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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.61 no.2 Campinas Mar./Apr. 2011
Daniel KishiI; Rogério Luiz da Rocha Videira, TSAII
IIAnesthesiologist of HC da FM/USP
BACKGROUND AND OBJECTIVES: Anesthesiologists play an important role in the prevention of nosocomial infections. In anesthetic practice, physiologic barriers are routinely breached, allowing patient contamination with microorganisms and the consequent development of infection. The lack of adhesion to recommended practices can facilitate transmission of microorganisms. It is important to describe prophylactic practices of anesthesiarelated nosocomial infections performed by anesthesiologists.
METHODS: Structured questionnaires were distributed to be answered voluntarily and anonymously by anesthesiologists.
RESULTS: Among 112 anesthesiologists, 75% answered the questionnaire. Surgical mask is used by 95.2% of anesthesiologists, 96.3% wear gloves frequently, 98.9% wear sterile gloves for neuraxial block, 91.3% use sterile technique for central venous puncture, 95.1% wash their hands between cases, 91.6% try to maintain the endotracheal tube sterile, 96.3% discard the prefilled propofol syringe at the end of each anesthesia, 30% clean the vials before using it in the neuraxial blocks, and 19.8% clean the vials before intravenous use.
CONCLUSIONS: Respondents showed good adhesion to practices of nosocomial infection prophylaxis and to improve them educational multidisciplinary campaigns are necessary.
Keywords: Infection Control; Universal Precautions; Asepsis; Anesthesia.
Anesthesiologists play an important role in the prevention of nosocomial infections. In anesthetic practice, invasive procedures that breach physiologic barriers, such as tracheal intubation, venous access, or neuraxial blocks are routinely performed allowing contamination of patients with microorganisms and development of infection. Non-adhesion to recommended practices can facilitate transmission of microorganisms from the anesthesiologist to the patient, from the patient to the anesthesiologist, and between patients 1.
Hygiene practices of professionals, adequate cleaning of equipment, and adequate execution of invasive procedures are among important aspects for the reduction of the risk of transmission of infections 2.
Hygiene practices related to the anesthetic procedures have been investigated in different countries, such as United States, United Kingdom, New Zealand, and France 3-6.
After approval by the Institutional Ethics Committee of the Hospital das Clínicas of Faculdade de Medicine of Universidade de São Paulo, questionnaires were distributed to anesthesiologists who work in the operating suite of the Instituto Central of that hospital.
The questionnaire was translated and freely adapted from prior studies on prevention of perioperative infections 4,5 and it was voluntarily and anonymously answered by anesthesiologists (Questionnaire).
One hundred and twelve questionnaires were distributed to anesthesiologists between September 2007 and August 2008.
Anesthesiologists from the Anesthesiology Division of the Hospital das Clínicas de São Paulo were included in this study as, a convenient, non-random population.
Exclusion criteria were: 1. Anesthesiologists who are not routinely involved in intraoperative care of surgeries conducted at the operating suite; 2. Refusal to answer the questionnaire or to sign the informed consent.
Out of the 112 questionnaires distributed, 84 were answered, which indicates that 75% of the professionals participated in the study. Routine use of eye protection was reported by 21.2% of anesthesiologists, while 95.2% always or frequently wear a surgical mask; 96.3% wear general procedure gloves, while 84.1% use them for venous cannulation; 98.8% wear sterile gloves for the neuraxial block, and 87% wear them for peripheral nerve blocks. Sterile technique including hand washing, mask, headwear, sterile gown, and sterile glove was reported by 91.3% of anesthesiologist (Table I).
Ninety-five per cent of anesthesiologists wash their hands between cases, 89% wash their hands when removing the gloves, and 74.1% wash their hands before a neuraxial block.
The endotracheal tube is maintained sterile by 91.6% of anesthesiologists, and 95.1% change the filter of the ventilation system between patients.
Prefilled propofol syringe was discarded at the end of each anesthesia by 98.8% of anesthesiologists; however, 52.4% refill the propofol syringe for the same patient.
A three-way stopcock is used for intravenous infusion of drugs by 96.3%; however, only 30% reported cleaning vials of drugs with alcohol for use in the neuraxial blocks, while 19.8% clean vials before intravenous administration.
Compared to other studies, such as that of Tait et al. in the United States 3, with 44% of participation, El Mikatti et al. in the United Kingdom 4, with 68%, and Ryan et al. in New Zealand 5, with 61%, the participation of anesthesiologists in the present study (75%) can be considered favorably.
