งานนำเสนอเรื่อง: "Recommendations for Infection Control for the Practice of Anesthesiology Developed by the ASA Committee on Occupational Health Task Force on Infection."— ใบสำเนางานนำเสนอ:
1Recommendations for Infection Control for the Practice of Anesthesiology Developed by the ASA Committee on Occupational Health Task Force on Infection Control (Third Edition)Good morning, I’m Dr.จิตสุภา ปริชาตปรีชาI’m here with. Dr.ประไพรัตน์ เหมราชAnd my adviser is อาจารย์ขัตติยา มโนมยางกูรToday, we would like to present a topic review about infectious control in operating room.Reference form ASA committee on Occupational Health Task ForceR2 Chitsupha ParichatprichaR2 Prapairat HemmarajAj Kattiya Manomayangkul
2Prevention of Healthcare-Associated Infection in Patients Prevention of Occupational Transmission of Infection to AnesthesiologistsWe divide to two topics.First, prevention of Healthcare-Associated Infection in Patients.Second, prevention of Occupational Transmission of Infection to Anesthesiologists.
3Prevention of Healthcare-Associated Infection in Patients A. Hand HygieneB. Preventing Contamination of MedicationsC. Prevention of Surgical Site InfectionThe things that we should to do in this section are hand hygiene, preventing Contamination of Medications and Surgical Site Infection.
4Prevention of Healthcare-Associated Infection in Patients D. Prevention of Intravascular Catheter-Related InfectionE. Prevention of Infection Associated with Neuraxial ProceduresAnd the prevention of Intravascular Catheter-Related Infection, neuraxial procedures.
5PREVENTION OF HEALTHCARE-ASSOCIATED INFECTION IN PATIENTS
6A. Hand Hygiene In this picture, Indications for hand hygiene: Number1 and 4-Before and after direct contact with patients.2-Before clean or aseptic procedure example before donning sterile gloves.3-After contact with body fluids, non-intact skin, mucous membranes or wound dressings.5-After contact with high-touch environmental surfaces surroundings patient.And other indications are after removal gloves, before eating and after using the restroom.
7Hand washing This is step for hand washing. First, we rub palm to palm, ……….and dry your hand.Don’t forget to wash – between your finger , under your nails and the tops of your hands.
8You will see the picture that the red and orange areas are most frequently missed during hand washing.
9This’s hand hygiene algorithm This’s hand hygiene algorithm. If your hand or gloves contaminated, is there adequate time to perform hand hygiene and reglove?If no, we should remove gloves and use gel hand.
10What germs are on your hands? So handwashing is the single most important thing you can do to stop the spread of infection.
11Next slide, we can use alcohol, 2-4% chlorhexidine and iodine compound for hand-hygiene antiseptic agents.Especially, alcohol and iodine , they’re excellent for disinfection.
12This study is talk about “Hand hygiene behaviors and taxonomize failures in anesthesia providers. In department of Anesthesiology, Medical Center, Virginia.
13Methods:Following 5 observers pose as nursing staff in an academic centerobserved the Hand-hygeine of anesthesia providers4-week period throughout the perioperative periodThe methods is Following 5 observers pose as nursing staff in an academic center, observed the HH of anesthesia providers over 4-week throughout the perioperative period. HH opportunities and HH failures were recorded and categorized.Conclusion revealed in this study that the HH and aseptic practices of anesthesia providers, were very poor.
14B. Preventing Contamination of Medications and Fluids Safe Injection PracticesAseptic techniqueCategory IAAseptic technique is a procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis.In this topic, we use aseptic technique to avoid contamination of sterile injection equipmentCategory IA: Strongly recommended and strongly supported by well-designed and experimental studies.
152. Syringes, needles and cannulae Category IA -Needles, cannulae and syringes are sterile, single-use items do not reuse for another patient.-And do not administer medications from a syringe to multiple patients, though the needle or cannula on the syringe is changed.-Such as a Dormicum syringe that we use in our operating room. It should not to do like this.
