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Asepsis in Regional Anesthesia

Denis Jochum, MD
Albert Schweitzer Hospital
Colmar, France

Gabriella Iohom, MD, FCARCSI, PhD


Cork University Hospital
Cork, Ireland

Herve Bouaziz, MD, PhD


University Hospital
Nancy, France

Ensuring patient safety is a core component of our professional


practice. Anesthesiologists are beginning to appreciate the important role
they may play in infection control. Hand washing is considered crucial for
reducing perioperative infection.1 Certain invasive medical specialties
(surgery, anesthesiology, emergency, and intensive care medicine), high
workload, and activities associated with a high risk for cross-transmission
have been identified as risk factors for nonadherence to hand hygiene. An
observational study carried out in a university hospital on 163 physicians
found a 57% adherence on average with marked variations across medical
specialties. Only 23% of anesthesiologists were compliant.2 This is
surprising considering that hand disinfection may be achieved with simple
measures. In a recent study, a novel personal hand decontamination
device delivering an alcohol-based hand cleanser and capable of recording
hand decontamination events was worn by healthcare workers in the
operating theater. An audible alarm set for 6 minutes prompted providers
to wash hands if there were no events recorded in that 6-minute interval.
This simple intervention resulted in a 27-fold increase in the hourly hand
decontamination events as compared with baseline rates, translating
into a reduced risk of intraoperative bacterial transmission. Healthcareassociated infection rates were also reduced (3.8%) as compared with the
control group (17.2%).3
REPRINTS: HERVE BOUAZIZ, MD, PHD, UNIVERSITY HOSPITAL NANCY, SERVICE DANESTHESIE REANIMATION
CHIRURGICALE, HOPITAL CENTRAL, NANCY, FRANCE, E-MAIL: H.BOUAZIZ@CHU-NANCY.FR
INTERNATIONAL ANESTHESIOLOGY CLINICS
Volume 48, Number 4, 3544
r 2010, Lippincott Williams & Wilkins

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Jochum et al

The incidence of infectious complications associated with the


practice of regional anesthesia (RA), although ill defined, remains
extremely low. General guidelines for infection control in anesthesia
have been published in the past.46 They are essentially limited to
disinfection of medical devices in anesthesia and intensive care and take
into account the risk of transmitting nonconventional agents (ie, prions).
In addition to general infection precautions, these recommendations
focus on airway instrumentation and vascular access. They only mention
RA as follows: The incidence of nosocomial infections after RA is
unknown. Rigorous prevention is dictated by their potential seriousness.4 Indeed, existing data are vague and recommendations refer
mainly to neuraxial regional anesthetic techniques. Studies examining
the role of asepsis during peripheral nerve blockade are lacking. Recent
developments in ultrasound-guided RA have not been followed with
specific recommendations.
In this chapter potential infectious complications during performance of RA are discussed with particular reference to risk factors. The
focus is placed on justified infection precautions for RA procedures and
those relating to the use of ultrasound equipment.

Risk Factors for Infection

Infectious complications have been reported following a national


audit in the United Kingdom. A total of 707,425 neuraxial blocks
including close to 325,000 spinals and 293,000 epidurals were performed.7 Fifteen out of 20 epidural abscesses met the inclusion criteria
at the time of reporting. Of these, 7 resolved during the subsequent 6
months. Of the 8 remaining patients, 2 died. Three out of 6 patients
with meningitis (3 excluded from the review) made a complete recovery.
Clearly, epidurals were associated with a higher risk of infection
compared with spinals. Nearly two-thirds of epidural abscesses occurred
after epidural anesthesia. In contrast, meningitis seemed to be more a
complication of intrathecal techniques. Staphylococcus was most commonly isolated in epidural abscesses, often in immunocompromised
patients. As for meningitis, Streptococcus originating from the upper
airway of the operator seemed to be the causative agent. Case reports of
meningitis after spinal anesthesia continue to be published. Recently a
case series of 5 including one fatality has been summarized, linked to
2 operators in 2 centers.8 Four of the cases were confirmed to be
infections with Streptococcus salivarius, a bacterium belonging to the
normal flora of the oral cavity. This was most likely transmitted directly
from the anesthesiologist to the patients. The cause in one cluster was
traced back to no mask worn by the anesthesiologist who performed the
procedure.
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In the literature infections related to single shot peripheral nerve


