ASA December 2002 Newsletter

On October 10, 2002, news reports revealed that reuse of needles and syringes to inject anesthesia medication into the intravenous tubing of multiple patients at a hospital in Norman, Oklahoma, resulted in a hepatitis C virus (HCV) outbreak that infected at least 52 patients.^1,2 The number of people infected could climb because additional patients have been advised to seek testing for HCV infection. The nurse and anesthesiologist involved have lost their hospital privileges, and an epidemiological study is under way.

Proper infection control techniques have been recommended by ASA since the first edition of Recommendations for Infection Control for the Practice of Anesthesiology was published in 1992.³

It is entirely unacceptable and extremely dangerous to reuse needles and syringes on multiple patients. It is essential that safe infection control practices are used at all times to prevent nosocomial infections in patients undergoing anesthesia or sedation. The following provides background information and lists the key points for proper infection control during anesthesia and sedation when using syringes, needles, medications and parenteral infusions.

In 1990, Trepanier et al. investigated the risk of cross-infection related to the multiple use of disposable syringes for anesthesia in the operating room. The rate of blood contamination in the intravenous (I.V.) tubing was 3.3 percent at the injection site closest to the I.V. catheter and 0.3 percent at the furthest site. The presence of a one-way check-valve did not affect the contamination rate. Trepanier and his group also found that changing the needle alone on a used syringe was useless for preventing contamination of blood into the syringe.⁴

In 1995, Rosenberg et al. surveyed 2,530 anesthesiologists, a 10-percent random sample of ASA members, to assess whether anesthesiologists are adhering to infection control guidelines, including protecting their patients from exposure to infectious diseases. Alarmingly, 39 percent of anesthesiologists reported reusing syringes from one patient to another.⁵

Similar work by Tait and Tuttle in 1995 found that 20 percent of anesthesiologists surveyed reported that they frequently or always reused syringes on multiple patients, and 34 percent reported that they never or rarely disinfected the septum of multidose vials prior to use.⁶ These practices must stop.

HCV infection is the leading cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma in the United States.^7,8 It is estimated that almost 4 million people in the United States have active HCV infection, making it much more common than the human immunodeficiency virus (HIV).⁷ Fifty to 85 percent of HCV-infected persons progress from acute to chronic disease, including hepatitis, with variable degrees of hepatic inflammation and fibrosis.^7-9 Ten to 30 percent of those infected develop cirrhosis, which can result in severe complications, including an increased risk of hepatocellular carcinoma.^7,9 Response to treatment of chronic HCV infection is variable, with about 50 percent of patients having clearance of HCV.¹⁰ A recent study showed that early treatment of acute hepatitis C has an even greater efficacy;⁷ however, larger studies are needed.⁸ There is no effective means of postexposure prophylaxis nor is there a vaccine available to prevent infection.⁹

Nosocomially acquired bloodborne infections due to improper attention to infection control have been documented previously with HCV, HBV and HIV. Contaminated multidose vials have been implicated in nosocomial infections with HCV,¹¹ hepatitis B (HBV)^12,13 and HIV.¹⁴ Three patients undergoing nuclear medicine procedures inadvertently received HIV-contaminated blood or white blood cells, and two of these incidents involved reuse of syringes.¹⁵ HCV was transmitted from an anesthesia provider to five patients, probably via a nonintact skin wound;¹⁶ in another case, HCV was transmitted from an anesthesiologist to a patient although the route of infection was not established.¹⁷ An investigation of two patients with postoperative HBV infections suggests that they became infected when an HBV-positive health care worker with severe exudative dermatitis on the hands handled arterial cannulae and obtained arterial blood gas specimens.¹⁸ Careful attention to infection control should nearly eliminate such tragic outcomes.

The key points from Recommendations for Infection Control for the Practice of Anesthesiology³ are as follows:

• Syringes and needles are sterile, single-patient-use items.

• After entry into or connection with a patient’s intravenous infusion, the syringe and needle should be considered contaminated and used only for that patient.

• Medication from a syringe must not be administered to multiple patients even if the needle on the syringe is changed.

• All infusion fluids, administration sets (intravenous tubings and connections) and pressure transducer setups are single-patient-use items. Absence of blood contamination cannot be guaranteed by visual inspection.

• Sterile needles and syringes should always be used to aspirate the contents of an ampule or vial.

