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ev Bras Anestesiol. 2020;70(4):398---418
YSTEMATIC REVIEW
BA 2020: Regional anesthesia safetyecommendations update�
iana Maria Tôrres de Araújo Azi a,b,c,∗,euber Martins Fonsecac,d,e,f, Livia Gurgel Linardg
Universidade Federal da Bahia (UFBA), Departamento de Anestesiologia e Cirurgia, Salvador, BA, BrazilHospital Universitário Professor Edgard Santos, Centro de Ensino e Treinamento em Anestesiologia, Salvador, BA, BrazilComissão de Norma Técnicas da Sociedade Brasileira de Anestesiologia (SBA), Salvador, BA, BrazilUniversidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, BrazilUniversidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de EnsinoeTreinamento em Anestesiologia,berlândia, MG, BrazilCoordinator of the Comitê de Estudo de Equipamentos Respiratórios e de Anestesiologia da ABNT, and Delegate andepresentative of the SBA Board at the Technical Committee 121/ISO --- Anesthetic and Respiratory Equipment, Uberlândia, MG,razilHospital Geral do Estado 2 and of Hospital Roberto Santos, Salvador, BA, Brazil
eceived 8 May 2019; accepted 8 February 2020vailable online 17 May 2020
KEYWORDSRegional anesthesia;Infection;Patient safety
Abstract The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional AnesthesiaSafety Recommendations Update is to provide new guidelines based on the current relevantclinical aspects related to safety in regional anesthesia and analgesia. The goal of the presentarticle is to provide a broad overview of the current knowledge regarding pre-procedure asepsisand antisepsis, risk factors, diagnosis and treatment of infectious complications resulting fromanesthetic techniques. It also aims to shed light on the use of reprocessed materials in regionalanesthesia practice to establish the effects of aseptic handling of vials and ampoules, andto show cost-effectiveness in the preparation of solutions to be administered continuously inregional blockades. Electronic databases were searched between January 2011 (final date ofthe literature search for the past SBA recommendations for safety in regional anesthesia) andSeptember 2019. A total of 712 publications were found, 201 of which were included for furtheranalysis, and 82 new publications were added into the review. The Grading of Recommendations,Assessment, Development and Evaluation (GRADE) system was used to assess the quality of eachstudy and to classify the strength of evidence. The present review was prepared by membersof the SBA Technical Standards Committee.
© 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).� Paper supervised by the Technical Norms Committee of the Brazilian Society of Anesthesiology (SBA).∗ Corresponding author.
E-mail: [email protected] (L.M. Azi).
ttps://doi.org/10.1016/j.bjane.2020.04.015 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CCY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
SBA 2020: Regional anesthesia safety recommendations update 399
PALAVRAS-CHAVEAnestesia regional;Infeccão;Seguranca dopaciente
SBA 2020: Atualizacão das recomendacões para seguranca em anestesia regional
Resumo O propósito desta atualizacão das Recomendacões da Sociedade Brasileira de Aneste-siologia para Seguranca em Anestesia Regional foi apresentar novas diretrizes com base narelevância e atualidade clínica nos aspectos de seguranca relacionados a analgesia e aneste-sia regional. Este artigo visa prover uma visão ampla sobre o conhecimento atual no tocantea assepsia e antissepsia pré-procedimento, fatores de risco, diagnóstico e tratamento dascomplicacões infecciosas decorrentes das técnicas anestésicas. Também visa esclarecer sobre ouso de materiais reprocessados na prática da anestesia regional, estabelecer as implicacões nomanejo asséptico de frascos e ampolas e elucidar sobre a relacão custo-efetividade no preparode solucões a serem administradas continuamente em bloqueios regionais. As bases de dadoseletrônicas foram pesquisadas entre Janeiro de 2011 (final da pesquisa de literatura das dire-trizes anteriores da SBA sobre seguranca em anestesia regional) e Setembro de 2019. Um totalde 712 artigos foram encontrados, dos quais 201 foram incluídos para análise posterior e 82novos estudos foram acrescentados nesta revisão. O sistema de Avaliacão, Desenvolvimento eAvaliacão da Classificacão das Recomendacões (GRADE) foi utilizado para avaliar a qualidadedo estudo individual e classificar a forca da evidência. Esta revisão foi elaborada por membrosda Comissão de Normas Técnicas da SBA.© 2020 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Anestesiologia.Este e um artigo Open Access sob uma licenca CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Description of method for collecting evidence
The present article updates the 2011 Recommendationsof the Brazilian Society of Anesthesiology for Safety inRegional Anesthesia1 and takes into account studies pub-lished between January 1, 2011 and September 31, 2019,in addition to articles published between 1965 and 2011,already considered in the previous review.1 A review proto-col was used to identify, retrieve and assess evidence in thefollowing databases: PubMed, Cochrane Library, and LILACS.Cross-references with the collected material were also usedto identify articles with better methodological designs. Thesearch was later limited to studies performed in humansand published in English, French, German, Portuguese, orSpanish.
The search strategies used for this update were identicalto the 2011 Recommendations:
1 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduc-tion’’ [MeSH Terms] AND ‘‘infection’’ [MeSH Terms]AND ‘‘prevention and control’’ [Subheading] OR‘‘prevention’’ AND ‘‘control’’ OR ‘‘prevention andcontrol’’ [MeSH Terms]
2 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduction’’[MeSH Terms] AND ‘‘infection’’ [MeSH Terms]
3 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduc-tion’’ [MeSH Terms] AND ‘‘infection’’ [MeSH Terms]AND ‘‘etiology’’ [Subheading] OR ‘‘etiology’’ OR‘‘causality’’ [MeSH Terms]
4 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduction’’[MeSH Terms] AND ‘‘immunocompromised host’’ OR‘‘immunocompromised patient’’ [MeSH Terms]
5 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduction’’[MeSH Terms] AND ‘‘meningitis’’ [MeSH Terms]
6 ‘‘regional anaesthesia’’ OR ‘‘anesthesia, conduction’’[MeSH Terms] AND ‘‘epidural abscess’’ [MeSH Terms]
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7 ‘‘anesthesia, epidural’’ [MeSH Terms] AND ‘‘catheters’’[MeSH Terms] AND ‘‘colonization’’ AND ‘‘infection’’[MeSH Terms]
8 ‘‘single-use’’ AND ‘‘equipment and supplies’’ [MeSHTerms] AND ‘‘devices’’ OR ‘‘medical devices’’ AND‘‘reprocessing’’
9 ‘‘single-use’’ AND ‘‘equipment and supplies’’ [MeSHTerms] AND ‘‘devices’’ OR ‘‘medical devices’’ AND‘‘reprocessing’’ AND ‘‘anaesthesia’’ [MeSH Terms]
0 ‘‘Medication Errors’’ [Mesh Terms] AND Anesthesia,Conduction[Mesh Terms]
1 ‘‘cost-effective’’ AND ‘‘pharmaceutical solutions’’[MeSH Terms] AND ‘‘regional anaesthesia’’ OR‘‘anesthesia, conduction’’ [MeSH Terms]
2 ‘‘drug contamination’’ [MeSH Terms] AND ‘‘ampoules’’
After searches, a critical analysis of content was per-ormed followed by classification according to the strengthf evidence. The list of selected articles was decided by peereview. In case of disagreement, the article was included foreading and a later decision as to its inclusion.
