Test 4: Infection Control Flashcards
What are the three elements necessary for human disease transmission?
1) A reservoir of infectious agent
2) Types of infectious disease microorganisms:
-Viruses, bacteria, fungi (most common)
-Parasitic organisms and prions
3) A susceptible human host
What are the links in the chain of infection that are most susceptible to interventions?
-Controlling or eliminating the pathogen at its source
-protecting portals of entry
-supporting the host’s defenses
What are Standard Precautions?
Basic level of infection control protocols that reduce the risk of disease transmission when providing patient care.
-Hand hygiene
-Personal protective equipment (PPE)
-Respiratory hygiene
-Safe injection practices
-Equipment and environmental cleaning, disinfection, and sterilization
What are ways that healthcare workers can strengthen the links of the chain of infection?
-practicing frequent hand hygiene
-being up to date on vaccinations
-staying at home while sick
-following recommendations for standard and contact isolation
-utilizing appropriate personal protective equipment (PPE)
-cleaning and disinfecting the environment
-sterilizing medical equipment
-following safe injection practices
What is Hand Hygiene?
The practice of removing microorganisms from hands.
-Significantly reduces the incidence of infection
-Gloves removed after contamination
-Alcohol-based sanitizer available in anesthetizing area
-Targeted cleaning anesthetizing area during/after each case
What is PPE?
Specialized clothing or equipment worn for protection against contamination.
-Protects the patient and the healthcare provider
-N95 respirators should be fit-tested (Covid-19)
-Always perform hand hygiene prior to and after removing PPE (except for respirators)
-Guidelines on how to properly wear/remove/dispose of PPE
What are the three categories of transmission-based precautions?
-Contact (direct or indirect)
-Droplet
-Airborne
What is the purpose of Contact Precautions?
Prevents transmission of infectious agents spread by contact with the patient or environment.
What is the purpose of Droplet Precautions?
Prevents transmission of infectious agents spread by close contact with respiratory secretions. (3 ft)
-Small liquid particles (>5 microns in size) of infected saliva or mucus expelled from an infected person’s mouth and/or nose during coughing or sneezing, which eventually are inhaled into the airway of an uninfected host, usually requiring close contact.
What is the purpose of Airborne Precautions?
Prevents transmission of infectious agents suspended in the air. (N95 masks/respirator)
-Very fine (<5 microns in size) airborne particles
-distance of spread depends on the material exhaled by the infected person, air currents, and environmental conditions.
What is Direct Contact transmission?
Transmission of an infectious microbe from an infected person to another person by direct contact with the body, or broken or damaged skin, or mucous membrane of the susceptible host, without any intermediary object.
What are the defenses against direct contact transmission?
-Intact, nondamaged skin
-Mucosal surfaces (include immune system cells)
-Efficacy of these barriers is r/t the host’s immune system function
What is Indirect Contact transmission?
An intermediary object serving as a connecting bridge between an infected human reservoir and susceptible host.
-Most commonly due to the contaminated hands of HCWs !!!!
-Occurs due to poor hand hygiene and not decontaminated equipment
What is the most common bridge of indirect contact transmission?
The Contaminated hands of healthcare workers!!!
What is respiratory hygiene?
Cough etiquette and the appropriate use of isolation precautions to prevent the spread of infection.
-Cover mouth and nose with a tissue when coughing or sneezing
-Dispose of tissue after use in the waste bin
-Perform hand hygiene following contact with respiratory secretions (with patients)
-Do not perform patient care when infected or ill.
-During times of elevated resp infection incidence, facemasks to patients and providers who are coughing.
List some of the Safe Injection Practices.
-Avoid recapping of needles and discard used needles/syringes into a puncture resistant sharps container.
-Use syringes, needles, and needleless access devices only once, even for the same patient.
-Use infusion, pump syringe, and intravenous administration sets only once.
-Do not use bags or bottles of intravenous solution as a common source of diluent for multiple patients.
-Clean and process intravenous infusion and syringe pumps according to manufacturer recommendations between patients.
-Use 70 percent alcohol to clean the diaphragm prior to access when removing the cap from a new vial.
-Use single-dose vials for medications when possible.
