Thoughts?

Discussion in 'Anesthesiology' started by anbuitachi, Apr 20, 2017.

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  2. partydoc

    partydoc 7+ Year Member

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    Actually not a bad idea. I'd use it
     
  3. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    Oh please.

    The fact that some of us have to wear those absurd disposable jackets in the OR is bad enough
     
  4. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 7+ Year Member

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    My place recently outlawed surgeon caps. I refuse to wear a bouffant so now so just wrap my head in Ioban.
     
  5. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    I have never heard of one case of infection caused by anesthesia machines!
     
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  6. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Probably yet another $50 expense per case that will start in academia, then filter down to hospital ORs, then when surgery centers are required to use it they will go out of business. Excessive costs are straining the budgets of many centers now, including the fact that one vial of ephedrine that costs 5 cents to manufacture, is sold at $76 per vial. The cumulative costs of out of control prices for drugs and equipment is causing cost escalations to patients. It is speculative that the anesthesia machine harboring bacteria causes transmission to patients although with respect to suction it is certainly a concern.
     
  7. gasdoc77

    gasdoc77 2+ Year Member

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    "Did you have surgery? Did you get infected? Do you suspect your anesthesiologist of practicing unprotected anesthesia with their machine? Call 1-800-bad-anesthesia to speak with an attorney"
     
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  8. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Thats an expensive ephedrine vial... it's not that expensive at my institution
     
  9. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 7+ Year Member

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    It's a fairly recent price hike. Check again.
     
  10. nimbus

    nimbus Member 10+ Year Member

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    A giant condom for the anesthesia machine? What about IV poles, electrocautery machines, infusion pumps, tourniquet boxes, bair huggers, etc? Shouldn't we be wrapping that s*** up? Why aren't we gowned up in space suits?
     
  11. GravelRider

    GravelRider ASA Member 2+ Year Member

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    This is just someone trying to capitalize on the enormous disposable/consumable market in medicine. Fear monger about the infection rates and every administrator will be jumping to buy them and every clipboard warrior will be checking to make sure your machine is properly covered and not an inch of skin is exposed. Then the patient will go to the floor and you'll check on them post-op day 1 and they'll be lying in a sweaty, smelly bed with dirty scrambled eggs in the sheets from the morning breakfast 6 hours ago. The entire unit will smell like stale pee, but yeah, it's the 1/4 inch of exposed ear lobe of the anesthesiologist that is responsible for the infection.
     
  12. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Funny.
     
  13. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    like how each vial of medication can only be used for 1 patient.. ive actually never finished a vial of 500mg ketamine on 1 patient in the OR
     
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  14. psychbender

    psychbender Cynical Member 10+ Year Member

    My old pharmacy didn't question when we split ketamine between patients (each got their own stick drawn up in proper fashion, don't freak out, purists). I told them once if they ever had concerns, then supply us with 100mg vials in our drug boxes.

    Sent from my SM-G930V using SDN mobile
     
  15. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Re: ephedrine- we checked three different suppliers and $76 per vial was the lowest obtainable by the surgery center. We called two manufacturers and were met with stunned silence when we told them what McKesson and others were charging, then they made the statement there had been a price hike but the cost should not be that high. Yet, the manufacturers we contacted have entered into an agreement with the government to not sell ephedrine directly to surgery centers or offices (ostensibly because of manufacture of illicit drugs). At these prices it wouldn't surprise me if some mid level or upper level surgery center administrator goes postal and starts taking out the greedy SOBs that are hiking the prices so much.
     
    Last edited: Apr 21, 2017
  16. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Jebus, might as well skip on the ephedrine and go straight to the epi

    and the whoel government agreement thing makes no sense.
     
  17. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    Akovaz, right
     
  18. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    That is the slippery slope this heads toward.

    Any infection control practices ultimately ignore the facts that you have to touch the patient and skin flora exist.
     
  19. waterbottle10

    waterbottle10 5+ Year Member

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    Dump the patient in a pool of betadione daily
     
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  20. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    The haters are wrong. This is a good idea. A great idea actually.

    plank- you haven't heard about it because you haven't looked. Nobody really has until recently. The data are emerging and we'd be fools to ignore it. If my kid was having surgery and I knew the previous patient was MRSA or VRE or CRE or ebola or whatever positive, I'd want them to use this.

