decontamination of anaesthesia equipments
TRANSCRIPT
DECONTAMINATION OF ANAESTHESIA EQUIPMENTS
DR. CHETAN SHAH
M.D.
Consultant Anaesthesiologist and
pain management
VADODARA
ARE WE responsible for transmitting the infection and hence increasing the
Health Care Associated Infections (HCAIs)????
STUDIES/EVIDANCES
• In 1932, Waters was the first to recognize anaesthetic equipment as a vector for nosocomial pathogens.
• Organism has been isolated from anaestheticequipment, and transmission of infection from such apparatus to patient has been confirmed in a number of instances (Joseph, 1952; Wyant and Nanson, 1957; Tinne et al., 1967; Old et al., 1972).
STUDIES/EVIDANCES
• Cross-infection from self-inflating breathing bags (Cartwright and Hargrave, 1969), humidifiers (Grieble et al., 1970), and ventilators (Phillips and Spencer, 1965) is now well documented.
• Babington, Baker and Johnston (1971) have even demonstrated the upstream spread of bacteria along the expiratory tubing of ventilator circuit.
STUDIES/EVIDANCES
• Laryngoscopes have been implicated in the nosocomial spread of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.
• In 1996, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) reported on the risk of blood-borne virus transmission and anaesthesia.
STUDIES/EVIDANCES
• Evidence that hepatitis C may be transmitted via anaesthesia breathing circuits, as well as the emergence of multiple resistant tuberculosis.
• More recently, the role of anaesthesia airway devices in the transmission of variant Creutzfeldt–Jakob disease (vCJD) has been considered by both the Department of Health and the Royal College of Anaesthetists.
STUDIES/EVIDANCES
• Canadian Anaesthetists’ Society
– Of 50 Bain circuits examined immediately following their use on patients, four were found to have become contaminated.
• P. J . Bennett D. H. P. Cope R. E. M. Thompson
– Five of twenty-five lengths of tubes examined were contaminated with pathogenic bacteria; three with Ps. aerugiitosa, one with Escli. coli and one with Staph.
IT CONCLUDES
• There is no doubt that, over the years, anaesthesia equipment has been responsible for outbreaks of nosocomial infection.
• A contamination rate of 8 per cent is far too high to permit consideration of re-use of these circuits on the susceptible patient without resterilisation.
Decontamination
• The removal of micro-organisms and unwanted matter from contaminated materials or living tissue.
It always involves cleaning followed by disinfection and/or sterilization.
Cleaning
The physical removal of foreign material including infectious agents and organic matter. This does not necessarily destroy infectious agents .
Disinfection
A process that eliminates many or all pathogenic organisms except bacterial spores.
Chemicals used to disinfect the objects are called disinfectants.
Chemicals used to disinfect body surfaces are termed antiseptics.
Sterilization
A process that renders an object completely free of all viable infectious agents by eliminating all forms of microbial life.
• Why surgeon sterilise every thing before use?
Because they are
CRITICAL ITEMS
Classification of devices
All medical instruments are divided into three categories according to degree of risk of infection they carry
• CRITICAL ITEMS
• SEMI-CRITICAL ITEMS
• NON-CRITICAL ITEMS
CRITICAL ITEMS
• Objects which enter normally sterile tissue or the vascular system or through which blood flows.
– This category includes surgical instruments, cardiac and urinary catheters, implants and needles etc.
SEMI-CRITICAL ITEMS
• Objects that touch mucous membranes or skin that is not intact .
– examples include laryngoscopes, fibre-optic endoscopes and thermometers, breathing circuits etc.
NON-CRITICAL ITEMS
Objects that touch only intact skin .
Examples include blood pressure cuff,pulseoximeters probe, ECG leads etc.
HOW TO DECONTAMINATE?
• All items first to be CLEANED.
• Critical items requires STERILISATION
• Semi critical items requires HIGH LEVEL DIS-INFECTION
• Non critical items requires LOW LEVEL DIS-INFECTION
Service cycle of medical device
Cleaning
Why Cleaning is important ?
• To prevent spread of infections between patients.
• To ensure that the anaesthesiologist does not contact infections from equipments .