blocks are extremely rare. There was, however, a fatal case of
necrotizing fasciitis with Streptococcus reported after an axillary block in
an elderly insulin-dependent diabetic patient.9 This case highlights
potential problems in terms of asepsis, that is, no alcoholic antiseptic
solution used and no mask worn, in a high-risk patient. Infectious risks
associated with perineural catheters are better characterized. Recent
studies have shown colonization of 23% to 57% of perineural catheters
resulting in a 0% to 3% incidence of localized infections and 0% to
0.9% proven systemic infections.10 Severe infectious complications described include axillary abscess (axillary catheter), cervical and mediastinal abscesses (interscalene catheter), psoas muscle abscess (femoral
catheter), and thigh abscess (popliteal catheter). The most frequently
isolated pathogen was Staphylococcus aureus. Reported potential and
nonrisk factors are summarized in Table 1.

Infection Precautions Pertaining to RA

With regard to neuraxial anesthesia techniques, the American


Society of Anesthesiologists has recently summarized the current
understanding and published expert opinions as well as views of other
members.11 According to these, it is considered good practice to identify
patients at risk of infectious complications, to consider alternative
anesthetic techniques in high-risk patients and to commence antibiotics
before performance of a neuraxial block in patients with proven or
suspected bacteremia. The anesthetic technique should be chosen
individually depending on the patients medical condition. For infection
prophylaxis in these cases, rigorous asepsis should be observed during
each step of equipment preparation (including the ultrasound machine)
Table 1. Risk Factors for Catheter-related Local Inflammation and Signs of Systemic
Infection During Continuous Peripheral Nerve Blockade
Reported Risk Factors Odds
Ratio (95% Confidence Interval)
Intensive care unit stay
5.07 (0.33-18.1)
Catheter use >48 h
4.61 (1.57-15.9)
No antibiotic prophylaxis
1.92 (1.03-3.9)
Axillary or femoral site
3.39 (1.48-7.79)
Frequent change of dressing
2.12 (1.37-3.29)

Potential Unproven
Risk Factors

Proven Nonrisk
Factors

Male sex

Patients age

Diabetes mellitus

Preexisting disease
(except diabetes)
Technical characteristics of the catheter
Securing the catheter
(except tunnelling)
Local anesthetic
infused

No tunnelling of
the catheter
Head and neck
mobility
No sterile gloves,
mask, hat, or gown

Adapted with permission from Anesthesiology. 2009;110:182188.