    It has recently been demonstrated that the contaminated anesthesia workspace is an important vector of bacterial transmission and is implicated in a significant number of SSIs. Everyone just assumes these are attributable to the surgical side of the drapes, or on postop nursing care. The data are damning on this and we have to pay attention.

    I'm getting these things in my hospital, and the plan is to use them in all known cases of drug-resistant bugs as a pilot. You can thoroughly clean the room between cases, or you can turn the cases over fast, but you can't do both. These will help with making sure the next patient doesn't get whatever superbug the previous patient may have had. I'm asking the techs to place these so that the MDs don't have to concern themselves with that task (though putting them on is very easy). It's really simple, really easy, and doesn't affect your work flow at all in any way once they're on. They come right off and don't leave any nasty residue or anything.

    Look through the April 2015 issue of Anesthesia and Analgesia. It's dedicated to this issue. It'll open your eyes.
     
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  21. vector2

    vector2 ASA Member 10+ Year Member

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    Machine condoms don't sound like a terrible idea- I'm just wondering why we have toilets impregnated with antimicrobial substances yet multi-thousand anesthesia machines don't
     
  22. algosdoc

    algosdoc algosdoc 10+ Year Member

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    The objection I have is to cost and to the fact that such barriers have not proven to alter outcome. Do the studies, then sell the product. It may also be just as efficacious to spray the work surface with chlorhexidine as a spray at the end of each case. (CDC - Disinfection & Sterilization Guideline:Disinfection - HICPAC)

    FURTHERMORE: once you go down that road, then you can no longer have blood pressure cuffs or pulse oximeters that are multiple use. You cannot have the ECG leads, blood pressure tubing, or pulse oximeter cable touching the next patient without disinfecting them between cases. The stool or chair you use would have to be disinfected between cases. Rolls of tape used by anesthesiology would have to become single use since the outside of the roll is potentially contaminated if touched. Temp strips would have to be packaged individually. Laryngoscopes would all have to be single use. Is this really where you want to go???
     
    Last edited: Apr 22, 2017 at 7:43 AM
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  23. waterbottle10

    waterbottle10 5+ Year Member

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    Wait that's not how it is at places??? Our temp probe, blades are all single use. Tape is discarded after the case and new tape for next patient. All monitors are wiped after a case.
     
  24. algosdoc

    algosdoc algosdoc 10+ Year Member

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    No, that is not how it is in most places. I work in 10 surgery centers and 3 hospitals. All but one reuses laryngoscope handles and blades. Temp probes are single use but temp strips are not packaged individually, therefore subject to contamination. Tape is used from case to case to case- the rolls are discarded only after the supply on the roll is exhausted. Monitors are wiped in some at the end of the day, and in some, never. In some it is once a day. None of them wipe the monitors down nor the components of the machine between cases. Only one uses disposable blood pressure cuffs, and reuses some of those. None of them use disposable pulse oximeter probes. None of them routinely wipe down cables, cords, or tubing between every case. None of them routinely wipe down the anesthesia tubing tree. Some use multiuse tubes of gel lubricant for ETT and LMAs. And we haven't even started discussing the anesthesia cart with its work surface. Say you need a drug or a piece of equipment from the drawer of an anesthesia cart during the middle of a case. Do you always unglove and put on a fresh pair of gloves before turning around and opening the drawer? If not, you have contaminated the outside of the drawer and the contents of the outside of the packages and drug vials inside the cart by not changing gloves. What I am saying is it is illogical to protect the work surface without addressing all the other commonly present potential contamination areas.
     
    Last edited: Apr 22, 2017 at 8:53 AM
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  25. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Interesting... Very different here. If i dont see a tech wiping my stuff, i wipe the machine/monitors/workstation. But then again I'm still in academic center so less pressure for speed.
     
  26. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

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    It's a Giant Condom for the machine/equipment.
     
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  27. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    So how about giant condoms for the IV poles, the IV pump channels, the table itself?

    Why not disposable OR tables? Disposable IV poles? Disposable IV pumps? Every time you touch the patient you have to autoclave yourself. Drape the whole OR, Dexter-style, for every case. Hell, why not have disposable operating rooms; after each case the entire OR is jettisoned into space. Oh wait, but then the patient went to PACU. Same thing for PACU too.