Cleaning
• The objectives of cleaning are:• (1) To reduce the number of organisms to be
destroyed.• (2) To remove pyrogens, tissue fragments and
organic deposits which may be toxic to the patient and interfere with the decontamination process.
• (3) To prevent the cumulative deterioration of equipment.
• (4) To meet hygienic anaesthesia standards.
Cleaning
• The water temperature should not exceed 45°C
• Cleaning before disinfection/sterilisation to removes bioburden (Populations of viable infectious agents contaminating medical device.)
Cleaning
• It is performed by manual or automated mechanical methods.
• Instruments should be dismantled
Automated methods
• Automated methods have largely replaced manual cleaning
• Ultrasonic Cleaners and Washer / Sanitizers / Disinfectors/ Sterilizers
Ultrasonic cleaners
• For equipments having joints, crevices, lumens Detergent added to liquid
• Time limit – 3 to 6 min.
• Advantage – superior to hand washing
• Drying - Towel drying, Air drying
DISINFECTION
TYPES:-
Low level disinfection
Intermediate level disinfection
High level disinfection
Low level disinfection
• Kills
– most vegetative bacteria(except mico and endospores)
– some viruses
– some fungi
• Alcohol and Quaternary Ammonium compounds are examples.
Intermediate level disinfection
• Kills– most vegetative bacteria(including mico)
– most viruses
– most fungi
– No spores
• Alcohol, sodium hypochlorite,Phenols, and Iodophors are examples.
High level disinfection
• Kills
– Vegetative bacteria(except endo spores)
– Micobacteria
– Fungi
– Viruses
• Aldehydes, Peracetic acid, and Chlorine dioxide are examples.
Comparison
LEVELS OF DISINFECTION
LEVELS BACTERIA LIPID & MEDIUM SIZED VIRUSES
NON LIPID OR SMALL SIZED VIRUSES
VEGETATIVE TUBERCLE SPORES FUNGI
HIGH + + +/- + + +
INTERMEDIATE + + - + + +/-
LOW + - - +/- + -
STERILISATION
• Kills
– All bacteria/viruses/spores
– Render a device free from infectious agents
STERILISATION
• Terminal sterilization :- sterilization process carried out after final packaging of the item.
• Sterility Assurance Level (SAL) :- the probability of survival of micro-organisms after a terminal sterilization process & is predictor of efficacy of the process.
• A SAL of 10−6 is deemed appropriate for ‘sterile devices’; this means that the probability of an organism surviving on the device is 1 in a million.
Modes
• OF DISINFECTION– CHEMICAL
– PASTURISATION
• OF STERILISATION• CHEMICAL
• STEAM
• GAS
• PLASMA
• RADIATION
Chemical agents
• Glutaraldehyde(cidex)• Paracetic acid • Formaldehyde• Alcohol• Quaternary Ammonium Compounds• Phenolic Compounds • Iodophors• Chlorine and Products • Hydrogen Peroxide
Glutaraldehyde (cidex)
• It is a saturated dialdehyde. It is used in 1.0% concentration (but highly effective in 2% concentration).
• It is high level disinfectant. It kills spores within 12 hrs and viruses within 20 min.
Glutaraldehyde (cidex)
• Widely used because
– excellent biocidal properties,
– activity in the presence of organic matter,
– less corrosiveness and
– noncoagulation of proteinaceousmaterial.
• The manufacturers state that it retain its effectiveness for up to 14 days after initial use.
Glutaraldehyde (cidex)
Disadvantages :
• It is noxious and irritating to tissues and hence thorough rinsing of all exposed materials is mandatory.
• Prepackaging is not possible and equipment will be wet.
• Pseudo-membranous laryngitis has been linked to disinfection of tracheal tubes with glutaraldehyde.
PERACETIC (PEROXYACETIC) ACID• It is acetic acid with an extra oxygen atom.
• It is bacteriocidal, sporicidal, fungicidal and viricidal.
• They are effective in the presence of organic matter
• It will replace cidex because of its short duration (5-10 min)
PERACETIC (PEROXYACETIC) ACID
• Used in wide variety of heat sensitive and delicate instruments.
• Used on wet or dry items and there is no personnel exposure. It can be situated in the Operating room suite.