163. Single-dose vials (SDVs) Category IA -Single-dose vials – If possible we should to use a single-dose vials for parenteral medications than a multidose vials.-And do not administer medications from ampules to multiple patients or leftover contents for later use.- If MDVs must be used both the needle or cannula and syringe must be sterile.- Discard if sterility is questionable.4. Multi-dose vials (MDVs)Category IA
175. Fluid infusion and administration sets (i. e 5. Fluid infusion and administration sets (i.e. intravenous bags, tubing, and connectors) Category IB- Fluid infusion and administration sets for example intravenous bags, tubing, and connectors- We should use for 1 patient only and do not use for multiple patients.Category IB: Strongly recommended and supported by some experimental.
18Medication and Fluid Use in the Immediate Patient Treatment - All medications and fluids are single-patient-use only.- Use appropriate aseptic technique and hand hygiene including use an alcohol swab to cleanse the vial's rubber septum before entering.- Cleanse the neck of glass ampules with an alcohol swab and let dry before opening.
19- Syringes should be capped when not in use. - Discard all used or opened medication/fluid containers (e.g., cap off, bag entered).- Opened single-dose ampules must be immediately discarded and not be stored for any time period.- Discard used needles in a sharps container.- Store unused syringes, needles and related items in a clean areas.
20This study is talk about “Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device”It was studied in department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon
21Method: The study was divided 2 group, control and device group from enrolled one hundred fourteen operative cases.Two sites on the anesthesia machine were selected, decontaminated and cultured via aseptic techniqueThese sites and the peripheral intravenous stopcock were cultured again after completion of the surgery.Conclusions: Improved hand hygiene compliance by using a novel device can reduces the risk of intraoperative bacterial transmission.
22The Sprixx GJ device (Harbor Medical Inc., Santa Barbara, CA) This is a novel hand sanitation device.Alcohol-based cleanser deployedby squeezing deviceDevice worn by providerThe Sprixx GJ device (Harbor Medical Inc., Santa Barbara, CA)
23C. Prevention of Surgical Site Infections Glucose controlHair removalNicotine usePreoperative ConsiderationsHair removal - Do not remove hair preoperatively unless the hair around the incision site.If necessary, remove immediately before the operation, preferably with electric clippers.Glucose control - Consider control serum blood glucose levels in all diabetic patients and avoid perioperative hyperglycemia. Especially, more than 200 mg/dL has been associated with increased SSI risk.Nicotine use - tobacco cessation for at least 30 days before elective operation. Smoking is a risk factor.Transfusion – is not associated with SSI.Antiseptic shower - Require patients to shower with an antiseptic agent on the night prior to surgery with povidone-iodine or chlorhexidine gluconate.Antimicrobial prophylaxis - Administer agent only when indicated and prior to incision.In order to, bactericidal concentration of the drug is present in the serum and tissues at the time of incision and maintain therapeutic levels throughout the operation.TransfusionAntiseptic showerAntimicrobial prophylaxis
24C. Prevention of Surgical Site Infections Operating Room VentilationCleaningNormothermiaIntraoperative ConsiderationsOperating Room Ventilation - Maintain positive-pressure ventilation in the operating room and adjacent areas. Keep OR doors closed except as needed.Cleaning - Use disinfectant to clean affected areas before the next operation.Asepsis and surgical technique - is the foundation of prevention.Normothermia – If core temperature less than 36 C has been associated with an increased risk by causing vasoconstriction,decreased oxygen delivery to the wound space and impaired phagocytic leukocyte function.Surgical attire - Wear a surgical mask, a cap or hood that fully covers hair on the head throughout the operation.Surgical attireAsepsis and surgical technique
25C. Prevention of Surgical Site Infections Postoperative ConsiderationsPostoperative Incision Care - Wash hands before and after dressing changes and any contact with the surgical site.Postoperative Incision Care
26D. Prevention of Intravascular Catheter-Related Infections General Considerations1. Hand hygiene2. Aseptic technique3. Catheter site care4. Dressing regimens5. Replacement of administration setsIntravascular catheters are an essential part of patient care for anesthesiologists.Although these catheters provide necessary vascular access, we put patients at risk for local and systemicinfectious complications.The recommendations are based on guidelines published by the Centers for Disease Control (CDC).It compose of general considerations such as hand hygiene, aseptic technique, catheter site care, dressing regimens and replacement of administration sets.
