The operating room is a highly controlled and regulated environment where surgeries to improve and save lives are performed to exacting standards. Guidelines restrict who can and cannot enter the rooms, when and in what attire. Rigorous procedures for cleaning rooms and equipment exist to ensure the protection of the patient from cross-contamination and infection.
After an outbreak of deadly Hepatitis C in Las Vegas from contaminated endoscopes, the Centers for Medicare and Medicaid Services surveyed all Nevada freestanding ambulatory surgery centers.1 When they found significant breaches in sterility procedures, they conducted a study of surgery centers across the US. The analysis in Nevada revealed well over half of the centers had lapses in infection control. The broader study showed an even higher rate of 67% of centers having at least one infection control failure. Many of these involved hand hygiene or the re-use of medication vials or glucose monitoring equipment, but a significant number also involved inappropriate reprocessing of reusable equipment, such as the endoscopes that prompted the investigations.
Regulations regarding procedure and policies of the operating room tend to focus on the surgeon, staff and the surgical process for which the patient entered the room. It is worth noting that anesthesiologists perform invasive procedures, manipulate the airway and have constant contact with the patient throughout their stay in the OR. It makes sense that anesthesiologists should be concerned about infections and preventive protocols, as well. It turns out that in addition to complying with federal, state and local regulations, anesthesiologists independently reevaluate and update their recommendations for such measures. The American Society of Anesthesiologists provides guidance in accordance with and beyond that of governmental regulatory agencies.4
Invasive procedures by anesthesiologists are performed under the same stringent rules as those performed by surgeons. Airway manipulation in the operating room is exclusively the realm of anesthesiologists. Devices such as laryngoscopes and bronchoscopes are required to be cleaned and disinfected but not necessarily sterilized.2,4 Bronchoscopes are very similar to endoscopes in that the FDA classifies them as “semi-critical” devices based on their contact with body fluid and contaminants, and in their common reprocessing considerations. Conventionally, these are reusable devices which are notoriously hard to clean and disinfect.2,3 Several outbreaks of infections have been linked to improperly cleaned bronchoscopes.5 Methods used for sterilization of other surgical equipment subjecting the instrument to high temperatures or harsh chemicals would ruin the delicate components of these scopes.2,5 Bronchoscopes, unlike other airway devices, have channels, angles and other features that make them difficult to properly clean and disinfect.2,3 This may position bronchoscopes as a more likely vector for transmission of infection and thus, make them a candidate for further scrutiny and improvement. As disposable scopes become more widely available, more technically equivalent and more economically sensible as is the current trend, this may be a source that can be easily eliminated. Replacing reusable equipment with single-use items as we are seeing with laryngoscopes and laryngoscope blades may be a logical step in our quest to eliminate infectious sources.
Anesthesiologists are vigilant in their protection of patients and should continue to look for opportunities to prevent transmission of infection in these responsibilities. Proper hand hygiene, maintenance of strict sterile technique when performing procedures, adherence to recommendations regarding medication vials, adoption of single-use equipment where available and properly cleaning and disinfecting reusable instruments all provide anesthesiologists with opportunities to maintain leadership in the prevention of infections during surgery.
1. Melissa K. Schaefer, Michael Jhung, Marilyn Dahl, Sarah Schillie, Crystal Simpson, Eloisa Llata, Ruth Link-Gelles, Ronda Sinkowitz-Cochran, Priti Patel, Elizabeth Bolyard, Lynne Sehulster, Arjun Srinivasan, Joseph F. Perz. Infection Control Assessment of Ambulatory Surgical Centers. JAMA. 2010;303(22):2273–2279. doi:10.1001/jama.2010.744 https://jamanetwork.com/journals/jama/fullarticle/186038
2. Reprocessing Medical Devices in Health Care Settings: Validation, Methods and Labeling. Guidance for Industry and Food and Drug Administration Staff. FDA. March 17, 2015 https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM253010.pdf
3. Preventing Cross-Contamination in Endoscope Processing. FDA. https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm190273.htm
4. Statement on Standard Practice for Infection Prevention and Control Instruments for Tracheal Intubation. American Society of Anesthesiologists, Committee on Quality Management. Oct 28,2015. http://www.asahq.org/quality-and-practice-management/practice-guidance-resource-documents/statement-on-standard-practice-for-infection-prevention
5. Infection Control in the Bronchoscopy Suite. American Journal of Respiratory and Critical Care Medicine. 167(8), pp 1050–56. http://www.atsjournals.org/doi/abs/10.1164/rccm.200208-797CC