• Corrosive and irritating to skin in concentrated solution.
FORMALDEHYDE:
• It is a high level disinfectant.
• For better effect it needs relative humidity of 60-80% and temperature of 37°C.
• Limited by its pungent odor and fumes.
• Should be handled as a potent sensitizer and probable carcinogen.
ALCOHOL• Intermediate level disinfectants.
• Ethyl alcohol is bactericidal in 60-90%concentration and isopropyl alcohol in 60% concentration.
• Recommended exposure to 70% ethanol for 15mins to inactivate the hepatitis virus but 1 min for HIV.
• Their effectiveness is limited because of rapid evaporation, lack of ability to penetrate organic matter.
ALCOHOL• They are used mainly to
disinfect external surfaces of equipment like stethoscopes, ventilators, fiberoptic cables.
• They can damage mounting of lensed instruments and tend to swell and harden rubber.
QUATERNARY AMMONIUM COMPOUNDS (QUATS)
• Low level disinfectants
• They are effective against gram positive than gram negative and marginally effective against Pseudomonas. They inactivate HIV but not hepatitis virus.
• They are inactivated by organic materials.
• Side effects are allergic reactions and contact dermatitis.
PHENOLIC COMPOUNDS• They are intermediate to low level disinfectants.
• Derived from carbolic acid (phenol), one of the oldest germicides.
• They are active in the presence of organic matter.
• They are irritant to skin & mucous membranes, have bad odour.
• They are absorbed by rubber and residual disinfectant may cause tissue irritation.
Chlorhexidine (Savlon) : • It is a non detergent
chemical disinfectant usually used in the concentration of 0.5% in 70% alcohol for skin.
• Tubes, masks etc. are sterilized by keeping for 20 min in 0.1% aqueous solution.
Chloroxylenol (Dettol): • It is used as mild antiseptic
agent
IODOPHORS• It is a combination of iodine and
carrier with a resulting complex providing sustained release reservoir of iodine.
• These are intermediate to low level disinfectants.
• They corrode the metallic items and non-metallic items may be stained or discolored.
CHLORINE AND CHLORINE PRODUCTS
• They are intermediate level disinfectants.
• They are available both in liquid(sodium hypochlorite) and solid (Calcium hypochlorite) forms.
• They are most widely used, inexpensive and fast acting.
CHLORINE AND CHLORINE PRODUCTS
• Highly effective against HIV.
• Household bleach is an inexpensive and excellent source of sodium hypochlorite.
• A 1:100 to 1:1000 dilution is effective against HIV.
• 1:5 to 1:10 dilution is effective against hepatitis.
• It also inactivates Cruetz Feldt Jakobdisease with an exposure time of 1 hr.
Hydrogen peroxide
• It is an effective bactericidal, fungicidal, viricidal and sporicidal.
• It is commercially available as 3% solution but can be used upto 25% concentration.
• It is non corrosive and not inactivated by organic matter but irritant to skin and eyes.
Ozone:• Sterilizers use O2, water & electricity to produce Ozone.
Advantages:
• Useful for most goods that need low temperature sterilization.
• Process is environmentally friendly.
• Treated objects are dry.
Disadvantages:
• Not approved for flexible scopes & reactive materials such as copper & brass.
• Unsuitable for natural gum rubber products
Chemical Disinfectant/steriliser
• Sterilisers– Glutaraldehyde (> 2.0%) , – Peracetic acid(0.2%)– Hydrogen peroxide(7.5%) are examples.
• High-level disinfectants – Gluteraldehyde– Stabilized hydrogen peroxide– Peracetic acid– Chlorine and chlorine-releasing compounds.
• Low-level disinfectants – Alcohols– Sodium hypochlorite– Iodophore solutions.
Factors Influencing Chemical Sterilization
a) Concentration of the Chemical:
Rate of kill of bacteria varies directly with the concentration of the disinfectant.
b) Temperature:
Designed to be used at room temperature.
Factors Influencing Chemical Sterilization
c) Evaporation and light deactivation:
Volatile agents evaporate easily. Exp: Chlorine Products. Exposure to light adversely affects the disinfectant.
d) PH:
Alcohols work best in alkaline PH while aldehydes work best in acidic PH.