In a second stage, two new searches were performed (thisime in the period between January 1, 1965 and Septem-er 31, 2019) for the inclusion of articles dealing with theew topics included in this review: techniques for surgicalntisepsis of hands and the use of ultrasound devices fornesthetic blockades, focusing on its cleaning, or as a factoror increasing infection in regional anesthesia. The searchas also limited to human studies and English, French, Ger-an, Portuguese, or Spanish publications. The following
earch strategies were used:
antisepsis[Mesh] AND hand disinfection[Mesh] ANDurgical wound infection[Mesh]anesthesia, conduction[Mesh] AND
ltrasonography[Mesh] AND infection[Mesh]
400 L.M. Azi et al.
Publications included according to search criteria
(n = 544)
Additional publications included by other sources
(n = 29)
Publications referring to USG device cleaning and anesthesiologist
hand antisepsis (n = 139)
Total publications assessed (n = 712)
Duplicate entries (n = 193)
Publications after elimination of duplicates (n = 519)
Abstracts assessed for subject adequacy (n = 201)
Excluded articles (n = 318)
- Did not address the topic (n = 279)- Another language rather than English, French, Portuguese or Spanish (n = 27)
- Laboratory or experimental studies (n = 12)
Abstracts excluded for not addressing the
topic (n = 62)
Full articles selected for analysis (n = 139)
New studies included in the recommendations
(n = 82)
Incl
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ligib
ility
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entif
icat
ion
Figure 1 Flowchart of publication search and selection process for systematic reviews and meta-analyses using PRISMA (PreferredReporting Items for Systematic reviews and Meta-Analysis).
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D
anesthesia, conduction[Mesh] ANDltrasonography[Mesh] AND disinfection[Mesh]
anesthesia, conduction[Mesh] AND ultrasonography¨Mesh] AND safety[Mesh]
egrees of recommendation and strength ofvidence
A) Experimental or observational studies of better consis-
tency.B) Experimental or observational studies of lower consis-tency.
C) Case reports or case series (uncontrolled studies).
taip
D) Opinion devoid of critical assessment, based on consen-sus, expert opinions, physiological studies or animalmodels.
Fig. 1 describes the sequence of information at the dif-erent steps of this systematic review, with the number ofecords included and excluded, and with the reasons forxclusions.
ntroduction
uring the regional anesthesia procedure, there are aspects
hat may cause or worsen infectious processes. Certainspects are related to patient characteristics (sepsis or localnfection, diabetes, immunodeficiency, use of immunosup-ressive drugs) or to supplies (reuse, contamination or poor
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SBA 2020: Regional anesthesia safety recommendations upd
sterilization). Now and then, however, anesthesiologists cancontribute to increase the incidence of infection by notcomplying with aseptic techniques or by contaminating thematerial to be used.2
Infectious complications related to regional anesthesia,although rare, are associated with increased hospital stay,costs, acute and chronic pain, morbidity and mortality.2
Infectious complications associated with neuraxial anesthe-sia can be devastating, such as meningitis, paralysis anddeath. The estimated risk of major infectious complicationsis 1:40,000, according to data from the 3rd National AuditProject of the Royal College of Anaesthesiologists in theUnited Kingdom, in which 15 epidural abscesses and threecases of meningitis were reported in 700,000 neuraxialanesthesia cases. According to the audit, epidural anes-thesia or analgesia was associated with a higher chance ofcomplications when compared to spinal anesthesia.3
The frequency of infections associated with peripheralnerve blockades is even more unclear. Risk factors thatseem to be associated with a greater likelihood of infectiouscomplications include the absence of antibiotic prophylaxis,use of a catheter for more than 48 hours, use of a catheterin the axillary and femoral sites, frequency of changingthe dressing to protect the catheter, in addition to patientrequiring ICU admission.4
A catheter used for neuraxial blockade, even if insertedunder aseptic technique, can be colonized with patient skinflora, and favors epidural or subarachnoid infection.5
The importance of the aseptic technique
Does hand washing by the anesthesiologist reducethe incidence of infectious complications inregional anesthesia?
In 1847, Hungarian doctor Ignaz Philipp Semmelweis(1818---1865) established that hospital infections could betransmitted by the hands of health professionals, and thatsimple washing with chlorine solutions could result in sig-nificant risk reduction. From Semmelweis’ study onwards,hands of health professionals have been linked to the trans-mission of microorganisms in the hospital environment.6
Basic hand washing is a simple and formidable compo-nent of the aseptic technique, and it has been stimulatedand emphasized worldwide by the World Health Organiza-tion (WHO) message ‘‘clean care is safe care’’. The WHOmessage emphasizes that proper hand washing needs to beconsidered as the most important technique in preventingcross-contamination between health professionals and theirpatients.7
Multi-resistant bacteria and fungi can be part of thecomponents of the transient microbiota of hands. Handcontamination of health professionals can occur by directcontact during handling of patients, and by indirect contactwith other objects and equipment (bed, stethoscope, anes-thesia machine and other operating room materials). Studies
show the association of contaminated hands with infectionoutbreaks in health facilities.8---10The hands of the anesthesiologist can act as a source ofcontamination in the procedures performed in the operating
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oom, and correct hand hygiene is vital to prevent infectiousomplications.11 Simple actions are essential anesthesiaafety measures, including hand hygiene between cases.12
hus, it is important to observe the five moments forand hygiene recommended by WHO: 1) Before touching aatient; 2) Before a clean or aseptic procedure, such as pro-iding anesthesia; 3) After risk of exposure to body fluids,uch as following glove removal after performing anesthe-ia; 4) After touching a patient; 5) After touching patienturroundings, which constitutes a variant of moment 4 (itccurs after hand exposure to any surface in the patient’srea and before subsequent exposure of the hand to anyurface in the care area, but without touching the patient.his normally encompasses objects contaminated by patientora that are to be decontaminated or discarded).