    This is diminishing returns for all of us except single-use-disposable medical equipment manufacturers who are making a killing. Medical care ultimately involves things touching patients.

    Antibiotic stewardship and common sense things like handwashing are essentially free.
     
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  28. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    My hospital approached us about pretty much all of these things. My reply was show me some data. Some of the clipboard nurses are really on another level.


    --
    Il Destriero
     
  29. nimbus

    nimbus Member 10+ Year Member

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    How do I get into the bottom drawers with that thing on? Will I need to shower and change scrubs between cases?
     
  30. Psai

    Psai Account on Hold 2+ Year Member

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    Also you need to wear individual bouffants for your eyebrows because of all those eyebrow viruses
     
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  31. partydoc

    partydoc 7+ Year Member

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    No, because that would cut into turnover time and that's not acceptable, even if it decreases OR infections
     
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  32. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Perhaps all anesthesiologists also need to scrub, wear sterile gown and gloves
     
  33. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

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    To Beard or Not to Beard? Bacterial Shedding Among Surgeons

    http://www.healio.com/orthopedics/journals/ortho/2016-3-39-2/{b6173fbb-00cf-4268-97fa-9dc8ccc5e4ff}/to-beard-or-not-to-beard-bacterial-shedding-among-surgeons

    Conclusion
    Bearded surgeons did not appear to have an increased likelihood of bacterial shedding compared with their nonbearded counterparts while wearing surgical masks. The addition of nonsterile surgical hoods did not decrease the amount of bacterial shedding observed compared with the use of surgical masks alone.
     
  34. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

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    Is it okay to wear home laundered cloth caps if they are covered by a disposable cap?


    “We have surgical team members in our facility that wear reusable cloth caps. The caps are not washed in a health care-accredited laundry. Our director has asked these team members to put a disposable cap over the cloth cap. Is this okay?”

    Yes. A reusable cloth cap that is contained within a disposable cap may be home laundered, just as other personal clothing (e.g.,T-shirts) contained within the scrub attire are home laundered.

    Resources:
    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Updated November 13, 2014.

    Surgical Attire - Association of periOperative Registered Nurses
     
  35. chocomorsel

    chocomorsel Senior Member 10+ Year Member

    We are killing this planet with the amount of disposable **** and plastic we throw away. The ORs generate tons of waste. Most Americans never think of where these items come from or where they are going after use. I come from a third world country and therefor view things a little differently.

    Most of the places I work at are leaning towards disposable everything. So wasteful IMO. And costly.

    I see my colleagues and nurses waste so much and it annoys me so much. Like opening up tons of unnecessary syringes for each case. Opening up too many gowns and gloves for the scrub tech and throwing them away. Disposable BP cuffs? Not necessary. EKG leads? Laryngoscopes? What a waste of money!!! And all this **** goes to landfills. We need to be aggressive in recycling.

    All I can do is do my best to minimize waste both on the front end and back end.
     
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  36. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Clearly the best solution is to have someone roll a cart full of cobalt-60 through each room between cases.

    I nominate the infection control committee chairnurse.
     
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  37. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    Again, I draw a distinction between outpatient cases at an asc or hospital surgery center and cases on inpatients with known infections.

    The latter patients are a big deal. Yes, I think everything on these folks should be single use. Yes, I think you need to take off your gloves and be clean before getting into your cart. Yes, I think you need to throw away the tape roll after you use it- on these patients.

    I hear you on the environmental concerns. I really do. But think of all the single use crap that'll be necessary if the next patient gets an infection that keeps them in house for days or weeks longer.

    Again, open the April 2015 A&A. We can pretend this isn't an issue, but it is. I have completely changed the way I physically interact with the anesthesia workspace because of it.

    If you could thoroughly clean the workspace between cases, that'd be one thing- but you can't do that and turn the cases over in any way approaching efficient.

    As a rule of thumb, pretend that your inpatient has a layer of sh!t covering them, and act accordingly. Because they do.

    Oh, and stop dragging your open stopcocks all over the patient's nasty bed, and stop injecting into luer ports that have been laying on the bed without cleaning them too.
     
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  38. algosdoc

    algosdoc algosdoc 10+ Year Member

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    So why not chlorhexidine spray? Squirt the work surface as you are leaving the room? Don't wipe it off, just leave it and it will dry or can be wiped when the next patient comes in.
     