Factors Influencing Chemical Sterilization
e) Bioburden:
The effectiveness of the disinfectant depends on the nature and number of contaminating microorganisms
f) Characteristics of the item to be sterilized:
A disinfectant solution will be effective only if it can contact all the surfaces on the item.
Factors Influencing Chemical Sterilization
g) Time:
Time required for different chemical agents to function effectively varies from seconds to hours.
Factors Influencing Chemical Sterilization
h) Use Pattern, Use Life & Storage Life:
• Use Pattern refers to how many times the solution can be used.
• Use Life indicates limited period of time during which activated solution can be used.
• Storage life is the time period after which the unused or inactivated product is no longer deemed effective.
Chemical Disinfection/Sterilisation
• Advantages
–Convenient
–Rapid
– cheap
Chemical Disinfection/Sterilisation
• Disadvantages– Toxic– Flammable – Act only on exposed surfaces– Unpleasant odor and irritability – Corrosive or Chemically incompatible with certain
devices– Absorption of chemicals into items– Can recontaminate during rinsing, drying, wrapping
Disinfectant Gm +veBacteria
Gm –veBacteria
Tubercle bacillus
Spores Viruses Fungi
Formaldehyde + + + - +
QUATS + + - - + +
Phenolic compounds + + +/- - + +
Alcohol + + + - + +
Chlorine + + + - + +
Hydrogen Peroxide + + + +/- + +
Glutaraldehyde + + + +/- + +
Pasteurisation
• Water at temperatures of 77°C for a period of 30 min to achieve intermediate-level disinfection
• Breathing tubes, ETT, Reservoir bags, Facemasks, Airways, Laryngoscope, Ventilator bellows
Pasteurisation
• Advantage
– low temperature to avoid damage
– No toxic fumes or residues
• Disadvantage
– wet equipments so needs time to get dried ?
– risk of contamination again
Steam Sterilization
• Uses saturated steam under pressure
• Equipments to be closed first, packed in linen or paper
• Steam circulated through chamber, maintains temperature
TEMPERATURE (°C)
PRESSURE(lb/in2)
TIME (MIN)
121 15 15
126 20 10
134 30 3.5
150 50 Few Seconds
Advantages
• Kills all bacteria,viruses,fungi
• Speed
• Good penetration
• Economy
• Easy of use
Disadvantages
• Damages heat sensitive equipments
• Causes blunting of cutting edges
• Corrosion of metal surfaces
Monitoring
• Mechanical Monitors
• Biological Indicators
• Chemical Indicators
Mechanical Monitors
• Sterilizer components that gauge & record time, temperature, humidity pressure during sterilizing cycle.
Biological Indicator
• Most accurate method of checking sterilization effectiveness.
• They contain a population of non-pathogenic spore-forming organisms that are highly heat resistant.
Biological Indicator
• Commercially prepared test packs are available.
• To be done once a week.
Chemical Indicator
• It is sterilization process monitoring device designed to respond with a characteristic chemical change to one or more parameters of sterilization cycle.
Chemical Indicator
Indicator tape, Colour change cards and Sealed glass tubes with pellets that melt once favorable time and temperature conditions are attained.
Indicator tape should be on all packages sterilized. The stripes that appear only serve to distinguish processed from unprocessed packages. Indicators are also placed inside test packages to check performance.
Chemical Indicator
• These are divided into 6 classes, higher the class, more sensitive the indicator.
• Class 1-
– These are Internal & External Process Indicator
– These inform that item has been exposed to sterilization process.
– E.g. External Process Indicator – Autoclave Tape.
• Class 2-
—E.g. Bowie-Dick test for vacuum steam sterilizer.
—They only access Vacuum Pump efficiency & detect the presence of air leaks &/or gases in steam.
• Class 3-
—E.g. Temperature Tube.
—Contains chemicals that melts & sometimes changes color when the appropriate temp is attained.
• Class 4-
—Respond to one or more sterilization parameters.
—Contains Ink that changes color when exposed to correct combination of sterilization parameters.
• Class 5-
—Known as Integrating Indicators or Integrators
—Respond to all parameters of sterilization over a specified range of temperatures.