-Dedicate multi-dose vials to a single patient when possible. Use a syringe or needle only once to withdraw medication from a multi-dose vial. Label the date on the multi-dose vial once opened and use/discard within 28 days of opening.
When should equipment be cleaned?
-The anesthesia work area and patient-specific equipment are cleaned between cases and terminally at the end of the day
-Need infection control policy and a method for monitoring compliance
-Minimize personal equipment brought into the OR and patient care areas
How can you prevent the transferring of microbes from the anesthesia machine to the patient?
-Clean anesthesia machine surfaces/knobs with an appropriate germicide between cases and at the end of each day
-Take protective measures to prevent materials stored on the anesthesia machine from becoming inadvertently contaminated by airborne debris (e.g., blood)
-Remove equipment from drawers, clean and disinfect drawers regularly
-Place a clean covering on the top of the anesthesia cart at the beginning of each case
In what two ways can contamination occur with the Anesthesia Delivery System (ADS)?
1) Pathogens can enter via the circuit and gas analysis sampling line
2) Pathogens can enter via the gas monitor
How do you reduce the risk of contamination of the anesthesia machine and the gas sample line and protect the patient from ADS contamination?
-Single patient use of heat and moisture exchange filters (HMEFs) on the distal end of the anesthesia circuit
-Add another filter (ex: one with a viral filtration efficiency of 99.99%) on the expiratory limb to provide backup for any particles that may pass through the airway filter.
What should you do if you suspect that the anesthesia machine is contaminated?
-Remove machine from use
-Consult manufacturer for cleaning and/or sterilization
Is it ok to perform safety checks of equipment?
Performing safety checks is acceptable with proper hand hygiene and laryngoscope blade placed back in clean sleeve.
What can you do as the anesthesia provider to reduce risk of infection?
-Put safety tested equipment back into clean sleeve
-Clean stethoscopes between use
-Clean reusable equipment per manufacturer’s guidelines
-Use disposable equipment when possible
What takes priority over all issues?
Maintenance of oxygenation!!!
How do you avoid the transmission of infection with airway manipulation/intubation?
Double glove for intubation, remove outer gloves after being in the mouth/airway, and then perform necessary actions for airway security and patency.
-Ventilate manually, auscultate breath sounds, and monitor EtCO2.
-Then, when the situation is stable, remove inner gloves, perform hand hygiene, and don clean gloves.
-When it is challenging to change exam gloves or perform hand hygiene, using an Alcohol-Based Hand Rub/sanitizer directly on nonsterile nitrile gloves is an option
-Targeted environmental cleaning of the anesthetizing area after each case
What is the motto for safe injection practices?
1 needle, 1 syringe, only 1 time → prevents the spread of dz & protect providers from disciplinary action/legal recourse
What are the 4 Categories of Aseptic Technique?
1) Equipment
2) Preparation
3) Environmental Controls
4) Contact
What are the guidelines for Equipment precautions of Aseptic Technique?
May include some or all of the following items depending on the procedure:
-Sterile gloves, gown, mask
-Sterile drapes
What are the guidelines for Preparation precautions of Aseptic Technique?
-Antiseptic skin preparation of patient prior to procedure
-Consult manufacturer product instructions for directions and warnings regarding the proper use and application of specific skin antiseptics such as chlorhexidine-alcohol or povidone-iodine.
-Confirm that all instruments, equipment, and devices are sterile.
What are the guidelines for Environmental Control precautions of Aseptic Technique?
-Close doors during operative procedures.
-Minimize unnecessary staff traffic in/out of operating room.
What are the guidelines for Contact precautions of Aseptic Technique?
-Precautions should be taken to mitigate contact with nonsterile surfaces and objects.
What makes an Ideal Skin Prep?
-Decreases microorganism count and inhibits rebound and regrowth of microorganisms
-Activates quickly
-Effective against a variety of microorganisms.
What is the preferred skin prep?
Chlorhexidine gluconate.
-Preferred skin prep agent due to immediate action, residual activity, and persistent effectiveness against a wide range of microorganisms
Which skin prep is a suitable alternative when Chlorhexidine is contraindicated?
Povidone-iodine
What is important regarding the use of Iodine-base with alcohol skin prep?