27- Sterile gloves should be worn for insertion of arterial and central catheters. Maximal sterile barrier precautions during insertion of arterial and central venous catheters (CVC) reduces the incidence of catheter-related bloodstream infections (CRBSI)- Catheter site care - Disinfect clean skin with an appropriate antiseptic before catheter insertion, preferably with a 2% chlorhexidine-based preparation
28- Dressing regimens - Cover catheter site with sterile gauze or sterile transparent, semipermeable dressing and do not routinely apply topical antimicrobial ointment to the insertion site (except with dialysis catheters).- Replacement of administration sets –No more frequently than 72-hour intervals unless catheter-related infection is suspected.Should use of 70% alcohol or an iodofor before accessing the system reduces microbial contamination of vascular catheter hubs.
30Central Venous Catheters 1. Catheter selection 2. Insertion iii.Central Venous Catheters1. Catheter selection2. Insertion3. Barrier precautions4. Catheter replacement5. Pressure transducers6. Catheter site dressingCentral Venous Catheters compose of- Catheter selection - Use an antimicrobial or antiseptic-impregnated CVC for catheters anticipated toremain in place >5 days in facilities.- Insertion - non-tunneled CVC and internal jugular vein insertion is less common mechanical complications.- Catheter replacement – use a guidewire exchange to replace a malfunctioning, non-tunneled, non-infected CVC or to exchange a catheter.- Pressure transducers - Used continuous flush devices and disposable transducers reduced the risk of infection.
31E. Prevention of Infection Associated with Neuraxial Procedures -Although infectious complications of neuraxial anesthesia (predominantly epidural abscessand meningitis) are rare but they’re serious sequelae.
32epidural abscess 1 : 145,000 Meningitis 0.2 -1.3 : 10,000 Post-dural puncture meningitis manifests 6-36 hours after dural puncturesymptoms : fever, back pain/tenderness and radicular pain leading to weakness and paralysisThe estimated incidence of epidural abscess is 1 in 145,000 (one in one hundred forty-five thousand)- while the incidence of meningitis is 0.2 to 1.3 per 10,000 (zero point two to one point three per ten thousand)- Post-dural puncture meningitis typically manifests between 6 and 36 hours after dural punctureThe presenting symptoms are typically fever, back pain/tenderness and radicular pain leading to weakness and paralysis.
33Summary of Advisory Statements Summary Advisory Statements of neuraxial proceduresThese include:- Removal of jewelry- Hand washing- Hand hygiene with alcohol-based hand gel.- Wear cap, mask, sterile gloves- Use of individual packets of antiseptic skin preparation (preferably a chlorhexidine/alcohol solution).-Sterile drape.-Sterile/ occlusive dressing over catheter site.-Consider in-line bacterial filter for extended infusions.-Limit the number of disconnections of the catheter/ infusion system.-Remove catheter as soon as no longer clinically necessary.
34Prevention of Occupational Transmission of Infection to Anesthesiologists The next part I will talk is about prevention of occupational transmission of infection to anesthesiologists
35Prevention of Occupational Transmission of Infection to Anesthesiologists Needlestick/Sharps SafetyTransmission-based PrecautionsBloodborne Pathogens (hepatitis B virus, hepatitis C virus, human immunodeficiency virus)Tuberculosis (TB)And these are scopes of my topic section. …
36Needle stick/Sharps Safety Since we have to work in OR. Everyday we expose with sharp equipment such as needle ,blades, including lots of pathogen. Exposure to many kinds of patients.That means nowsday we take risks of danger from needle stick and infections.So the prevention of infection is very important.