Washing hands with soap and water removes bacteriarom the surface of the skin, but it is not efficient toill microorganisms. The use of alcohol (e.g., isopropyl) orlcohol-based solutions will provide improved disinfectionhen compared to alcohol-free antiseptic solutions (e.g.,
odopovidone11 or chlorhexidine 4%13). When these antisep-ic solutions are combined with an alcohol compound (e.g.,hlorhexidine gluconate in ethyl alcohol), bacterial growths reduced to very low levels. Generally, the risk of intra-perative bacterial transmission and infections associatedith healthcare professionals can be significantly reduced by
mproving compliance with hand hygiene.14 Proper hygienean also reduce medical costs related to the treatmentf blood-borne infections caused by methicillin-resistant S.ureus.15
Therefore, correct hand hygiene means the combinationf the five WHO moments with the correct aseptic tech-ique, and it is one of the most important components inerforming anesthetic procedures.14
Adequate asepsis should always be used in the prepara-ion of regional anesthesia, both for single shot and catheternsertion techniques. Still, a study assessing the membersf the Pediatric Anesthesiology Society of Australia and Newealand showed that 3.6% of anesthesiologists did not washheir hands or did not use sterile gloves to perform caudalpidural blockade.16
Watches and rings are risk factors for infectiousomplications. Studies show greater potential for contami-ation when adornments are not removed, as they precludeorrect hand hygiene.17 Long nails and with cracked polishlso hamper proper hygiene. Although there is contro-ersy on the subject, adornment removal is recommendeds a prophylactic measure against infections.18 Avoidingearing artificial nails, and nail glues or gems is also
ecommended.19
Measures can be implemented to spread the impor-ance of hand washing among health professionals, suchs educational material and the availability of sinksnd alcohol gel dispensers in easily accessible places.lcohol-based products used for hand hygiene in health-are services are available in solution (liquid), gel andoam forms. Thanks to their formulations, gel-based prod-cts have a more comfortable feeling, with less alcohol
mell and tend to have greater acceptance, althoughhey do not have superior antimicrobial efficacy to otherormulations.7
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ecommendations
Hand washing prior to procedures11 is recommended as animportant step in the aseptic technique when perform-ing regional anesthesia, both for single shot puncture andtechniques with catheter insertion.14
Adornments, such as watches, rings and artificial nails,should be removed as a prophylactic measure to improvethe technique.17---19
oes the use of surgical garments bynesthesiologists reduce the risk of infectiousomplications when performing continuouspidural blocks?
terile gloves should be considered as a supplement, not replacement for hand washing.20 Accessories such asings, watches or bracelets should be removed before handashing.6,17 Sterile gloves protect not only patients, but alsoealth professionals themselves from contamination.5
As for glove perforation, it has been well established thathis type of incident occurs more often with vinyl gloves thanith latex gloves, causing contamination of the hands ofealth professionals.5 To date, no study has assessed the riskf microbial contamination or perforation of sterile latexr neoprene gloves. Sterile single-use or disposable gloveshould never be washed, re-sterilized, or disinfected, and aew pair must be used for each new procedure.21
Surgical gowns are used as a strategy to preventross-contamination between patients, preventing infec-ious material from coming into contact with the healthcarerofessional’s clothes. However, investigations have shownhat wearing a gown did not reduce the rates of colo-ization, infection, or mortality in neonatal intensive carenits.22 Another study showed that patients undergoingabor analgesia under continuous epidural anesthesia did nothow significant differences in rates of colonization of theatheter tip between groups with or without gown (9.2% vs..6%, respectively), with coagulase-negative Staphylococ-us being the most commonly found microorganism.23
So far, the evidence is insufficient to make definitive rec-mmendations regarding the use of a routine gown withinhe operating room environment during regional blockade,oth for simple punctures and for placement of a short-termeuraxial catheter.5,24
Reports have drawn an analogy between the installationf a central venous line and neuraxial blockade, suggest-ng the use of surgical garments. However, some aspectsre questioned, such as the increase in time to performhe procedure and the increased associated costs.25 It isrgued that, if surgical gowning is indicated for insertionf a central venous line, then it should also be indicatedor neuraxial blockade.26,27 In central venous line place-ent techniques, full barrier precautions (sterile gloves,
urgical gown, mask, cap and large sterile drapes) reducehe incidence of infection associated with central venousatheters, when compared to standard precautions (ster-
le gloves and small drapes). The incidence of infection is.3% and 7.2% when complete barrier precautions and stan-ard precautions are used, respectively. The extrapolatednfection rates were 227:10,000 and 718:10,000 with the usecamm
L.M. Azi et al.
f complete barrier devices and standard barrier devices,espectively.25
However, the incidence of infection associated with neu-axial anesthesia is in the order of 1/718 of the infectionncidence associated with central venous access (consider-ng 1:10,000 with standard precautions).25 So far, there areo consistent data to recommend using surgical gowns foringle-shot or for catheter insertion neuraxial procedures.
The surgical mask, initially considered a protective bar-ier mechanism for health professionals against patientecretions and blood,21 is now considered mandatory dueo cases of post-spinal puncture meningitis described as theesult of contamination of the epidural space or subarach-oid with pathogens of the anesthesiologist’s oropharyngealucosa.28---30 In Schneeberger et al.,29 four cases of iatro-
enic meningitis after spinal anesthesia were describedver a period of 4 years, all involving the same anesthe-iologist, who had a history of recurrent pharyngitis, didot wear a mask, and frequently spoke during the proce-ure. Its use seems to be critically important for protectingatients against physicians who have sore throats, sufferrom pharyngitis or recurrent tonsillitis, or who are chronicarriers of Staphylococcus aureus in the nasal region.28---30
The routine use of surgical masks while performingegional anesthesia techniques has been recommendedince 2006 by the American Society of Regional Anesthesiand Pain Medicine in its advisory on infectious complicationsssociated with regional anesthesia. It recommends wear-ng masks correctly, covering the entire nose and mouth.his recommendation starts with the exposure of sterileaterials during the anesthetic-surgical procedure.26,27 The
eplacement of the surgical mask should be consideredetween cases, if it is soiled or has moistness.26
ecommendations
Sterile gloves should always be used and are considered asa supplement, not a replacement of hand washing.5,20,26
So far, there are no consistent data to recommend theuse of surgical gowns to perform single shot or catheterinsertion procedures.24
The use of the face mask is recommended, being stronglyadvised for anesthesiologists who present signs and symp-toms of upper airway infections,28---30 and should alwayscover mouth and nose.26
hat is the best antiseptic technique forreparation of the patient’s skin before performinghe regional blockade?