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  39. Psai

    Psai Account on Hold 2+ Year Member

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    Just sprinkle iodine over everything and then let it dry
     
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  40. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Or sprinkle nitrogen tri-iodide crystals over everything then watch this contact explosive resolve the microbial infestation....
     
  41. MonteChristo

    MonteChristo

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    Seems like something pretty hard to confirm
     
  42. nimbus

    nimbus Member 10+ Year Member

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    Is it okay to home shampoo my hair under my disposable cap? This is absurd. They need to do a study comparing home laundered garments to the ones from the laundry service. Bet there is no difference in bacterial contamination.
     
  43. facted

    facted ASA Member 7+ Year Member

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    The majority of these guidelines come from nursing guidelines and have zero evidence behind them. We've been told by NY DOH that we can't have Tshirts under our scrubs. It's utterly ridiculous. I'm glad they let me wear underwear and socks.
     
  44. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Do you have to change into special OR shoes?
     
  45. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    I'd have to see one of these things in action before I could go along with it. How hard is it to adjust flowmeters or vaporizers through it? Use the APL? Grip the bag? They show some knob turning in the video ... but somehow I doubt it's so easy in real life. Especially touch screen manipulation.

    I'm not totally opposed. The anti-glare coatings on all our monitors are absolute crap now. They're flaking bits off because of whatever corrosive nasty cleaning liquid use the techs use to wipe them down. There's at least one up side to using these things.

    What about all the extra monitors stacked on top of anesthesia machines? Cerebral oximetry, PA catheter, Bis, etc. Echo machine? Infusion pumps? Monitor cables actually touch the patient.

    New scrubs between patients?

    There's no cover for the anesthesia cart, of course. But we have to get into those drawers during the case.

    I put new clean sterile towels or paper covers on my cart and the tray part of the anesthesia machine between patients. Cart is clean, machine is dirty. Nothing from my machine ever goes back to the cart ... except my hands. Wear gloves for 100% of the case? Take them off ever time you go to the cart?
     
  46. facted

    facted ASA Member 7+ Year Member

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    Either put covers on shoes or they have to be OR dedicated.
     
  47. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    They offer a fitted cover with pockets for just the machine table top. They approached us about them and we were considering a trial for just that option. My concern is that people will put blades, etc in the pocket and they'll end up being tossed out when the room is rapidly turned over. Anesthesia techs used to do "stuff", but now they're mostly a specialized cleaning crew and, at least here, they are always running.


    --
    Il Destriero
     
  48. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    You started strong and faded, HB.

    Patients with known drug-resistant infections or who are immunocompromised - these patients need careful and diligent attention to contamination of lines, cross-contamination from cart and machine etc. I agree with you.

    That is a tiny, tiny, tiny minority of all surgical cases. But the device makers would have you treat all patients like this tiny minority where it matters. You buy what they are selling, literally.

    Your command about "dragging stopcocks across the bed" is clipboard-nurse-level paranoia; your use of the word "nasty" gives you away. You're a germaphobe, we get it. But it's not good evidence based practice.
     
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  49. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    You seem to be misrepresenting my position. Again- I'm only advocating that these be used in known cases of drug-resistant infection to prevent transmission to the next patient. Indeed, this is a very small fraction of the surgical volume.

    As for the stopcocks- anybody who knows me will tell you that I am not at all a militant germophobe. I just don't believe in mainlining fecal bacteria directly into the patient's bloodstream. I happen to think that's nasty. Sorry if you disagree.

    Let's see what the Anesthesia Patient Safety Foundation, that clipboard-nurse-level organization, has to say about the issue- HAIs: When in Doubt, Blame Anesthesia. Could They Be Right?
     
  50. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    "Loftus, Koff, and Birnbach... note that “bacterial transmission in the anesthesia work area of the operating room environment is a root cause of 30-day postoperative infections affecting as many as 16% of patients undergoing surgery.” In their view, the “evidence suggests that a multimodal approach targeting improvements in intraoperative hand hygiene, patient screening and decolonization, environmental decontamination, and improvements in intravascular handling and design may reduce the risk of postoperative infections.”"

    Making a Difference in Perioperative Infection : Anesthesia & Analgesia
     

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