37Needleless device needleless intravenous access systems In prevention of accidental needle stick you should use the needleless device or devices with autosafetyThis is the needleless intravenous access systemYou should handle device in safety mannerneedleless intravenous access systems
38Devices with safety protection features This is the self – sheathing needles and the scalpels with safety-activated blade coversscalpels with safety-activated blade coversself-sheathing needles
39Devices with safety protection features This is the syringe with a retractable needlesAnd the safety intravenous cathetersSyringe with a Retractable Needlesafety intravenous catheters
401-handed techniqueAvoid recapping but if necessary you should do with one hand technique
41Sharp disposal container After using the sharp device you shouldn’t bend or break it ,You have to put it in the hard ,not leaked containerThe container should place near youIt should be sealed and replaced before completely filledPuncture-resistant, leak-proof containers located closely ,sealed and replaced before completely filled
42Mode of transmission Direct contact transmission Blood , secretion, mucous membraneIndirect contact transmissionEnviromental surface, clothingDroplet transmissionCoughs, sneezes, talks, sings,intubation,suctioningAirborne transmissionDroplet nuclei (<= 5 micron)The prevention of infection bases on mode of transmissionThere are four classes includeDirect contact transmission : This is the transmission of an infectious agent directly from one person to another. This occurs when you touch the blood or secretion of the infected patientIndirect contact transmission : the infectious agent is transmitted via intermediate object such as environmental surface or clothingDroplet transmission: This is a specific type of contact transmission,Droplets are more than five micron in size and formed when a person cough,sneezed,talks,sings ,during intubation and suctioning. Droplet can remain in air with short period ,and 3 feet far away from where they are generatedAirborne transmission: This occurs with organism that very small,less than five micron in sizes such asTB ,it can spread and remain in the air longer than the droplets
43Isolation precautions Standard precautionsTransmission-basedprecautionsIsolation precaution can be divided into standard precautions and transmission base precautionsStandard precautions are work practice for prevention of infectious transmission in suspected case or in case with no definite diagnosis of infectious diseaseTransmission base precautions prevent the spread of infectious diseases in patients who have the definite diagnosis and route of transmissionAirborne precautionDroplet precautionContact precaution
44So the Standard precautions are applied for all patients These practice reduce the risk of transmission of infectious agents from patient to patient, patient to HCW or HCW to patientIt’s a simple and effective way to control infection includePerform Hand washing before and after contact to the patient and after removal of glovesWear gloves when u will contact with blood, body fluids (except sweat), non-intact skin, and mucous membranes.Use PPE : Wear Gown, face, and eye protection if there is a risk of splash or spray. Use a standard surgical mask when inserting a central line or performing neuraxial anesthesia.Perform Needle and sharp safetyDecontaminate of equipmentSafe handling of WasteSafe handling of contaminated linenEnvironmental cleaning
45Contact precautionsContact precautions are used when the Infectious agents can spread by direct or indirect contact such as VRE,MRSA, ESWL, SARS-CoVviral/bacterial conjunctivitis,Or bacterial that cause impetigo, severe abscess, NF
46Standard precautions and Private 3 feet between patients Signage outside roomGown and gloveFace and eye protectionRemove gloves and gown before exiting room.Avoid self-contaminationPerform hand hygiene after removal of PPE.Dedicated patient equipmentClean equipment prior to its use with other patients.Cleaning of roomMaintain transport and entire perioperative period.CommunicateContact precautions includeStandard precaution and separate the patient but If it is not possible ,the patient can be admited with roommates that have the same infectious agent,and the patient should be placed far away form each other at least3 feet Wear gown and gloves when caring for patients Perform hand hygiene after removing gown and/or gloves. Minimize sharing of equipment.Appropriately clean equipment before use with other patients.Appropriate cleaning of room when vacated.Maintain contact precautions during transport and entire perioperative period.Communicate precaution level to those who will receive patient postoperatively
47Droplet precautions mumps pertussis diphtheria Rubella=German measles Droplet precautions are practice for prevention of Infectious disease that spread via droplet such asInfluenza, Bird fluSARS-CoVMumps, RubellaPertussisDiptheriaRubella=German measlesdiphtheria
48HCWs surgical mask, gloves, gown, and eye protection Single3 feet.HCWs surgical mask, gloves, gown, and eye protectionPatient standard maskRespiratory hygiene/cough etiquette.Communicate precaution levelIf you have to contact with these patient you should do droplet precaution includeStandard precaution andAdmit pt in Single room ,or with existing roommate when necessary but separate at least 3 feet between each ptSignage “ Droplet precaution” outside room to indicate level of precautions.HCWs should wear standard surgical mask, gloves, gown, and eye protectionPatient should wear standard mask (if tolerated) when transport outside roomRespiratory hygiene/cough etiquette.Maintain precautions throughout perioperative period.Communicate precaution level to those who will receive patient postoperatively.