isinfection is the process of destroying the vegetative formf microorganisms, pathogenic or not, present in inani-ate objects. Antisepsis is the set of measures used toestroy or inhibit the growth of existing microorganismsn the superficial (transient microbiota) and deep (resi-ent microbiota) layers of skin and mucous membranes.uch measures involve the application of germicidal agents
alled antiseptics.24 Such products must have immedi-te antimicrobial action, persistent residual effect andust not be toxic, allergenic or irritating. It is recom-ended that they should be mild and cost-effective.31,32
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SBA 2020: Regional anesthesia safety recommendations upd
The antiseptic activity of alcohol occurs by denaturingproteins and removing lipids, including the envelopes ofsome viruses. To achieve maximum germicidal activity, alco-hol must be diluted with water, which enables proteindenaturation. The recommended concentration to achievegreater microbicide speed is 70%. However, its volatility,flammability, rapid evaporation at room temperature, andlow or no residual activity on surfaces limit its use asa standard antiseptic. In addition, the presence of highconcentrations of organic matter can decrease the micro-bicide activity of alcohol. Alcohol-based preparations arenot appropriate when the skin is visibly soiled or contami-nated with protein material. The emergence of antibiotic-and antiseptic-resistant bacteria has underlined the needfor more effective, well-tolerated and easy-to-handle anti-septic formulations. Most studies on alcohol have evaluatedits individualized effect at different concentrations, oremphasized its combination with solutions containing lim-ited amounts of hexachlorophene, quaternary ammoniumcompounds, polyvinylpyrrolidone iodine (PVP-I), triclosan orchlorhexidine gluconate.33
Using products containing triclosan has been ques-tioned, as they do not seem to be as effective, giventriclosan is mainly bacteriostatic, inactive against Pseu-domonas aeruginosa, and has been associated with waterpollution in lakes.34 In regional anesthesia, the most fre-quently used alcohol-based preparations are those withchlorhexidine or iodophors (PVP-I). When they are comparedin terms of prevention of epidural catheter coloniza-tion in children, using chlorhexidine showed superiorbactericidal effect, faster action and greater residualeffect.35
Thus, despite initial controversies on the best antisep-tic solution for skin preparation before regional anesthesia,there is consensus that the antiseptic that most satisfiesrequirements for application in living tissues is alcoholdiluted in water in combination with chlorhexidine glu-conate solution. Chlorhexidine is a potent germicide and,when added to alcohol, accelerates this effect.35 Chlorhex-idine gluconate adheres to the skin corneum stratum,resulting in prolonged action.33
A meta-analysis study presented by Cochrane in 2015evaluated antiseptic solutions for preventing surgical woundinfection, and described evidence that preoperative skinpreparation with 0.5% chlorhexidine in denatured alcoholwas associated with lower infection rates after clean surg-eries when compared with PVP-I. However, the study leavesprofessionals free to choose other alternatives, based oncosts or side effects.36
A systematic review evaluating the primary outcomeof the incidence of surgical wound infection and sec-ondary skin bacterial contamination revealed that inall studies that compared chlorhexidine with iodophor,chlorhexidine showed lower incidences of both out-comes (wound infection surgical - Risk Ratio [RR = 0.70];95% Confidence Interval [95% CI 0.52---0.92] and bac-terial skin colonization [RR = 0.45; 95% CI 0.36---0.55]).The conclusion was that there is moderate qualityevidence that supports chlorhexidine use for preopera-tive skin antisepsis and high-quality evidence indicating
that chlorhexidine is associated with fewer positive skincultures.37so
403
ecommendationor providing safe and effective patient skin antisepsisefore performing regional anesthesia, the recommenda-ion is to remove any organic or inorganic material fromnclean skin by cleaning it with water, soap and rinsing it;24
hlorhexidine can be used in back and forth movements for0 seconds, waiting for it to dry completely.35---37
hat concentration of antiseptic solution shoulde used and how, and what are its associated risks?
dhesive arachnoiditis is a rare, but well recognized cause ofeurological deficit after neuraxial anesthesia. In the casesescribed in the literature, there is an evident time rela-ionship, but the mechanisms proposed are still speculativend uncertain, including the inflammatory response to theresence of blood in the subarachnoid space, the local anes-hetic intrinsic action (previously implicated as the majorause), or the accidental contamination of the injectate byeurotoxic substances.36,38
In 2008, alcoholic chlorhexidine was implicated as theausative agent of the disease in a court case in Englandnd, since then, it has been considered the most consistentechanism for the development of adhesive arachnoiditis.39
njections above 0.1 mL (about 2 drops) are defined asnough to trigger adhesive arachnoiditis.38 Chlorhexidine inigher concentrations (2%) has also been implicated as aause of adhesive arachnoiditis.40
The solution commonly used in Brazil is chlorhexi-ine gluconate 0.5% in 70% isopropyl alcohol. Solutionsf 2% chlorhexidine gluconate in 70% alcohol are autho-ized by ANVISA (trade name BD Chloraprep®, registration0033430733), but the company does not recommend usinghe antisepsis product in neuraxial anesthesia procedures.
Chlorhexidine in spray is used in regional blockades inome countries. Its proponents argue that the solution isept in a closed bottle, which is used away from the equip-ent tray and can be applied by an assistant who will not
ake direct part in the procedure.39 However, spraying thentiseptic solution from a distance increases the possibilityf droplets going astray. When inhaled, released aerosolsan irritate the airways, exacerbating asthma or causingccupational asthma. There is also a risk of permanent eyeamage and ototoxicity after contact with the tympanicembrane.41
Regarding the number of applications required, despitehe lack of evidence to support the practice, it is com-on to perform two applications of chlorhexidine for
reater efficiency of skin antisepsis before regional anes-hesia. A study comparing bacterial growth after one orwo applications showed the absence of a number ofolony-forming units after the first use of the solution, andhat, therefore, a new application was devoid of advan-age, because it could add risks of neurotoxicity of theolution.42
Antiseptic solution of 0.5% chlorhexidine in 70% alcoholignificantly reduces the probability of colonization of the
olutions. Therefore, it should be considered the antisepticf choice before regional anesthesia techniques.24
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After antisepsis, some recommend waiting at least minutes before performing regional anesthesia,3 but iteems reasonable to start the procedure only after vis-ble drying of the skin and, therefore the excess thatay still be present in the liquid form should not be
emoved.
ecommendation meticulous technique is recommended when 0.5%hlorhexidine in 70% alcohol is used for skin antisepsis. Everyffort must be made to avoid dripping or splashing and tovoid contamination of the injectate, including the removalf any sources of chlorhexidine[39,40 by using the appropri-te amount of antiseptic, avoiding removing excess liquidnd waiting for its evaporation, in order to guarantee actualffectiveness of the solution.3,24,35
hat is the best technique for antisepsis for thenesthesiologist before regional anesthesia?