• Class 6-
—These are emulating indicators.
—These are designed to react to all critical parameters over a specified range of sterilization cycles for which the stated values are based on the settings of the selected sterilization cycles
Gas Sterilization
• Ethylene oxide is a colorless, poisonous gas with sweet odor.
• Flammable.
• Kills bacteria, spores, fungi, viruses
• Costlier – so restricted to objects that might be damaged by heat or excessive moisture
Advantages
• It is an effective sterilant for a variety of medical devices.
• It offers rapid low-temperature sterilization.
• Does not have environmental problems associated with EO.
• No personnel protection equipment are needed.
Preparation for EO
• Verify suitability of equipments.
• Disassemble, clean, dry items before packing.
• Hollow bore products must open at both ends.
• Items must be free of water droplets.
Preparation for EO
• Relative humidity of 35% to 70% ;
• temperature of 18º C to 22º C is recommended throughout.
• Items to be loaded loosely.
Factors affecting EO sterilization
• Temperature
• Humidity
• Packaging
• Exposure time (1.5 to 6 hrs.)
Aeration
• Degassing or desorption after EO sterilization to remove EO to a safe level.
• May be done passively (ambient) or in mechanical aerator
Complication of EO sterilization
• Acute exposure of personnel causes Upper respiratory complications,Eye irritation, Nausea, Vomiting, Diarrhea, Drowsiness, Weakness etc.
• Repeated exposure can weaken structured integrity of items.
• Liquid EO causes burns
• Chronic exposure Corneal burns, Neuropathy, Anaemia Cataracts
Advantages of EO
• Effective against all organisms.
• Reliable.
• Damage to equipments is minimal.
• No recontamination due to package .
Disadvantages
• Fire or explosion hazard.
• Needs time for aeration.
• More costly.
• Frequent biological monitoring.
Other Methods
• Gamma Radiation
• Infrared radiation
• Ultraviolet radiation
• Gas plasma
Gamma Radiation
• Items are exposed to gamma rays from Cobalt-60source.
• Non-polluting, Environment friendly process• Does not leave any harmful residue.• The sterility of the items is retained indefinitely,
as long as the packaging is intact. • Sterilisation of equipment of any shape can be
achieved due to the high penetration ability of gamma rays
• Costlier impractical for everyday use.
INFRARED RADIATION
• This is method of sterilization by dry heat usually used to sterilize the syringes and small instruments
ULTRAVIOLET RADIATION
• It is done by submitting the whole operation area to the light but the staff has to be protected from sun burn
Gas Plasma Sterilization
• Relatively new technique which has the potential to displace ethylene oxide sterilization
• For heat and moisture sensitive instruments since temperature does not exceed 50°C and sterilization occurs in low moisture environments.
• In this system, hydrogen peroxide is the precursor of active species of plasma.
Gas Plasma Sterilization
• Sterilise glass items, plastics, polyvinyl chloride (PVC),metal items, electric and fiber optic cables as well as rigid endoscopes.
• Not suitable for celluloric materials e.g. cotton, powders, linen, paper etc.
• Advantages
– Non-toxic, Dry, Low-temperature sterilization with a cycle time of only 75 min.
Gas Plasma Sterilization
P.J.BennettD.H.P.CopeR.E.M. Thompson
• All methods for decontaminating have serious practical drawbacks.
• Autoctaving -economically prohibitive due to the rapid deterioration in the rubber of the corrugated tubes and bags.
• Ethylene oxide -requires expensive special apparatuss, skilled management and prolonged sterilization and airing time.
• Formaldehyde -relatively inefficient
P.J.BennettD.H.P.CopeR.E.M. Thompson
• Chemical- chlorhexidine or glutaraldehyderequire suitable soaking facilities, rinsing must be scrupulous and draining and drying is a problem.
• Pasteurisation - beset with problems of floating loops of corrugated tubing and masks, with resultant inadequate decontamination
P.J.BennettD.H.P.CopeR.E.M. Thompson
• Lastly, the efficiency of all these methods depends for success upon separate and adequate initial washing to remove organic material, such as sputum or blood, which could protect the bacteria from the sterilisingagent.