Highly effective against a broad range of microorganisms, acts immediately, but highly flammable!!!
Fire Risk: Agents that are alcohol-based or have flammable properties have the potential to increase the risk of surgical fires.
What is important to know regarding aseptic technique and invasive procedures?
-Patients and HCWs are at increased risk of exposure/infection during invasive procedures
-Perform HH before assembling equipment, and before/after procedure
-Follow facility policy
-Take proper measures to prevent adverse events (SSIs, CLABSIs, CAUTIs)
T/F: US guided procedures are associated with increased infection rates.
False; Ultrasound guidance for procedures such as vascular access and catheter placement has been shown to reduce infection rates and improve patient satisfaction.
What mitigates risk of contamination with US guided procedures?
Hand hygiene
-PPE
-skin preparation and drape
-sterile sheath
-sterile probe covers
-sterile ultrasound gel
-Disinfect ultrasound probes between each procedure and patient per manufacturer’s guidelines
How can you prevent contamination during Epidural or Continuous PNB Catheter placement?
-Strict aseptic technique and single-use sterile gel
-Maximal sterile barriers during procedure
-Prepare patient skin with an appropriate agent
-Dress the insertion site with a sterile transparent, occlusive dressing
-Use chlorhexidine-impregnated dressings at insertion sites to reduce epidural skin entry-point colonization
-Check the insertion site and overall patient status at least daily for early identification of infection (erythema, tenderness, itching; fever, weakness, HA) and sensory/motor status
-Remove once no longer clinically indicated
How can you prevent contamination during Central Venous Catheter placement?
-Consider the risks and benefits of placing a central line (site placement matters: femoral vs subclavian, peripheral, or jugular)
-Perform hand hygiene, sterile gloves and gown, surgical cap and mask, and cover the patient with a large sterile drape prior to insertion
-Prepare patient skin using appropriate agent
-Use antibiotic-impregnated catheter if the catheter is to remain in place > 5 days
-Replace catheter when adherence to aseptic technique cannot be ensured, otherwise do not routinely replace CVCs, and remove once no longer indicated
What is important to know regarding accessing and maintenance of a CVC?
-Closed access systems preferred
-Scrub the injection cap with appropriate antiseptic agent
-Type, concentration/volume, and frequency of flush per manufacturer’s guidelines/policy
-Specimen collection maintains aseptic technique
-Change injection port caps when signs of contamination/damage
-Scrub cap and catheter hub with agent
-CVCs in OR are dressed the same throughout facility
What is important to know regarding minimizing infection risk with Arterial Lines?
-catheters that need to be in place for > five days should not be routinely changed if no evidence of infection is observed
-Maintain sterility of stopcocks: cap when not in use: apply 70 percent alcohol prior to access
-Maintain sterility of pressure monitoring devices
-Minimize the number of manipulations and entries into the pressure monitoring device
-When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, scrub the diaphragm with an appropriate antiseptic agent before accessing the system.
What are the personal preventative measures associated with arterial catheters?
-Use of radial, brachial, or dorsalis pedis less infectious risk than femoral or axillary
-Hand hygiene, surgical cap/ mask, sterile gloves, small sterile fenestrated drape
-Use of closed flush systems and keep stopcocks free of blood/covered with sterile cap
What are the personal preventative measures associated with CVCs?
-Maximum barriers, hand hygiene; chlorhexidine prep and Abx impregnated catheter
-Topical Abx disc
-Use R IJ or subclavian preferred site if possible
What are the personal preventative measures associated with Regional Anesthesia?
-Meticulous aseptic technique: Jewelry removal, cap/mask, hand hygiene, sterile glove and drape
-Skin preparation: 0.5% chlorhexidine with alcohol best choice followed by povidone-iodine with alcohol. Must allow time to dry
-Barriers: Facemasks for all neuraxial procedures, Hand hygiene prior to sterile gloving, Gowns inconclusive (indwelling catheters)
-Epidural Catheters: should be indwelling for the shortest amount of time.
What is the definition of Surgical Site Infection?
A SSI is acquired by a patient in a health care facility following surgery, which was not present or incubating at the time of admission. The infection occurs at or near the surgical site within 30 days of the procedure or within 90 days of a prosthetic implantation.