espite the apparent need for surgical antisepsis beforenesthetic-surgical procedures, it has never been provenhrough a randomized controlled clinical trial, most likelyecause such a study would never be accepted by an ethicsommittee.43 Thus, antisepsis of hands has been recom-ended since the 19th century as a measure to reduce
urgical-related infection through indirect evidence. Whenorrectly performed, it is associated with a significanteduction in morbidity and impacts positively on patientafety and health resource expenses.6,44 Historically, sur-ical preparation of hands consists of washing them withater and antimicrobial soap, often with brushes. Brushing
ime varies considerably among institutions.43
Currently, almost all studies discourage the use ofrushes, which are no longer recommended for preopera-ive hand preparation, given using a disposable sponge orrush/sponge combination reduces the bacterial count onands as effectively as rubbing with a brush.45,56 The Worldealth Organization (WHO) does not recommend the use ofrushes for this purpose due to their abrasive effect.47
Several studies have evaluated techniques for pre-urgical hand antisepsis. When comparing the use of spongeswith soap) with hand rubbing (with alcohol-based formu-ations), it was found that both methods are suitable forrevention of surgical wound infection. However, althoughedicinal soaps are still used worldwide by surgical teams, it
s important to note that the antibacterial efficacy of prod-cts containing high concentrations of alcohol far exceedshat of any medicinal soap.48 A randomized clinical trialomparing hand rubbing with alcohol-based product versusands brushed with degerming chlorhexidine demonstratedimilarity in the incidence of surgical site infection, despitehe significantly better in vitro activity of the alcohol-ased formulation to rub hands.49 A study comparing spongeith chlorhexidine gluconate at 4% (degerming) with hand
ubbing with a solution containing 57% ethanol and 22.5%
-propanol showed greater, statistically significant (p <.001), reduction in microbial count with the use of alcohol-ased solution, with approximately -0.63 colony formingnits. In this study, the alcohol-based solution reduced byAtt
L.M. Azi et al.
3.4% the microbial count by cm-2 when compared to 4%hlorhexidine.50
The initial reduction in the cutaneous resident flora is soast and effective that bacterial regrowth to the baselinen gloved hand takes more than 6 hours,51 which makes theequirement of sustained effect products superfluous. Thus,here is a strong reason to prefer alcohol-based products.ast antimicrobial action, broader spectrum of activity,ewer side effects and no risk of hand contamination byashing water clearly favor the use of alcohol-based prod-cts, especially in resource-limited countries where waterupply is scarce or of suspicious quality.43
Other benefits of hand rubbing with alcohol-based prod-cts include time saving and no risk of recontamination byinsing hands with water.51 Finally, there is the advantage ofn ecological perspective, by reducing water consumptionnd generating less waste for disposal, without the use ofponges.52
However, some surgeons consider the time required forurgical hand washing to be a ritual for preparing an inter-ention. The potential policy change in an institution muste carefully prepared and understood by all members of therocess.53
The protocol for hand hygiene practice in health ser-ices, published by the Ministry of Health/ANVISA/Fiocruzn 2013, establishes practices for hand hygiene of healthrofessionals.54 The Anvisa website also provides a toolor planning and calculating costs of alcohol-based prepa-ations for hand hygiene to help health facility managerso check the feasibility of implementing accessibility ofealth professionals to alcohol-based preparations for handygiene.55
But which product would be the most suitable? Ideally,he surgical antiseptic should enable complete eliminationrom hands of transient microbiota, significant reduction inesident flora at the beginning of the procedure and inhibitts growth in gloved hands until the end of the surgery.56
lcohol Preparations (AP) have been used in Europe forurgical hand antisepsis for roughly 30 years.57 To be mar-eted, they must be approved by the EN 1500 (antisepticand rubbing) and EN 12791 (surgical hand antisepsis) stan-ards of the Comité Européen de Normalisation (CEN).hen this solution (45% alcohol and 18% n-propanol) was
pplied for 90 seconds, compared to the mixture 61% alco-ol and 1% chlorhexidine applied for 180 seconds, it wasound to achieve significantly greater microbial reductionn both measured time points (p ≤ 0.025 immediately afterpplication and p ≤ 0.01 maintenance after 6 hours underurgical gloves, according to the protocol EN 12791).58
mong the different types of alcohol (ethanol, isopropanolnd n-propanol) commonly used for hand and skin antisepsis,-propanol has the most potent general microbicidal activ-ty at relatively low concentrations.59 In Brazil, a solutionested by EN 1500, EN 12054/13727, EN 1275/13624 and EN2791 which contain <55% ethanol and <25% propanol-1-ol isvailable. The solution has been approved by Anvisa (MS no
.0151.0002) since 2010, for the purpose of hand antisepsisnd surgical hand antisepsis.
For surgical hand antisepsis with alcohol-based products,nvisa recommends a duration of 60 seconds, subsequento hand washing with liquid soap and water upon arrival athe operating room. The sequence must be repeated two
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to three times, as recommended by the manufacturer. Itis essential to wait for hands to dry completely. Betweensurgical procedures, if there is any residue of powder/talc orbody fluids when removing gloves, hands should be washedwith liquid soap and water.59,60
In a cost-effectiveness study, Graf ME et al foundadvantages in the use of alcohol-based solutions for handantisepsis in pre-surgical preparations, among them, sig-nificant reduction in microbial count, improvement inprofessionals’ adherence due to shorter preparation timewith the use of alcohol-based solutions (1 minute vs.3 minutes for cleaning with chlorhexidine), and less irri-tating effect on the skin, in addition to greater watersavings and reduced waste material. The economic modeldemonstrated a 46% cost reduction when compared tochlorhexidine degermation.61 Findings were consistent withthose found in a previous review.62
A systematic review on the outcome of microbial handcount, or rates of surgical site infections, showed thatalcohol-based preparations presented an equal and/orgreater microbial reduction compared to traditional prod-ucts in 17 studies, and lower in 4, while surgical siteinfection rates were similar. The authors concluded thatthere is evidence to support the safety of alcohol-basedpreparations for surgical hand antisepsis.63 However, ameta-analysis study presented by Cochrane in 2016 foundno evidence of superiority associated with one specific typeof hand antisepsis regarding reduction in surgical site infec-tion. Hand rubbing with chlorhexidine gluconate can reducethe number of Colony-Forming Units (CFU) compared torubbing with povidone-iodine; however, the clinical rele-vance of this outcome is unclear. Rubbing with alcohol withadditional antiseptic ingredients can reduce the number ofcolonies compared to rubbing with water. There is no evi-dence that nail brushes have an impact on the number ofCFUs remaining on hands.64
Thus, it is concluded that there have been major changesin the past decades regarding surgical hand antisepsis, favor-ing the use of alcohol-based solutions without using waterand brushes, and generating cost-effectiveness and ecolog-ical sustainability when compared to traditional proceduressuch as surgical hand degerming using chlorhexidine glu-conate or polyvinylpyrrolidone iodine. To incorporate bestpractices based on scientific evidence, a programmaticapproach must be adopted. Policies that govern the pro-cesses and products used must be implemented, in additionto monitoring compliance.65
Studies on the preparation of the hands of the anesthe-siologist before performing regional anesthesia are scarce,but they confirm the findings regarding the preoperativepreparation of surgeons.66 Thus, it can be inferred that thesame procedures should be followed.24
RecommendationsBrushes for brushing are not recommended for the anes-thesiologist’s hand hygiene before performing regionalanesthesia.45---47
Although hand washing with sponges with chlorhex-idine soap and water is still used, current evidencefavors hand rubbing with products containing alcohol andn-propanol, especially in places where the quality of rins-
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ng water cannot be guaranteed. The procedure shouldake 60 seconds and follow the steps recommended byNVISA.48---50,60---64
actors associated with infectiousomplications in regional anesthesia
hat are the risk factors related to infection inegional anesthesia with or without catheternsertion?