The data presented here shows good adhesion to practices of prophylaxis of nosocomial infections, which can be favorably compared to studies in other countries.
In this study, 73.8% of those interviewed never or rarely wear protective goggles. The only study in which this item was mentioned, performed by Ryan et al. 5 in New Zealand (NZ), reported similar rates, 63%. Regarding the mask, we observed a proportion similar to the American study of Tait et al. 3 (94.9%) and higher than that of the United Kingdom (UK - 68.3%) 4 and New Zealand (59.5%)5. A higher proportion of anesthesiologists reported wearing gloves (96.3%) than that of the studies of Tait et al. 3 (USA - 86.3%), El Mikatti et al.4 (UK - 54%), and Ryan et al. 5 (NZ - 84.2%). Regarding neuraxial block, a similar proportion to that of the study of Ryan et al. 5 (NZ), i.e., 98.8% vs. 99.3%, reported wearing sterile gloves, indicating a well established practice in both countries, but this data is not available in the other studies. Adhesion in our institution (91.3%) to the sterile technique, with sterile cap, mask, gloves, and gown for central venous access was lower than that reported by Tait et al. 3 (USA), but higher than that reported by El Mikatti et al. 4 (UK) and Ryan et al. 5 (NZ), with 70.4% and 70%, respectively (Table II).
Washing hands between cases, a simple procedure that can prevent transmission of microorganisms with the best cost/benefit relationship 7, was reported by 95.1% of anesthesiologists in the present study, compared to 83.9%, in the study of El Mikatti et al. 4 (UK), and 93.7%, in the study of Ryan et al. 5 (NZ). Adhesion to this practice is lower before neuraxial blocks (74.1%); despite this, it represented more than double of that observed by Videira et al.7 (32%) in a prior study performed in Brazil. According to a recent recommendation of the ASA (American Society of Anesthesiologists), before a neuraxial block, one should wash his/her hands, wear sterile gloves, cap, and mask covering the mouth and nose, besides using individual packages in skin preparation, and remove all jewelry; however, the recommendation of wearing a sterile gown and changing masks before a new case is uncertain 8.
The results suggest effective care with airways contamination, since 91.6% of anesthesiologists try to maintain the endotracheal tube sterile, and 95.1% change the filter of the ventilation system between patients. This care was considerable lower in the study of El Mikatti et al. 4 (UK - 7.2%), while in the study of Ryan et al. 5 (NZ), 97.1% reported this change. This suggests an improvement in practice in the last decade, although the places of the studies were different (Brazil, UK 4, and NZ 5), but this item was not analyzed in the American study.
Similar to the study of Ryan et al. 5 (NZ), the prefilled propofol syringe was not used in different patients, revealing an adequate practice; however, more than half of those interviewed frequently refill the syringe for the same patient, but the studies undertaken in the USA 3 and UK 4 did not report this data.
Although Hemingway et al. 9 have shown that cleaning the exterior of vials with alcohol can reduce contamination of the contents, the majority of anesthesiologists does not clean vials before using them, which increases the risks of drug contamination.
Adhesion to prophylactic practices of nosocomial infection reported in the present study was comparatively better than that observed in prior studies.
Some aspects, such as cleaning drug vials with alcohol, are still well below which is desired, indicating that this practice should be stimulated.
To improve hygiene practices, it is possible to suggest placement of signs and charts in anesthesiologist work stations, besides a procedures manual, available in electronic form and as an easy access booklet. Besides, manufactures of drugs used in our specialty could stimulate good clinical practice by printing on packages the recommendation of cleaning them before using them or adopting a sterile package for drugs used in neuraxial blocks.
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Correspondence to: Submitted on July 13, 2010. Received from the Disciplina de Anestesiologia Faculdade de Medicina da Universidade de São Paulo (USP) - Study performed at Hospital das Clínicas (HC) of Faculdade de Medicina of USP (FM/USP), Brazil.
Dr. Daniel Kishi
Rua Serafim Dias Machado nº 171 Vila Maria
12209-240 - São Jose dos Campos, SP, Brazil
Approved on September 9, 2010.
Submitted on July 13, 2010.
Received from the Disciplina de Anestesiologia Faculdade de Medicina da Universidade de São Paulo (USP) - Study performed at Hospital das Clínicas (HC) of Faculdade de Medicina of USP (FM/USP), Brazil.