A ‘one step’ washing machine
• The ideal method of decontamination is a cheap ‘one-step’ procedure with a rapid turnover requiring minimal handling and therefore minimal staff. This procedure must satisfy the following criteria:
A ‘one step’ washing machine
• 1 Thorough cleaning to remove all dried organic matter.
• 2 Rinsing to remove all traces of detergent or other chemical additive.
• 3 Sterilisation of vegetative organisms without damage to equipment or risk or injury to the skin or mucous membrane of patients and staff.
• 4 Adequate drying of equipment, including the lengths of corrugated tubing, is essential if Ps. aeruginosa contamination during storage is to be avoided.
Barrow & Meynell reported the use of a modified dishwashing machine
Barrow & Meynell reported the use of a modified dishwashing machine
INDIVIDUAL ITEMS
Face masks
• Rinsed, soaked & scrubbed after use.
• Wash with soap & water & thoroughly dried.
• Keep in water at 60-70°C for 20min. this reduces number of pathogens to very small no.
• Gas sterilization is v.effectivemethod.
• It should not be boiled as boiling deteriorates masks
Laryngoscope Blades
• Boiled or Autoclaved after cleaning, but they may spoil electric connections.
• Gas sterilisation.
• Formalin oven can be used.
• Wiping with 70% alcohol or 0.1% Chlorhexidine in 70%alcohol is useful.
Tracheal tubes, Suction Catheters, Airways
• Ideally disposable
• Washed with soap & water & rinsed.
• A malleable brush may be used to clean the inner aspect of tubes & airways.
• Boiling will sterilize it but tubes will be softened.
Tracheal tubes, Suction Catheters, Airways
• Chlorhexidine 0.1% solution can be used. Here equipments should be soaked for 30-60min for complete sterilization.
• Autoclaving will be effective. But ETT should be replaced after 6 uses.
• Gamma radiation is satisfactory.
Supraaglotic airway
• Ideally, supraglottic airways designed for repeated use should be sterilised no more often than the manufacturer recommends.
• A supraglottic airway used for tonsillectomy or adenoidectomy should not be used again .
• The AAGBI recommends single-use supraglottic airways.
Breathing tubes & Reservoir bags• Wash thoroughly, rinse & allow
it to dry in air.
• Can be Pasteurized at 75°C for 10min.
• Chemical disinfection with glutaraldehyde for 1hr can be carried out by using automatic washing machine or by immersion. Tube should be inserted vertically during procedure
Y-piece
• Chemical disinfection.
• Ethylene oxide or Plasma sterilization can be used.
• It can be soaked in solution of water & detergent, then scrubbed manually or placed in washing machine.
Mapleson System
• Should be disassembled & component cleaned
• Metal components can undergo Autoclaving.
• Rubber & Plastic parts can undergo Gas or Plasma Sterilization.
Adaptors
• Rinsed & soaked in solution of detergent & water.
• May be washed manually or in washing machine.
• Rubber & plastic adaptors- sterilized with EO, plasma sterilization or in Glutaraldehyde.
• Metal adaptors may be autoclaved or Pasteurized.
Unidirectional valves, APL valves & Water Traps
• Cleaned & disinfected periodically.
• They are disassembled & cleaned by wiping disc. The inside of the plastic dome & the valve seat with alcohol or detergent.
• Some APL valves may be autoclaved & some may be Pasteurized.
Gas Cylinders
• Washed with water & detergent.
• Then wiped or sprayed with germicide
Circle Absorber
• Gamma radiation
• Ethylene oxide.
• Formalin chamber.
• Can be dismantled & disinfected with spirit.
• Entry of organisms, while in use, can be prevented by using filters.
Anaesthesia Carts & Machines
• Top surface should be cleaned of visible material between cases.
• Bacterial ⁄ viral filter is used between patient and circuit.
• Disinfected with germicide at end of day
Ventilators
• Bacterial filters
• ETO of the complete respiratory circuit before use,
• Internal irrigation with antiseptics, provided the circuit is water tight.
• Some have breathing units which can be autoclaved.
• Formalin Chambers can be used.
Blood pressure cuffs, Tubing's & Stethoscopes
• Washed & dried thoroughly.