evere CNS infections, such as arachnoiditis, meningitis,nd abscesses are rare complications of neuraxial anesthe-ia. However, literature data show an increasingly frequentccurrence of these events, perhaps because there are moreublications on the topic or more frequent use of long-termatheters.67---69
Epidural abscess occurs more frequently in immunocom-romised patients, with prolonged epidural catheterization.taphylococcal species are the organisms most commonlyound in epidural infection, related or not to the use ofatheters. Only 15% are caused by other bacteria.70
Reports show that patients who developed meningitisfter neuraxial anesthesia were healthy and underwentpinal anesthesia.71---73 Case reports and literature reviewslert to the occurrence of cases of meningitis caused bytreptococcus salivarius, a bacterial species prevalent inormal oral flora in humans, whose source of infection waspper airway droplets of health professionals (confirmedy genotyping techniques).74 Anesthesia professionals whoerform neuraxial procedures without wearing a surgicalask, expose patients to devastating risks and infectious
omplications, including death.75
Epidural catheter-related infections can occur by directissemination of cutaneous flora that migrate alonghe catheter, contamination of the infused solution orlood-borne dissemination from a distant source.76 Directropagation with bacterial growth along the catheter ishe most common cause, which may result in superficialr deep infection. Tunneled catheters reduce the likeli-ood of infection of the epidural space by increasing theistance to the site.76 Contamination of the solution canccur by breaking a closed system, by accidental discon-ection of the catheter, or during bag solution change.acterial filters can potentially reduce the risk of epidu-al contamination.76 The main agent described in this cases Serratia marcecens, an opportunistic gram-negative bac-erium that colonizes the human gastrointestinal tract.77,78
isconnection of the epidural catheter and infusion systemxposes the catheter internal lumen to the environment,hich can lead to subsequent epidural infusion of con-
aminated solution. A study with catheter contaminatedy Staphylococcus epidermidis concluded that cutting theroximal end of the catheter exposed to the environment,ith disinfection of the contaminated site and subsequent
nfusion of the local anesthetic, can prevent contaminationf the infusate.69
Studies have shown that 0.5% bupivacaine and 2% lido-aine inhibit the growth of microorganisms (e.g. S. aureusnd coagulase negative Staphylococcus) in culture media.owever, the bactericidal effect decreases significantly at
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ow concentrations of local anesthetics, which are typicallysed to promote analgesia. Further studies are needed tonvestigate the bactericidal effect in vivo of local anes-hetic solutions at low concentrations.79 Opioid solutionso not exhibit any ability to inhibit bacterial growth.80 Theumber of disconnections, duration, portion of catheter toe removed and the decision on whether to proceed withhe infusion are still controversial parameters, and studiesust be carried out to elucidate such questions.70,81 Thus,isconnections and the length of catheter stay should beimited.26,27,82---84
Delays in diagnosing patients with epidural/spinalbscess are common, often causing irreversible neurologi-al deficits. Risk factor assessment is more sensitive thansing the classic diagnostic triad (fever, spinal pain and neu-ological deficits) to screen patients.85 ESR can be a usefulcreening test before MRI in selected populations, such asmmunocompromised patients.86 Hematogenous spread ofnfection from another site to the epidural space is veryare. Intravenous drug users, patients with dental abscessesnd patients with long-term central venous catheters con-titute a higher risk population.76 Additional risk factors arehe presence of infection in adjacent anatomical structuresnd the colonization of central venous devices.75
Dressings for the epidural catheter must be transpar-nt and cover the catheter entry site in order to maintainterility during the infusion. Dressings impregnated withhlorhexidine were assessed by culture at the catheter entryite, observing 3.4% of positive bacterial culture comparedo 40.1% for dressings without chlorhexidine. In addition,atients should be instructed to keep the area clean andry during therapy to avoid compromising the dressing.76
The incidence of epidural catheter-associated infec-ions can be minimized by the use of catheters implantedith subcutaneous injection ports or externalized siliconeatheters with subcutaneous Dacron cuffs (e.g., Du Pen®;ard Access Systems®).76
Currently, two main types of bacterial filters being usedre the particulates (5 �g pores) and the antimicrobials0.2 �g pores). They are used to decrease the risk of bac-erial contamination while changing solution medicationags. There is a recommendation by the American Societyf Anesthesiologists Task Force on Infectious Complicationsssociated with Neuraxial Techniques to routinely use thentimicrobial filter in situations of long-term continuousnfusion.76
The epidural catheter insertion site influences theccurrence of colonization and potential infection of theuncture site.87---89 Continuous caudal epidural catheters areore frequently colonized than continuous lumbar epidu-
al catheters.88,89 Short-term catheters (up to 120 hours)how direct correlation between bacterial skin colonizationround the insertion site and bacterial growth from the sub-utaneous segment to the catheter tip.90
The epidural catheter insertion site influences the occur-ence of colonization and potential infection of the punctureite.87---89 Continuous caudal epidural catheters are morerequently colonized than continuous lumbar epidural
atheters.88,89 Short-term catheters (up to 120 hours)how direct correlation between bacterial skin colonizationround the insertion site and bacterial growth from the sub-utaneous segment to the catheter tip.90L.M. Azi et al.