49movieSuch a long period of topic, someone are bored, someone fall asleep. I think I should break with this interesting movie.Let’s see.…What s a thrilling movie !! PrapairatYes this is a movie about infectious agent that could spread by many modes. It spreaded shortly and killed so many people worldwide.The ways to stop it were airborne precaution and contact precaution. Like the SARS which used to be contagious 10 years ago.So infectious control is very improtant.
50Airborne precaution Measles Chicken pox Well, come back to the topic. The next is airbourne precaution.It’s used for preventing infectious agents that can spread via air includeTB , measles, chicken pox, SARS-CoVChicken pox
51Airborne infectious isolation room(AIIR) N95 for HCW Standard surgical mask for patientDoor closed all timePostponed elective procedureSignage and communicationAirborne precautions includeStandard precaution and….You have to isolate patient in an airborne isolation room (AIIR).Signage outside room “ Airborne precaution” to indicate level of precautions.Use N95 respirator or greater when in the patient‘s room.Patient should remain in AIIR with door closed at all times, except for medically necessary procedures.Elective procedures should be postponed until patient no longer requires respiratory isolation.Patients should wear a standard surgical mask when transported outside the AIIR. The purpose of the mask is to prevent respiratory droplets from being expelled into the environment where they can become droplet nuclei.Operating rooms (ORs) are designed to be positive pressure in relation to the environment. Therefore, it is important to choose the most appropriate OR to minimize the risk of contamination. Options include the OR that is most remote from others, one with an antechamber, or one in which a portable negative pressure isolation chamber can be installed at the door.The surgical procedure should be scheduled at a time when it will minimize exposure of other patients and medical staff to the airborne infectious disease.Post-anesthesia recovery must take place with the same level of respiratory precautions.Communicate precaution level to receiving personnel.Room should remain vacant after the patient leaves until adequate time has elapsed to result in a 99.9% air turnover (duration dependent on number of air exchanges per hour in room).2หารูปห้อง airborn isolation room
52Airborne infection isolation room (AIIR) Negative pressureDoor close all-time6-12 air exchanges per hour (ACH).Air exhausted directly to the outside or recirculated through a HEPA filter.AIIR is the Room that has negative pressure in relation to adjoining spaces.Door must be kept shut to maintain negative pressure.6-12 air exchanges per hour (ACH).6 ACH for existing structures, 12 ACH for new construction.Air exhausted directly to the outside (away from trafficked areas) or recirculated through a HEPA filter.
54Blood borne Pathogens (HBV, HCV, HIV) RecommendationAll anesthesiologists should be vaccinated and have documented immunity to hepatitis B virus (HBV).Standard precautionsSharps safetyPost-exposure prophylaxis guidelineNext is about specific pathogen and immunizationHIV,HBV and HCV are blood borne pathogens and can cause chronic infectionCDC recommend that all anesthesiologists should be vaccinated and have documented immunity to hepatitis B virus (HBV).You should do standard precautions, sharps safety and receive post-exposure prophylaxis after a significant exposure
57Tuberculosis Postponed until the patient is no longer infectious. Elective Surgery for Patients with Active TB InfectionRecommendationPostponed until the patient is no longer infectious.We should postpone surgery for the active TB infected patient in case of elective surgery.
58Tuberculosis Airborne Precautions Urgent/Emergent Surgery for Patients with Active TB InfectionRecommendationAirborne PrecautionsFor urgent and emergent procedures that must be performed on patients with diagnosed or suspected TB, measures must be taken to minimize the exposure of other patients and health care workers (HCWs) who are in the operating room suites.For Transmission-Based Precautions, we use Airborne Precautions.