What is Creutzfeldt-Jakob Disease?
A fatal neurodegenerative disease due to accumulation of pathologic proteins (prions).
-Also called transmissible spongiform encephalopathy
-Prions are resistant to sterilization
What are equipment concerns when caring for a patient with CJD?
-Use disposable equipment when possible for patients with CJD; incinerate equipment after use
-Destroy laryngoscopes and supraglottic devices used on patients with CJD
-Safely discard devices that are difficult or impossible to clean
-Clean and perform steam sterilization of instruments for 30 to 60 minutes at 132° C
-Perform steam sterilization for 18 minutes at 134° C-138° C when using a prevacuum sterilizer
-Immerse instruments in 1N sodium hydroxide solution for one hour at room temperature followed by steam sterilization for 30 minutes at 121° C as an alternative to the prevacuum sterilizer
-Disinfect noncritical items and environmental surfaces with bleach or 1N sodium hydroxide for 15 minutes at room temperature
-Consult the CDC recommendations for best infection control practices when working with patients with CJD.
What is iatrogenic transmission?
The spread of a pathogen, (bacteria or virus) through a medical procedure or treatment such as a blood transfusion, reuse of needles or IV sets, or by touching a wound on an infected patient and then touching another patient.
What is Tuberculosis?
Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis.
-Usually attack lungs, but can attack kidney, spine, brain, etc.
-Latent vs active disease
What are the S/Sx of TB?
-Cough that lasts 3 weeks or longer
-Pain in the chest
-Coughing up blood or sputum (phlegm from deep inside the lungs)
-Fatigue, weight loss, lack of appetite, fever, night sweats
How do you prevent the spread of TB?
-Place a high-efficiency particulate air (HEPA) filter between the breathing system and the patient!!!!
-Sterilize or perform high-level disinfection on equipment used on patients with cases of suspected or confirmed Tuberculosis
-Culturing anesthesia equipment is not required.
What is a hypersensitivity reaction?
An immune system response to a foreign, environmental antigen that causes an altered T cell and antibody response upon reexposure to the antigen.
-Requires prior sensitization
-Immediate or delayed onset of symptoms
-Common antigens: environmental (grass, pollen, animal dander), topical (latex), food (gluten), and medications.
-I-V classification system
What is a Type 1 Hypersensitivity Reaction?
-Immediate hypersensitivity (IgE mediated)
-15-30 minutes of exposure to antigen
-S/Sx: Mild cutaneous, GI, bronchospasm, CP collapse
-Tx: Antihistamines, bronchodilators, Cromolyn sodium to inhibit mast cell degranulation, leukotriene receptor blockers, COX inhibitors
-60-70% of anesthesia related reactions
-Usually NMBAs: 50-70% of rxns
Order the NMBAs from highest to lowest in terms of causing a Type 1 Hypersensitivity Reaction?
Succinylcholine
Vecuronium/Rocuronium
Atracurium
Pancuronium
Mivacurium
Cisatracurium
Describe Type 2 (Cytotoxic) Hypersensitivity
-IgG/IgM/Complement mediated
-Rxn to cell surface or tissue antigen
-Antigen-Antibody complex activates complement and destroys target cell
-Transfusion rxns, Myasthenia gravis
Describe Type 3 (Immune Complex) Hypersensitivity?
-IgG/IgM/Compliment/Neutrophils
-Antigen-Antibody complexes are deposited in tissue, stimulating inflammation
-SLE and RA
What is the treatment plan for intraoperative anaphylaxis? (Know this)
-D/c triggering agent
-Tburg to offset vasodilation
-FiO2 100%
-Epinephrine
-Fluids (NS/LR)
Secondary tx:
-Vaso or NE if unresponsive to Epi
-Albuterol or Ipratropium if Bronchospasm
-Glucagon if they are Beta Blockaded
-ALWAYS give antihistamines and corticosteroids
Post resuscitation:
-Serum Tryptase < 120 minutes
-24-hour monitoring for recurrence
-Patient/family notification of reaction
-Referral to allergist
What surgery and anesthesia factors contribute to a state of immunosuppression?