• Then subjected to chemical disinfection or Gas Sterilization.
• Nonfabric cuffs – plasma Sterilization is used.
• Stethoscopes can be washed with water & wiped with alcohol.
Pulse oximeter probes & cables
• Cleaned by wiping with alcohol.
• Cables – Plasma sterilization
Endoscopes
• Detached all parts/ports etc
• Vigorous mechanical cleaning and rinsing
• Internal channels to be brushed
• Gluteraldehyde 2% for 20 mints is the agent of choice for high-level disinfection of endoscopes
• Followed by thorough rinsing
Ultrasound probes
• Non-critical use. Following non-invasive procedure it is disinfected with a cloth soaked in alcohol based solution (either alcohol alone or alcohol combined with antiseptic).
Ultrasound probes
• Semi-critical use. For invasive procedures ( nerve block or central venous catheterisation), the probe and cable ideally should be covered with a long sterile sheath. Any conducting medium (for example, ultrasound gel) between the probe cover and the skin should be sterile.
Ultrasound probes
• The cleaning procedure should include the entire cable from the transducer to the machine and extend to the surface of the machine.
• Any probe that is contaminated with blood or other biological fluid should be cleaned as for critical use.
Environmental surfaces
• It includes surfaces of medical equipment, laryngoscope handles, infusion pumps, equipment carts, anaesthesia carts, monitor knobs, blood warmers, monitoring cables, and other equipment not in direct patient contact.
• Intermediate or low level disinfection is the acceptable mode of decontamination for this category.
ORDER OF RESISTANCE• In descending order are-
Prions
Coccidia (cryptosporodium)
Bacterial spores (bacillus)
Mycobacterium
Cysts
Small non-enveloped viruses (Polio)
Trophozites
Gram Negative Bacteria (Pseudomonas)
Fungi
Large non-enveloped viruses (adenovirus)
Vegetative Bacteria (Staph Aureus)
Lipid or medium sized viruses (HIV, Hepatitis B)
SPECIFIC DISEASE STATES
• TUBERCULOSIS
• As far as possible elective surgery on a patient with TB should be delayed until the patient is no longer infectious and if unavoidable, single-patient use items should be used.
• High-efficiency particulate air (HEPA) filter should be placed between the anaesthesiacircuit and the patient’s airway if patient with confirmed or suspected tuberculosis.
SPECIFIC DISEASE STATES
• TUBERCULOSIS • Reusable items that are used for these patients
should be subjected to sterilisation or high level disinfection.
• 0.1% Chlorhexidine solution for 1hr, then it is cleaned & scraped with soap & water & then sterilized by boiling or autoclaving.
• Boiling for 3min will kill tubercle bacilli.• It can also be immersed in 2%Glutaraldehyde
solution for 1hr.
SPECIFIC DISEASE STATES
• HepatitisB(HBV),HepatitisC (HCV)and HIV
• Autoclaving & Gamma Radiation.
• Chemical sterilization- Sodium Hypochlorite 50ppm,
• Glutaraldehyde 2% for 10 min.
• Iodophor 80ppm
• Isopropyl alcohol 70% for 15 min.
Prion diseases
• Transmissible Spongiform Encephalopathies(TSEs).
• Progressive neurological degeneration.
• TSEs are caused by abnormal prions, which are infectious proteins.
Prion diseases
• Microscopic traces of tissue often remain on surgical instruments after washing and autoclaving or disinfecting and any prionprotein in these traces could still transmit the disease.
• Successive washing after use reduces the concentration so that, after about 10 decontamination cycles, infectivity becomes negligible.
Prion diseases
• Variant Creutzfeldt-Jakob disease (vCJD) is a TSE caused by the same prion protein that causes Bovine Spongiform Encephalopathy (BSE) in cattle.
• Incubation period of several years.
• It is similar to sporadic CJD, which has been spread by neurosurgical instruments, duramater grafts and pituitary extracts.
Prion diseases
• Sporadic CJD prion protein is to be found only in brain, spinal cord and posterior eye,but in vCJD, it can also be found in lymph nodes, appendix and tonsils.