Some patients are at higher risk for infection. Diabetess identified as a risk factor in several studies, with a higherncidence of spontaneous epidural abscesses. One studyemonstrated that obesity is also an important risk fac-or for infections; however, it was not related to a higherisk for neuraxial catheterizations. Immunocompromisedatients (on treatment with chronic steroids or immuno-uppressants, and those with autoimmune disorders, cancer,uman immunodeficiency virus/AIDS, chronic kidney diseasend liver cirrhosis) are also at high risk.76 Data suggest thaterforming epidural or spinal anesthesia during an episodef bacteremia is a risk factor for neuraxial infection.67,69,91,92
owever, studies showed that is safe to insert and keep aatheter in patients with infection at a distant site.87,93 In anbservational, prospective and multicenter study, perform-ng epidural analgesia for ICU patients was observed to beafe and with benefits in improving pain control, and redu-ing pain impact on cardiovascular and immune functions.owever, several precautions for early diagnosis and infec-ion control must be carefully observed when performingpidural analgesia in ICU patients.94
Adverse events that occur in the ward, such as cathetercclusion, damage or replacement of transparent dressings,artial displacement of catheters, disconnections, bloodransfusion and positive skin culture close to the insertionite are important risk factors for bacterial colonizationf the epidural catheter. It is argued that maintain-ng sterile skin around the insertion site can reduce tipolonization.90,95
As for peripheral regional anesthesia techniques, the fre-uency, diagnosis and prognosis of infectious complicationsemain uncertain. Several series involving continuouseripheral blockade technique have reported erythemat the insertion site and high incidence of colonization20%---60%),96,97 Specifically observing the risk of infectionith continuous peripheral nerve blockade, bacterial colo-ization is present in 29% of catheters, the most commongent being Staphylococcus epidermidis. The incidence ofocal inflammation is present in 3% of patients. There iso correlation between inflammation and the presence ofever. Risk factors for local infection/inflammation are ICUdmission, male, catheter kept for more than 48 hours andbsence of antibiotic prophylaxis.96 The incidence of infec-ious complications in continuous femoral catheters occursn most catheters examined 48 hours later, with S. epider-inidis being the main agent (71%).97
Bomberg H et al. demonstrated that antibiotic prophy-axis in a single dose is related to reducing the risk ofatheter infection for peripheral and epidural catheters,ith no difference whether the antibiotic was administeredefore or shortly after catheter insertion.98
ecommendations
For epidural techniques, assess the patient for conditionsthat add risk to developing infections, such as diabetes,obesity, dental abscess, IV drug abuse, bacteremia and
presence of a long-term central venous catheter. Theperiod of time the catheter remains in-place in thesepatients should be as short as possible, and the anes-thesiologist must comply with the correct technique of
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catheter insertion and maintenance. Using a bacterial fil-ter also adds to security.99
2 Handle catheters carefully to avoid contamination,reduce breakage of closed systems, and use and exchangebacterial filters.100
3 Professionals assisting the anesthesiologist in regionalanesthesia procedures should routinely wear surgicalmasks.75
4 Prophylactic single-dose antibiotics should be adminis-tered before or shortly after the insertion of epiduralcatheters.98
What is the risk of infectious complications inregional anesthesia in the febrile or infectedpatient?
There are specific recommendations regarding regionalanesthesia in febrile or infected patients.101,102 Severeneuraxial infections, such as arachnoiditis, meningitis andabscess related to epidural or spinal anesthesia are rare. Thedecision to perform a regional anesthetic technique must beindividualized, considering anesthetic alternatives, benefitsof regional anesthesia and the risk of CNS infection, whichin theory can occur in patients with bacteremia. In patientswith orthopedic prosthesis infection, neuraxial anesthesiahas been considered safe.100,103
The placement of an epidural or subarachnoid catheterin this group of patients remains controversial. The epidu-ral catheter must be removed in the presence of erythemaand/or local discharge, and there is no convincing data sug-gesting that concomitant infections in remote sites or theabsence of antibiotic therapy are risk factors for infection.Even a few hours of delay in the diagnosis and treatment ofmajor CNS infections can significantly worsen neurologicaloutcomes.102
RecommendationPatients with evidence of systemic infection can be submit-ted to spinal anesthesia as long as, prior to the puncture,antibiotic therapy has been initiated and some treatmentresponse demonstrated, such as reduction of fever.99,100,103
What is the risk of infectious complications inregional anesthesia
Patients with impaired immune function (e.g., cancer, dia-betes, infected with Acquired Immunodeficiency Virus (HIV)or Herpes Simplex Virus (HSV), drug and alcohol abuse,on glucocorticoid therapy, on immunosuppressive treatmentand/or chemotherapy for inflammatory bowel diseases,autoimmune diseases and transplant patients) have beenincreasingly submitted to regional anesthesia.86,101 Thesepatients are more susceptible to infection by opportunisticgerms. Antimicrobial therapy is less effective in these cases,resulting in greater morbidity and mortality when comparedto patients with preserved immune function. Immune system
suppression increases both frequency and severity of infec-tion, in addition to diminishing its characteristic signs andsymptoms. In these individuals, the extent and duration ofgranulocytopenia (< 500 granulocytes.mL-1) is a well-known407
nfection risk factor. When granulocytopenia persists for 6o 10 days, the risk is higher (30% risk of infection witheukopenia < 1000 m L-1 or 50% with granulocytes < 100 m L-). If granulocytopenia lasts more than 10 days, patient islassified as high-risk (70% risk of bacterial infections).86
The number of pathogenic microorganisms (atypicalnd/or opportunistic pathogens) is higher in the immuno-ompromised host than in the general population. The delayn diagnosis and treatment of CNS infections worsens neuro-ogical outcome and increases mortality. For these patientshe risk of epidural abscess increases proportionally to theeriod the epidural catheter remains in situ. Neuraxial anes-hesia has been shown to be safe in patients with recurrentSV virus infection, although there are reports of exacerba-ion of HSV-1 infection associated with the use of epiduralr intrathecal opioids.101
Some scenarios in immunocompromised patients deservepecial attention:
a) Chronic glucocorticoid therapy: The degree of hyper-cortisolism correlates with the risk of opportunisticbacterial diseases and infections. Even after a singledose of glucocorticoids, lymphopenia, monocytope-nia and eosinopenia last for 4---6 hours. Cell count isreduced and cell function is impaired. The risk ofinfection in chronic glucocorticoid therapy dependson the type, dose, administration route and durationof treatment. In patients with rheumatoid arthri-tis, the risk of severe bacterial infection has beenshown to double when glucocorticoids are used whencompared to methotrexate, with a dose-effect rela-tionship when using doses of prednisone above 5 mgper day. Prednisone has also been shown to be a riskfactor for serious infections in patients with Crohn’sdisease.86
b) Chemotherapeutic agents: The main side effect ison hematopoiesis, resulting in anemia, leukope-nia/neutropenia and thrombocytopenia. Neutropeniais the most frequent effect and its degree and dura-tion are directly correlated with the incidence ofinfections.86 In a study carried out with children andyoung patients from an oncology clinic and undergo-ing epidural analgesia for a lengthier time period thanusually recommended showed low incidence of infec-tion. The results suggest that the pain control methodis safe, with limited risk for infection.104
c) Immunosuppression after organ transplantation: Intraand postoperative neuraxial techniques are increas-ingly used in organ transplant centers to improveperfusion during solid organ transplantation. However,only a few studies have been published address-ing the potential risk of complications in individualsundergoing transplants combined with epidural anes-thesia. Among them, Trzebicki et al. reported nocomplications associated with thoracic epidural anes-thesia in patients undergoing liver transplantation.There are, however, two reports describing spon-taneous epidural abscess during immunosuppressive
treatment without any anesthesia procedure.86d) HIV infection: It has been suggested that approxi-mately 20%---25% of HIV-positive patients may requiresurgery during the period of their illness. Pregnant
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patients who are HIV positive with high viral loadsare referred for elective cesarean surgery in orderto reduce transmission rate to the child. In the studyby Gronwald et al, regional anesthesia (epidural andspinal) was performed without complications. How-ever, the authors themselves emphasize safety criteriasuch as CDC stages A2 or B2 (CDC stages: A, asymp-tomatic HIV infection; B, symptoms and diseasesassociated with HIV, but no AIDS-defining disease;C, AIDS-defining diseases; 11/4 CD4 cell count > 350cells.mL-1, 21/4 CD4 cell count < 50 cells.mL-1, 31/4 CD4cell count < 200 cells.mL-1.86 Some data suggest that,in HIV-infected patients, peripheral and neuraxialblockades are feasible, including blood patch. Pre-existing neurological diseases are common in thesepatients and should be considered when performingneuraxial techniques.95
ecommendations
Limit epidural catheterization time to up to 72 hoursin immunosuppressed patients. In patients whowill receive immunosuppressive therapy, it may beuseful to measure absolute and differential leuko-cyte counts preoperatively and perform follow-upmeasurements.86
Change dressing at the insertion site with aseptic tech-nique. Daily inspections and early treatment in case ofsuspected complications should be routine.86
In case of suspected neuraxial infection, it is recom-mended to request consultation from the infectiousdisease service to help early and effective initiation ofantibiotic therapy.101
iagnosis and treatment of regionalnesthesia-related infections
ow are meningitis and epidural abscess diagnosednd treated?