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Jochum et al

and neuraxial placement of needle and catheter. This includes removal of


jewelry (watch, ring, etc), hand disinfection, and wearing of theater hat,
mask (over mouth and nose, and changed before each procedure), and
sterile gloves. Individually packed antiseptic solution (ideally clorhexidine
alcohol, alternatively polyvidone-iodine with alcohol) should be used for
skin disinfection, allowing enough time for it to dry. The use of sterile
drapes during and a sterile wound dressing over the catheter insertion
point after the procedure is recommended. Bacterial filters should be
used when prolonged epidural drug administration is envisaged.
Catheter disconnections and reconnections should be kept to a minimum
to decrease the risk of infectious complications. Removal of catheters
should be considered when accidentally disconnected. In addition, no
catheter should be kept in situ any longer than clinically indicated.
Experts and American Society of Anesthesiologists members do
not seem to unanimously agree with wearing a surgical gown for all
neuraxial RA techniques. However, more stringent recommendations
exist for catheter insertion, in similarity to central venous access.12 This
is a controversial issue and there are insufficient data to conclude the
debate.13,14 Another important point made in this setting was that the
assistant should also obey the recommendation of wearing a hat and
mask and using an antiseptic hand wash.4
The American Society of Regional Anesthesia guidelines make no
distinction between performing neuraxial or peripheral blocks.14
Important elements of asepsis are summarized in Table 2.
Differences exist between the recommendations of various scientific
societies. Most of them make a distinction between asepsis precautions
during neuraxial versus peripheral nerve blocks.6 Skin preparation and
hand disinfection are advocated in both cases, but for peripheral nerve
blocks sometimes only sterile gloves and small sterile drapes without the
other barrier precautions have been suggested. Of note, recommendations specific to RA use maximum precautions regardless of neuraxial or
peripheral site.12,15 For patient preparation, only before perineural
catheter insertion is hair removal (by shaving or depilation) recommended along with surgical skin disinfection of the site in question
using a nonalcoholic solution. Surgical gloves, mask, and hat should be
worn for all blocks. For catheter insertion maximal sterile barrier precautions are recommended. Skin disinfection should be systematic, of
surgical standard, and should be sufficient in size (larger if sterile drapes
are not used). Assistants should also wear mask and hat.15
In our view, some additional clarification may be warranted. If hair
removal is necessary, this is best performed using shears, clippers, or
depilatory cream as opposed to shavers. By analogy to peripheral
intravenous cannulation, similar asepsis measures should be taken for a
single shot peripheral nerve block. Skin disinfection usually comprises
4 steps: (1) washing with an antiseptic liquid soap, (2) rinsing, (3) drying,
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Table 2. Important Components of Aseptic Technique (Applicable to Continuous Peripheral


Nerve Blocks)
Major
Removal of watches and jewelry
Preprocedural hand washing with
hydroalcoholic solution
Protective barriers
Surgical hat and mask
Sterile gloves
Surgical gown
Appropriate selection and application
of skin disinfectant: alcohol-based
antiseptic or clorhexidine gluconate
Proper sterile draping technique(s)
Maintenance of a sterile field
Appropriate dressing techniques

Minor
Proper use of bacterial filters during
long-term catheterization
Prevention of catheter, hub, and site
violations or repetitive injections/
disconnections
Catheter tunnelling?

Adapted with permission from Reg Anesth Pain Med. 2006;31:311323 and Anesthesiology.
2009;110:182188.

and (4) applying a soap-based antiseptic. For elective surgery, assuming


the patient received a wash with an antiseptic soap, 2 consecutive
applications of antiseptic seem sufficient. For emergency surgery, taking
all 4 steps is advisable. In all cases, sterile gauze swabs should be
generously soaked in antiseptic solution. Recommended solutions
include chlorhexidine alcohol and povidone-iodine in alcohol. Adequate
contact time should be allowed with the antiseptic solution and the
injection site should not be palpated after disinfection. A 2007 French
regional evaluation of hygiene practices in anesthesia found skin
disinfection before RA up to standards in only 60% of the cases with
an increased use of chlorhexidine alcohol disinfection (Biseptine) compared with 1998.16 In the same survey, the anesthesiologist performing
the RA procedure wore sterile gloves, mask, and hat in more than 95%
of the cases.
A French national survey looking at RA practices before total knee
replacement found less impressive results.17 Written infection prevention protocols for RA were found in only a third of the cases. The
preferred antiseptic was polyvidone-iodine in alcohol (69% of cases).
For femoral catheter insertion the majority of operators wore a hat
(90%), a mask (87%), and sterile gloves (90%), but fewer had a sterile
gown (45%). This fact highlights discrepancy between existing guidelines and every day practice in the field of RA. The physical space
dedicated to performing RA procedures may impact on the infection
precautions taken. Ideally, a block room adjacent to the operating
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Jochum et al

theater and part of the operating suite should be available. In this


regard, in the 2007 regional survey, blocks were performed in the
recovery room in 63% of the cases.16 Data from the national survey
revealed that femoral catheters were inserted in recovery rooms (43%),
anesthetic induction rooms (28%), operating rooms (16%), and a
dedicated block room (11%).17 Of these, the recovery room is the only
open environment, amenable to cross-transmission of infection.

