double gloving dramatically reduced contamination during the same simulation.

Makes sense. Many surgeons do it. Good luck to us in trying to achieve 100%

compliance with this practice. Unknown how disposable blades/handles

would affect these simulations. Would be interesting.

Simple Solution?

2 residents in the double-glove group placed the contaminated laryngoscope blade in the outer glove when it was removed so that the blade was contained in a sheath formed by the outer glove.

In neither of these cases was the anesthesia machine surface nor unused syringes contaminated.

Observation

We have to consider what we’re smearing as well.

MRSA, VRE are the prototypical infectious bugs we’re trying to prevent.

Staph from our hands (not picked up from another patient)- not so virulent.

Staph from patients (nasopharynx, for example)- virulent.

So We Can Smear Dye Around the Room. So What?

Patients frequently arrive colonized, and less than 20% get adequate treatment prior.

Patient skin colonization is a major factor impacting other patients undergoing care in the same arena (i.e., between operative cases), is the main source of S aureus origin and transmission, and is the main source of 30-day postoperative infections (both between and within operative cases) from S aureus.

Staph Epidemiology

Pseudomonas, acinetobacter, enterobacter, etc.

4.0% (23/548) of patients suffered from HCAIs and had an intraoperative exposure to gram-negative isolates. In 8.0% (2/23) of those patients, gram-negative bacteria were linked to the causative organism of infection.

Gram Negative Organisms

Among patients with VRE bacteremia…all these subjects had VRE in their stool. In addition, 86% and 57% of these patients had concomitant colonization of the skin in their inguinal areas and antecubital fossae (i.e., even at skin sites remote from the rectum), respectively.

VRE (Vanc Resistant Enterococcus)

All patients with infectious diarrhea/enteritis should be considered to have the bug on the skin.

Everything in their room should be considered contaminated.

Even silent carriers are a problem.

The “Stool Veneer”

New at QMC this month! Will probably become standard soon. Gets around the age-old problem of lazy

anesthesiologists and nurses. Each cap 30 cents. Sounds expensive, but CLABSI/HAI more

expensive.

Alcohol Caps

“The approach of using a continuously applied alcohol impregnated sponge as a cap on the hub for a standard approach to catheter care may eliminate the problem of teaching health care providers one additional disinfection process they need to use as part of their busy patient care schedule.”

One reason this is so important: more and more bugs resistant to common antibiotics.

Some may only be susceptible to very expensive novel antibiotics.

Some may be essentially untreatable. We should not be part of the problem.

Drug Resistant Bugs

Every hospital I’ve ever worked at has had different antibiotic dosing schedules.

When two hospitals on the same island have different schedules, you know the science is not perfect.

Antibiotic Dosing

Antibiotics only are effective above a certain concentration.

Minimum Inhibitory Concentration (MIC). Some (like gentamycin) have an effect after

falling below MIC. Most (like Ancef) have NO effect. Takes time for drug to reach target site.

Antibiotic Concentration

We used to give 1g every 4 hours Where I trained we gave 2g for >80kg

patients. Now we give 2g for almost everyone, and

3g for >120kg. We probably spend too much time below

MIC for many cases.

Ancef

Timing of administration- 1 minute prior to incision is insufficient, EVEN IF it meets “quality” criteria.

15-45 minutes prior to incision is ideal. In obese patients, more than half an hour is best.

We should not be substituting with clindamycin etc. for vague PCN allergies.

Infusions should be considered for long cases!

Opportunities For Improvement

Say we want to keep a patient asleep with propofol.

For a short, simple case, we might give intermittent boluses.

For a long TIVA, we run a drip. Why? Not too deep, not too light. Keep concentration optimal.

Pharmacokinetics

Running an antibiotic drip is a fairly radical concept for most, but it makes pharmacologic sense.

Would we do it for a knee scope? No. Should we do it for a CABG? Probably.

Why Not Antibiotics?

Better patient prep (i.e. preop Hibiclens scrub, nasal abx)

Much better hand hygiene in the OR. We need to better educate ourselves on

best practices. Intubation is a time where contamination

occurs, and we can improve greatly in this area.

We should make sure our antibiotics are having the effect we want.

Conclusion