OVERWHELMED? It may be impossible for multi-tasking anesthesia providers to maintain total sterility, but increased awareness is a step in the right direction.

Many have long suspected that anesthesia providers play a significant role in the transmission of potentially pathogenic organisms during surgery. Now we know for sure. A study published recently in the Journal of the American Society of Anesthesiologists (osmag.net/kdw5mn) has essentially caught us in the act, underscoring both the challenges and the importance anesthesia providers face in striving for aseptic technique and preventing infections.

The researchers devised a clever way to measure how common the problem is. They had 23 anesthesiologists inject all bolus drugs used in 303 cases — except propofol and antibiotics — through a 0.2-micron filter designed to trap microorganisms. What they found was disturbing, if not altogether surprising. In 6.3% of the cases, the filters trapped potentially pathogenic microorganisms that would have reached patients. On top of that, when they cultured the insides of the syringe barrels, 16% were contaminated. Where did all the pathogenic organisms come from? In all likelihood, from a breach in technique that let them be transferred from such sources as the anesthesia workstation, the anesthesia provider's hands, the room or the patient.

ENEMY WITHIN Researchers found that 16% of syringes were contaminated by microorganisms that could have reached patients.

Complex task
But while the disturbing findings speak to a need for improved techniques and heightened awareness, they also speak to the complexity and difficulty that anesthesia providers face when trying to engage in high-quality asepsis in the OR. The fact is, it's almost impossible to inject a drug sterilely into a patient during anesthetic care — unless, that is, it's the only job you have. But anesthesia providers have multiple jobs. And they aren't gowned and gloved the way surgeons are, and they're not operating in an area that has a dedicated laminar flow.

So, what's the answer? The study authors suggest that maybe we should routinely use those same 0.2-micron filters for injections. But the study participants rated ease of use with the filters as a 3.5 out of 10, with 0 being very easy and 10 being very difficult.

It's an easy leap to make, but I'm not sure it's the best answer. Using filters would increase the resistance to injection, and as suggested by the study, there are some drugs you can't inject through the filters — propofol, for one — because they're too viscous. Also, while filters might trap organisms that are larger than 0.2 microns, a lot of viruses are much smaller than that.

New ways to draw up drugs
I think what this study really tells us is that we need to be doing a better job of drawing up drugs. It's eminently clear that there's a lot at stake here. We need to design new systems, have new training and come up with some new approaches. It may not be possible to reduce that 6.3% rate to zero, but there are some things we can do immediately to begin to bring the numbers down. We can:

• Make sure to routinely use alcohol or some other disinfectant on vials and injection ports.
• Transition to pre-filled syringes. Some drugs we'll always have to draw up ourselves — opiates, for example — but pre-filled syringes can take one step out of the potential microbial contamination process (see "The Case for Pre-Packaged Medications,");
• Be sure to double-glove. Studies (including by me) show a decreased rate of site contamination when anesthesia providers are able to remove contaminated outer gloves before moving on to subsequent tasks.
• Be cautious while approaching injection ports and think about what we're approaching them with.
• Always make sure our hands are as clean as possible, and that we clean vial tops before we draw up drugs.

Caught red-handed
Some providers still don't fully appreciate the severity of the problem — who don't accept or understand the frequency with which we may be inadvertently injecting microbes into patients. Now we have another layer of information, one that adds to the growing body of literature and says we have to do better. Beyond merely suggesting our roles in SSIs and infectious processes, this most recent study actually implicates us at the scene of the crime. OSM