Infection Precautions Pertaining


to Ultrasound-guided RA

Ultrasound-guided RA requires the use of a nondisposable medical


device, namely the ultrasound probe. Currently no specific recommendations exist for infection control during this application. No data are
available in the literature regarding disinfection methods for this
particular nondisposable device. Aseptic conditions are often mentioned, whereas sterile conductive gel, sterile protective cover for the
ultrasound probe, or covering it in a fenestrated sterile drape with
adhesive margins, are only rarely referred to. This is despite the fact that
general recommendations for disinfection of medical devices exist and
could be extrapolated.6,18,19 It is common knowledge that anesthesia is
associated with iatrogenic complications. Nosocomial infections are top
of the list, resulting from the invasive nature of procedures performed.
In addition, anesthesia predisposes to interpatient transmission of
infection, owing to direct contact with blood and other bodily fluids.
When new nondisposable medical devices are purchased, the financial
burden is increased further by the subsequent sterilization demand
(superior to disinfection) in line with infection control demands.
Specifications need to address the imperative requirements of minimizing infectious risks. Ultrasound probes are not thermoresistant; therefore disinfection remains the only option. In addition, traceability would
be highly desirable, that is, information on the equipment used for each
patient should be available.
Medical devices are classified according to use and risk of transmitting conventional infection as follows20: (Table 3)
 Noncritical (NC) medical devices: which have no direct contact
with the patient or come in contact with intact skin (low risk of
infection). They require a low level disinfection. Transcutaneous
ultrasound probes fall into this category.
 Semicritical medical devices: which are in contact with an intact
mucosa or nonintact skin (medium risk of infection). Disinfection
needs to be of intermediate level and is achieved by immersion
into a disinfectant solution after predisinfection and cleaning.
Endovaginal and transesophageal probes fall into this category.
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Asepsis in Regional Anesthesia

Table 3.

41

Classification of Medical Devices and Required Disinfection Levels


Level of

Destination

Category

Infectious Risk

Penetrates into the vascular system, a cavity,


or sterile tissue

Critical

High

Comes in contact with


mucosa or nonintact
skin
Comes in contact with
intact skin or no
direct contact with
patient

Semicritical

Intermediate

Noncritical

Low

Required
Treatment
Sterilization or
sterile disposable;
high level
disinfection
Intermediate level
disinfection
Low level
disinfection

Adapted with permission from J Hosp Res. 1972;9:531.

 Critical medical devices: which penetrate a tissue, a sterile cavity,


or the vascular system (high risk of infection). Invasive surgical
devices require sterility or high level disinfection. The ultrasound
probe used by the surgeon intraoperatively is one such example.
As no specific documentation for disinfection levels of ultrasound
probes used for RA exists, recommendations for intraoperative ultrasound may be adopted. It is desirable to use a sterile protective cover for
the ultrasound probe. After removal of this, the probe should be
sterilized or at least disinfected according to a high level disinfection
protocol owing to the possibility of cover perforation.19 It may be
conceivable to use the recommendations developed for endocavitary
ultrasound probes. Recommendations for these vary. Some suggest high
level disinfection considering the risk of perforation of the cover may
reach close to 10%.19 Others promote a low level disinfection if the
protective cover remains intact and an intermediate level disinfection if
the cover has been pierced or the probe has been soiled.21
The ultrasound probe used for RA is usually positioned on intact,
clean, disinfected skin area and does not penetrate any tissue. If so, is it
a NC medical device? Other factors contributing to the assessment of
infection risk are: (1) is the probe kept in a sterile environment, (2) is
there a risk of contamination by bodily fluids, and (iii) does the probe
material permit sterilization or disinfection? If so, is it a semicritical or
even a critical medical device? The ultrasound probe may be compared
with the cameras used for video-assisted surgery. Disinfection is carried
out by wiping the camera with a disinfectant detergent solution aimed
at reducing the number of microorganisms present on its surface to a
minimum. A sterile cover is subsequently applied before using the
camera in the operative field.
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Jochum et al