59Tuberculosis N95 (or higher protection factor) Filters with an efficiency rating of >95% for particle sizes of 0.3 μm on the Anesthesia Breathing CircuitRecover in a respiratory isolation room or in the ORThese are measures we use.
60Tuberculosis TB Screening Programs for HCWs Recommendation Baseline screening and yearly testinga tuberculin skin test (TST)a QuantiFERON®-TB Gold (QFT-G) blood test.Positive TST-> chest radiography and review of symptomsExposed to TB screened shortly after the exposure and again in 12 weeksThere is recommendation for medical personnel to have TB screening by using tuberculin skin test. If it ‘s positive, there is the role of CXR and reviewing the symptom.Personnel who have been exposed to TB should be screened shortly after the exposure and again in 12 weeks to test for conversion.(baseline screening and yearly testing for exposure to MTB.Baseline screeninga tuberculin skin test (TST) or a QuantiFERON®-TB Gold (QFT-G) blood test.Individuals with a positive TST require chest radiography, and a review of symptoms is used for future screening.The QFT-G test exposes whole blood to MTB antigens and measures the interferon-gamma released from the white blood cells.Personnel who have been exposed to TB should be screened shortly after the exposure and again in 12 weeks to test for conversion)
61Emerging Infectious Diseases/Pandemic Influenza Droplet precaution VS airborne precaution VS contact precautionVaccination against H1N1 and seasonal influenza in all healthcare workers
62Operating room Set OR for emergency and urgency case Limiting the personnel involved in the caseChoosing an operating suite remote from othersRemove all unnecessary equipmentFull PPERecovery of the patient should be in isolation.PPE should be disposed of upon leaving the ORThe anesthesia circuit and gas sampling line should be disposed of at the conclusion of the case.All surfaces should be disinfected with an agent approved by the Environmental Protection Agency (EPA).14,17Patients should be brought to the OR for urgent or emergent cases only.Efforts should be made to limit exposure of personnel and patients. This may include performing the surgery when the fewest people are present, limiting the personnel involved in the case,and choosing an operating suite remote from others.All unnecessary equipment should be removed from the room to avoid possible contamination.Full PPE should be used.Bacterial/viral filters should be used on the anesthesia circuit to prevent exposure of the machine to respiratory pathogens.Recovery of the patient should be in isolation. PPE should be disposed of upon leaving the OR and clean PPE donned for transport. The anesthesia circuit and gas sampling line should be disposed of at the conclusion of the case. All surfaces should be disinfected with an agent approved by the Environmental Protection Agency (EPA).14,17
63Respirators for the Care of Patients With Virulent Respiratory Pathogens SARS หารูป จากoutbreak….หนังจากหนังNIOSH-approved N-95 respiratorpowered air-purifying respirators (PAPRs)PAPRs use HEPA filters (high-efficiency particulate air filters), which are as efficient as P-100 filters and will protect against SARS
64Most N95 respirators are manufactured for use in construction and other industrial type jobs that expose workers to dust and small particles. These respirators are evaluated for effectiveness by the National Institute for Occupational Safety and Health (NIOSH), which is part of the Centers for Disease Control (CDC). These are labeled "For occupational use.”
65Immunization of Health-Care Workers Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC)
66Strongly recommendations for HCW BCGHepatitis BInfluenzaMMRVaricella-zoster
67Hepatitis B No serologic evidence of immunity or prior vaccination If you’re no evidence of serologic immunity or prior vaccination.You should got 3 dose series at 0, 1 and 6 month.And follow up anti-HBs serologic at 1-2 month after dose3.
68Influenza Get 1 dose of influenza vaccine annually You should got 1 dose vaccine annually.
69MMR (measles, mumps, rubella) No serologic evidence of immunity or previous vaccinationGet 2 dose of MMR , 4week apartIf no evidence of serologic immunity or prior vaccination.You should got 2 dose of MMR and 4 week apart.
70Varicella-zoster (chicken pox) No serologic evidence of immunity or previous vaccinationGet 2 dosed of varicella vaccine , 4 weeks apart