• Each time a multidose vial is entered, aseptic techniques should be used, including cleansing the rubber stopper with alcohol and using a sterile needle and syringe. If visible contamination of a multidose vial has occurred or if sterility is questionable, the vial should be discarded.

• Immediately after use, or at least at the end of each patient’s anesthetic, all used syringes and needles should be discarded in an appropriate puncture-resistant sharps container. Unused syringes, needles and related items should be stored in a clean area to avoid contamination by contaminated syringes and equipment.

• Health care workers with breaks in the skin or exudative or weeping lesions should refrain from direct patient contact and from handling patient care equipment unless the open area can be protected. Strict attention to hand washing, hand antisepsis, aseptic technique and use of gloves and other barrier precautions is important to avoid transmission of pathogenic microorganisms to patients and health care workers.^3,19

This recent tragic outbreak of hepatitis C should remind us all to carefully review our own practice and the infection control efforts at our place of work. The Recommendations for Infection Control For The Practice of Anesthesiology, prepared by the ASA’s Task Force on Infection Control can be obtained from the ASA Executive Office or reviewed online at <www.ASAhq.org/publicationsAndServices/ physician.htm#rec>.

References:

1. Trougakos N. Warning issued on reuse of needles. Associated Press. Oklahoma City, OK. October 10, 2002.

2. Meier B. Reuse of needle at hospital infects 50 with hepatitis C. New York Times, October 10, 2002:A22.

3. American Society of Anesthesiologists Task Force on Infection Control, Committee on Occupational Health of Operating Room Personnel. Recommendations for Infection Control for the Practice of Anesthesiology. 2nd Edition. Park Ridge, Illinois. 1998.

4. Trepanier CA, Lessard MR, Brochu JG, et al. Risk of cross-infection related to the multiple use of disposable syringes. Can J Anaesth. 1990; 37:156-159.

5. Rosenberg AD, Bernstein DB, Bernstein RL, et al. Accidental needlesticks: Do anesthesiologists practice proper infection control precautions? Am J Anesthesiol. 1995; 22:125-132.

6. Tait AR, Tuttle DB. Preventing perioperative transmission of infection: A survey of anesthesiology practice. Anesth Analg. 1995; 80:764-769.

7. Jaeckel E, Cornberg M, Wedemeyer H, et al. German Acute Hepatitis C Therapy Group. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med. 2001; 345:1452-1457.

8. Hoofnagle JH. Therapy for acute hepatitis C. N Engl J Med. 2001; 345:1495-1497.

9. Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med. 2001; 345:41-52.

10. Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002; 347:975-982.

11. Widell A, Christensson B, Wiebe T, et al. Epidemiological and molecular investigation of outbreaks of hepatitis C virus infection on a pediatric oncology service. Ann Intern Med. 1999; 130:130-134.

12. Alter MJ, Ahtone J, Maynard JE. Hepatitis B virus transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Med. 1983; 99:330-333.

13. Oren I, Hershow RC, Ben-Porath E, et al. A common-source outbreak of fulminant hepatitis B in a hospital. Ann Intern Med. 1989; 110:691-698.

14. Katzenstein TL, Jorgensen LB, Permin H, et al. Nosocomial HIV-transmission in an outpatient clinic detected by epidemiological and phylogenetic analyses. AIDS. 1999; 13:1737-1744.

15. Centers for Disease Control and Prevention. Patient exposures to HIV during nuclear medicine procedures. MMWR. 1992; 41:575-578.

16. Ross RS, Viazov S, Gross T, et al. Transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients. N Eng J Med. 2000; 343:1851-1854.

17. Cody SH, Nainan OV, Garfein RS, et al. Hepatitis C virus transmission from an anesthesiologist to a patient. Arch Intern Med. 2002; 162:345-350.

18. Snydman DR, Hindman SH, Wineland MD, et al. Nosocomial viral hepatitis B. A cluster among staff with subsequent transmission to patients. Ann Intern Med. 1976; 85:573-577.

19. Centers for Disease Control and Prevention. Guidelines for hand hygiene in healthcare settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. MMWR. 2002; 51(No. RR-16):1-34.

Elliott S. Greene, M.D., is Associate Professor of Anesthesiology, Department of Anesthesiology, Albany Medical College, Albany, New York.

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