• Lymphoid tissue, including that of the adenoid and tonsil, is of ‘medium infectivity’ for vCJDand it is possible that a patient undergoing surgery could be incubating this disease.
Prion diseases
• Surgeons routinely operate with traceable reusable instruments in accord with latest national advice, since single-use instruments were associated with low risks of CJD transfer.
• Tracheal tubes, supraglottic airways and oral airways should be destroyed after use for these operations as they can be contaminated by infectious tissue.
Prion diseases
Steps to reduce the risk of transmissionof prion disease
• 1 Adherence to the same universal precautions as for other potential infections.
• 2 Minimising the use of transfusion of blood and blood products.
• 3 Use of SSD decontamination and sterilisation with tracing for all reusable equipment.
Prion diseases
Steps to reduce the risk of transmissionof prion disease
• 4 Ensuring that any instrument that contacts the brain, spinal cord or dura is destroyed afterwards.
• 5 The employment of single-use equipment when this is as reliable and safe as the re-usable alternatives.
• 6 Destroying or quarantining instruments used on cases who may have CJD and for those known to be at risk.
Prion diseases
• Steps to reduce the risk of transmissionof prion disease
• 7 Ensuring that all airway devices used during tonsillectomy and adenoidectomy are discarded after use.
• 8 For Critical Devices – Steam Sterilization for 30min at 132°C is recommended.
HOW DO I DO? SHOULD I DO?
• IF I AM WORKING IN
• Tertiary care corporate hospital.
• Multi specialty nursing home.
• Periphery.
HOW SHOULD I DO?
• WASH HAND
HOW SHOULD I DO?
• WASH HAND
• CHANGE CLOTH ON TROLLY EVERYDAY
HOW SHOULD I DO?
• WASH HAND
• CHANGE CLOTH ON TROLLY EVERYDAY
• ALL DISPOSIBLE SYRINGES
HOW SHOULD I DO?
• BAIN CIRCUIT AND VENTILATOR CIRCUIT
HOW SHOULD I DO?
• BAIN CIRCUIT AND VENTILATOR CIRCUIT
• MASK (no cidex)
HOW SHOULD I DO?
• BAIN CIRCUIT AND VENTILATOR CIRCUIT
• MASK (no cidex)
• LARYNGOSCOPE
HOW SHOULD I DO?
• ET TUBE
• AIRWAYS
• DISPOSIBLE
• ETO
• CIDEX
(Rs.500/- for
14 days)
HOW SHOULD I DO?
• ET TUBE
• AIRWAYS
• WEAR GLOVES
– (disposable/
examination)
• DISPOSIBLE
• ETO
• CIDEX
(Rs.500/- for
14 days)
HOW SHOULD I DO?
• DISPOSE OFF ALL USED MATERIAL IN SAPERATE VESSEL
GUIDELINES
• The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines of Infection Control in Anaesthesia.
• In addition to AAGBI Officers and Council members, representation included the Royal College of Anaesthetists and the Medicines and Healthcare Products Regulatory Authority (MHRA).
• Australian and New Zealand College of Anaesthetists (ANZCA) Guidelines on Infection Control in Anaesthesia in 2013.
SUMMARY
• Anaesthetic equipment is a potential vector for transmission of disease.
• We are involved in the care of patients who harbor potentially pathogenic organisms.
• Hand hygiene, Decontamination, and Sterilisation of equipment is often overlookeddespite the adequate knowledge of nosocomial infection.
SUMMARY
• Single-use equipment should be utilized where appropriate.
• Re-usable items must be processed by a Central Sterile Supplies Department.
• The choice of decontamination method depends on the infection risk associated with the item.
SUMMARY
• Cleaning is an essential pre-requisite to equipment decontamination.
• Precautions against the transmission of infection between patient and anaesthetist or between patients should be a routine part of anaesthesia practice.
CARRY HOME
• Precautions are recommended for all patient regardless of their diagnosis or presumed infectious status and must be implemented when there is a possibility of contact with:
• 1 Blood.
• 2 All other body fluids.
• 3 Non-intact skin.
• 4 Mucous membranes.
ARE WE responsible for transmitting the infection and hence increasing the
Health Care Associated Infections (HCAIs)????
Thank you