-Surgery
-Blood transfusion
-Hyperglycemia
-Hypothermia
-General anesthesia
-Opioids
Can result in a reduced resistance to infection, development of postoperative septic complications, and tumor metastasis.
What can happen with surgical excision of tumors?
May stimulate proliferation and metastasis of tumor cells
-Disrupts blood vessels supplying tumor, allowing tumor cells to enter systemic circulation
-Angiogenesis is increased postop to promote tissue repair, but also contributes to tumor growth and metastasis.
-Catecholamines promote angiogenesis
What is the effect of Blood Transfusion on the immune system?
-Associated with depression of the immune system, increased incidence SSI, and earlier recurrence of CA
-Irradiated or leukocyte-depleted blood products recommended for CA patients
-Use of intraoperative cell savers may contribute to CA recurrence
What is the effect of DM/Hyperglycemia on the immune system?
-Inc susceptibility to infection r/t depression of both innate and adaptive immune systems
-Inc SSIs, Poor patient outcomes
-BG level of 100-150 mg/dL can attenuate immune system effects
What is the effect of Hypothermia on the immune system?
-Hypothermia occurs in 70% of patients
-Increased SSIs, increased blood loss, impaired wound healing, decreased immune function
-Inc need for blood transfusions (bad)
What is the effect of Anesthesia on the immune system?
-Depressed function of NK cells, neutrophils, macrophages, DCs, and T cells
-Uncontrolled postop pain contributes to immune suppression and amplifies tumor promoting effects of surgery. Need multimodal approach.
What is the effect of opioids on the immune system/cancer?
-Suppress NK Cells (which are vital for eradication of tumor cells/viruses)
-Promotes angiogenesis
-Suppresses Apoptosis
Promote cancer progression and reduce long-term survival. Promote cancer cell growth, inhibit cellular immunity, enhance angiogenesis and tumor cell signalling pathways; inhibit natural killer cell functionality.
What is the effect of Regional Anesthesia on immune response?
Regional anesthesia attenuates surgical stress response and preserves normal immune function!!!
-Associated with decreased cortisol levels and normal NK cell function
-Decreases opioid and volatile inhalation agent usage
-Amide LAs have cytotoxic effects on CA cells
-Lower incidence SSIs
What is the effect of Volatile Anesthetics on the Immune system?
Conflicting evidence; some in vitro studies suggest enhanced expression of tumorigenic markers, migration of cancer cells, angiogenesis and metastasis in tumors. Insufficient evidence exists to avoid in cancer surgery
What is the effect of N2O on the Immune system?
No impact on cancer recurrence
What is the effect of Local Anesthetics on the Immune system?
Reduced cancer recurrence and metastasis secondary to anti-inflammatory actions and direct effects on the proliferation and migration of cancer cells
What is the effect of Neuraxial Anesthesia on the Immune system?
Conflicting results but generally thought to reduce cancer recurrence and metastasis by attenuating the immunosuppressive consequences of the stress response and possibly an opiate sparing effect.
What is the effect of NSAIDs on the Immune system?
Acute or chronic use associated with tumor regression presumably via cyclo-oxygenase-2 (COX 2) and prostaglandin inhibition in cancer cells. Beneficial choice as analgesics in cancer patients
What is the effect of ASA on the Immune system?
Reduces cancer metastasis
What is the effect of Supplemental O2 on the Immune system?
Patients given 80% oxygen postoperatively have a shorter cancer free survival period. Has an angiogenic effect on micrometastasis
What is the effect of Dexamethasone on the Immune system?
No effect on cancer survival
Describe anesthetic management of the Immunocompromised patient.
-Strict aseptic technique and maximum barrier precautions
-Scrub the Hub!!! (Needleless connectors responsible for 50% of infections)
-Neuraxial can blunt SNS response that suppresses immune system
-Prophylactic ABX administered 30 min before incision
-Active warming measures to avoid hypothermia
-Perioperative management of blood glucose to avoid hyperglycemia
-Leukocyte poor and irradiated blood products should be used when transfusion unavoidable
-Postoperative pain control: multimodal approach including a combination regional anesthesia and nonopioid agents (control SNS Stimulation)