Clearly, different interpretations will lead to variable precaution


practices. A recent survey evaluated anesthesiologists knowledge regarding infection precautions pertinent to ultrasound-guided RA.22 The risk
of contamination owing to cross-transmission related to the reusable
medical device was considered low, moderate, and high by 43%, 48%,
and 9% of anesthesiologists, respectively. The ultrasound gel used was
presented in sterile single-dose sachets in 83% of the cases and in a
multidose nonsterile plastic bottle used for more than 24 hours from
opening in 13% of the cases. No written protocols for skin disinfection
existed in 73% of the cases. In 68% of the cases a nonspecific protective
cover (ie, transparent semipermeable occlusive dressing; Opsite in 52%
of the cases) was used for the ultrasound probe and no cover at all in
5% of the cases. Anesthesiologists believed to have used appropriate
protective covers in 27% of the cases. Between 2 patients, 86%
performed probe decontamination whereas 13% did not. No microbiological control was performed in 83% of the cases. This survey
highlights diversity in both knowledge and practices of infection
precautions in anesthesia. It also stresses the importance of establishing
specific recommendations.
Recommendations pertinent to peripheral nerve blockade in
general apply to ultrasound-guided peripheral nerve blockade. In addition, for both single shot and continuous peripheral nerve blocks, sterile
gel and a sterile probe cover are necessary. This, at best, may represent a
dedicated (Food and Drug Administration approved, European Conformity Marking marked) sheath that fits the probe used and is of
sufficient length to ensure a sterile environment. Ideally, a telescopic
sleeve should be used, fixed in place by an elastic band as opposed to a
sticky tape. The latter is at increased risk of tearing during removal, thus
there is a real possibility of soiling the probe. Between 2 patients, the
probe should at least be disinfected according to regulations for
disinfection of NC medical devices. Transcutaneous probes and cables
should be wiped and cleaned with products recommended by the manufacturer, that is, a nonwoven wipe impregnated in a disinfectant detergent. Keyboards and carts should be cleaned regularly. If a tear of the
sterile sleeve is witnessed, the probe should undergo a higher level
disinfection.23 Most manufacturers do not offer completely immersible
probes and cables. The probe material may be predisinfected with a
detergent, but not always with a disinfectant such as peracetic acid. It
may be useful to inquire about alternative methods facilitating the
disinfection process. These may entail automatic rapid disinfection
devices using ultraviolet light for physical disinfection or nebulized
hydrogen peroxide for chemical disinfection. The cleaning process
remains extremely important in ensuring a more effective disinfection.
The protective sleeve facilitates the cleaning process. Finally, even if the
sleeve is intact after removal, at the end of the operating list the
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Asepsis in Regional Anesthesia

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ultrasound probe should be cleaned with detergent, rinsed, dried, and


kept in a clean environment.21 It is imperative to develop and follow
cleaning and disinfection protocols at each institution.24

Conclusions

The risk of infection associated with the practice of either neuraxial


or peripheral RA remains very low. When it does happen, however, it
may result in major possibly lethal complications regardless of the
injection site. Therefore, during all RA procedures rigorous asepsis
should be observed as per national or international guidelines and recommendations. Currently, some of these recommendations are evidencebased (ie, hand disinfection before invasive procedures, wearing a mask,
or using alcohol-based skin disinfection at the injection site) whereas
others rely on expert opinion. For best practice regarding asepsis of
ultrasound probes, recommendations have been published for the
use of adequate sleeves. For ultrasound probes used in RA, different
interpretations of existing guidelines may influence how disinfection
is ensured. Clear detailed protocols should be developed to solve the
current problem of adequacy of asepsis during ultrasound-guided RA.

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