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1.   INTRODUCTION

In order to ensure that the practice of anaesthesia is as safe as possible for patients, anaesthetists and other health care workers it is imperative that infection risks to all parties be minimised.

It is impossible to issue guidelines which if observed would ensure that infection was never transmitted via anaesthetic apparatus. What follows are guidelines based on current understanding of the risks of such transmission. In certain clinical situations there may be a need to adopt more stringent practices. These guidelines should be considered with documents on this subject issued by other Authorities.

2.   DEFINITIONS

Decontamination: The removal of micro-organisms and unwanted matter from contaminated materials or living tissue.

Disinfection: The inactivation of non-sporing micro-organisms using either thermal or chemical means.

Sterilisation: Complete destruction of all micro-organisms, including spores.

Asepsis: The prevention of microbial contamination of living tissues or sterile materials.

For disinfection or sterilisation to occur there must have been previous thorough decontamination.

For technical aspects of these procedures the reader is referred to the Code of Practice for Cleaning, Disinfecting and Sterilising Reusable Medical and Surgical Instruments and Equipment, and Maintenance of Associated Environments in Health Care Facilities (AS/NZS 4187, 4815, or equivalent protocol).

3.   MINIMISATION OF INFECTION RISK TO PATIENTS

Measures to protect patients against acquiring infections through anaesthesia procedures need to address (i) risks related to invasive procedures; (ii) risks or potential risks related to airway management. In both situations appropriate levels of sterility, disinfection and decontamination are to be applied to all equipment used. A microbiologist should be consulted about any matters requiring clarification with local application of this policy.

Handwashing by the anaesthetist and the anaesthetic assistant is the most important infection control measure. Hands should be washed before touching a new patient or equipment to be used on a new patient, after leaving a patient, whenever they become contaminated and before any invasive procedure. Gloves are to be removed after procedures to minimise contamination of the work place. Hands should be washed before and after use of gloves.

3.1   INVASIVE PROCEDURES

Invasive procedures are to be performed with aseptic technique.

3.1.1   Vascular Cannulation

The cannulation site is a potential portal of entry of micro-organisms into the subcutaneous tissues and circulation. The anaesthetist's hands must be washed and protective gloves should be worn. The skin should be disinfected with an appropriate preparation prior to cannulation being performed in a manner which ensures that the tip and shaft of the cannula remain sterile.

3.1.2   Central Vascular Cannulation

The insertion of central venous and pulmonary artery catheters carries added infection hazards for the patient. Cannulation of central veins is to be performed using full aseptic technique including the wearing of facemask, sterile gown and gloves, and the use of a sterile field bordered by sterile drapes is required.

3.1.3   Regional Anaesthesia

When regional blocks are being performed, the hands should be washed and gloves worn, the skin should be disinfected with a suitable preparation and the procedure done in such a way that the needle remains sterile. When a spinal or epidural block is being performed, and when a regional anaesthesia catheter is to be left indwelling, full aseptic technique including the wearing of facemask, sterile gown and gloves, and the use of a sterile field bordered by sterile drapes is required.

3.2   ANAESTHETIC APPARATUS

The following measures are intended to minimise the risk of transmission of infection in the respiratory tract via anaesthetic equipment. This policy does not address the processing of equipment during long term ventilation.

3.2.1   Disposable Items

Items of airway equipment to be placed in direct contact with the respiratory tract such as endotracheal tubes and airways labelled by the manufacturer as disposable or for single use only should not be reused.

3.2.2   Devices to be sited in the upper airway

Devices passing through the mouth or nose will become contaminated in the upper airway. Endotracheal tubes, nasal and pharyngeal airways should be kept sterile until used.

Reusable face masks must be thoroughly decontaminated and then undergo disinfection prior to each use. Items to be placed in the upper airway which may cause bleeding e.g. laryngoscope blades and temperature probes, must be disinfected before reuse. It is not ordinarily necessary to package these items separately while they await their next use. Where the manufacturer advises that a particular piece of equipment is to be sterilised before use, e.g. the laryngeal mask, that advice is to be followed. Laryngoscope handles should be decontaminated between uses.

There should be separation of unused items and soiled items during use.

3.2.3   The Breathing Circuit

For each patient the breathing circuit should have been sterilised, or decontaminated and disinfected or protected by the use of appropriately positioned new filters. When a filter is used it is recommended that disposable items between the patient and the filter be disposed of and non-disposable items, including in-line measurement devices, be decontaminated and disinfected prior to reuse.

3.2.4   Sampling Lines for Side Stream Gas Analysis

These need not ordinarily be sterilised before reuse because of the one way flow of gas through them. Sampled gas from a capnograph or other such measurement device should not be returned to the anaesthetic circuit unless it is first passed through a viral filter.

3.2.5   Carbon Dioxide Absorbers

When a filter is used in the circuit as described in 3.2.3 above, sterilisation of the carbon dioxide absorber prior to every case is not necessary nor with most models is it practicable although disposable versions and models capable of being sterilised are available. The device including the unidirectional valves should be disinfected regularly.

3.2.6   Ventilator Circuits and Bellows

These items should be cleaned and disinfected regularly.

3.2.7   Flexible Laryngoscopes and Bronchoscopes

The College endorses the policy on the care and handling of these instruments and accessory equipment laid down in the appropriate National Standard. High level disinfection is the minimum level of processing required.

3.3   PRESENTATION OF DRUGS FOR INJECTION

Because of the potential for cross infection, incompletely used ampoules, vials and syringes must be discarded after each patient use.

3.4   PATIENT FACTORS

In immunosuppressed or immune deficient patients to whom infection poses a particular threat, there may be reason to apply more stringent practices than those outlined.

4.   PREVENTION OF INFECTION OF HEALTH CARE WORKERS

4.1   Health care workers should protect themselves from exposure to blood or body substances by wearing gloves, protective eyewear or face shields, masks, gowns and/or plastic aprons when there is potential for splashing, splattering or spraying of blood or body substances.

4.2   Sharps must be handled with care at all times, disposed of safely immediately following use, and not be resheathed, bent, broken or manipulated by hand.

4.3   Any person exposed to a needlestick or other blood or body fluid incident should access and follow the protocol for this in the institution in which it occurs. This includes having a medical evaluation with particular reference to the risk of infection with HIV, HBV or HCV. The Australian National Council on AIDS, Hepatitis C and Related Diseases has published a comprehensive Bulletin for the management of exposure to blood and body fluids contaminated with blood, including needlestick/sharp injuries.

4.4   Vaccination recommendations for health care workers are contained in the most recent edition of the Australian Immunisation Procedures Handbook. It is available at www.1.health.gov.au/immhandbook diseases, or www.immunise.health.gov.au.

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY – defined as ‘a course of action adopted and pursued by the College’. These are matters coming within the authority and control of the College.

RECOMMENDATIONS – defined as ‘advisable courses of action’.

GUIDELINES – defined as ‘a document offering advice’. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS – defined as ‘a communication setting out information’.

This document is intended to apply wherever anaesthesia is administered.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated: 1995

Reviewed: 2004

Date of current document Feb 2005

© This document is copyright and cannot be reproduced in whole or in part without prior permission.

College Website: http://www.anzca.edu.au/