high level of suspicion is vital for diagnosing an infectiousomplication. The incidence of catheter-related epiduralbscess is low, and cases of meningitis and osteomyelitis arearer.76,78 Delaying diagnosis and treatment of major CNSnfections, even for a few hours, significantly worsens neu-ological outcome. Bacterial meningitis is a medical emer-ency. The mortality rate ranges from 10% to 30%. Sequelae,uch as nerve damage and hearing loss, occur in 5% to 40% ofatients.104---106
Meningitis presents more often with fever, headache,ltered level of consciousness and meningism. The diag-osis is confirmed by lumbar puncture. Usually clinicalanifestations start 48 hours after performing spinal anes-
hesia puncture. Antibiotic therapy can delay the onsetf symptoms and laboratory evaluation is a useful com-lement to confirm the diagnosis. Tests may include aombination of laboratory tests, wound and cerebrospinal
uid cultures, white blood cell count, Erythrocyte Sed-mentation Rate (ESR) and C Reactive Protein (CRP)nalysis.107,108 CRP may be a more sensitive indicatorf infection than other biochemical markers as it has
L.M. Azi et al.
ore predictable kinetics and is more responsive in theostoperative period, being regarded as the best diag-ostic test. Repeated CRP tests and assessment of CRPrends are valuable measures for establishing diagnosis ofnfection.76,85,109
Cerebrospinal fluid analysis shows leukocytosis withncrease in polymorphonuclear cells, low glucose (<0 mg.dL-1), high proteins (> 150 mg.dL-1). Gram-staineveals bacterial presence and culture is positive foracteria.73 Level of lactate in CSF (greater than 35 mg.dL-) is recommended to differentiate bacterial from asepticeningitis, since the use of previous antibiotics can reduce
linical accuracy.110---112
Lumbar puncture should not be performed if an epiduralbscess is suspected, as it can also cause contamina-ion of the subarachnoid space. Abscess formation afterpidural or spinal anesthesia can be superficial, requiringimited surgical drainage and intravenous antibiotic admin-stration, rarely leading to neurological problems, unlesshey are not treated. The epidural abscess usually occursrom days to weeks after neuraxial blockade and whenhe patient has already been discharged.113---116 The timef onset of symptoms may suggest the etiologic agent.74
t presents as a progressive disease, starting with localizedack pain (most common initial symptom), local hypersen-itivity, and fever and chills in the first stage; nerve rootrritation and headache occur in the second stage; neuro-ogical deficits, such as muscle weakness, sensory deficits,ladder and bowel dysfunction occur in the third stage, fol-owed by paralysis in the fourth stage.76,87,108 Initial backain and nerve root symptoms can remain stable for hourso weeks. However, after the onset of muscle weakness, theondition progresses quickly to complete paralysis within4 hours.117,118 The radiological image of an epidural massssociated with variable neurological deficit are diagnostic.agnetic resonance imaging with gadolinium administra-
ion is recommended because it is the most sensitive testor assessing spinal cord, when an infectious process isuspected,119 as it defines the extension of the lesion andelps differential diagnosis.108
The combination of antibiotic therapy and surgicalpproach (drainage and/or debridement) is the treatmentf choice.107,119,120 Neurological recovery depends on severalactors, and almost half of survivors are left with neu-ological deficits, 15% of them with complete paresis oraralysis, with reports of mortality rates ranging from 5%o 16%.107,119---121
ecommendations Meningitis should be suspected if a patient presents
fever, headache, altered level of consciousness andmeningism within 48 hours after spinal puncture.Sequelae will depend on early diagnosis and timelytreatment.104---106
Epidural abscess should be suspected in patients pre-senting localized back pain, local hypersensitivity andfever, chills, root irritation, headache and neurolog-
ical deficit in days or weeks after neuraxial block,usually after the patient has been discharged.76,84,108Magnetic resonance imaging is the diagnostic test ofchoice.119
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Antibiotic prophylaxis and regional anesthesia
Should the patient undergoing continuous regionalanalgesia receive antibiotic prophylaxis?
Systemic infection, or local abscess due to a regionalanalgesia catheter is rare, although colonization of thecatheter is more frequent.122 Depending on the catheterinsertion site, the incidence of infection ranges from 0%to 7% for peripheral catheters, and from 0.8% to 4.2% forepidural catheters.98 Tunneling of a short-term catheter(mean of 48 hours) seems to decrease bacterial coloniza-tion of the catheter tip. The incidence of colonization is6.2%, and is higher in trauma patients. Keeping epiduralcatheters in situ for an average of 56 hours without tunnel-ing have shown 28% of positive cultures, with no correlationwith the type of preoperative antibiotic administered.123
According to a study involving 40,362 cases of peripheraland epidural catheters for continuous use, patients whoreceived single-dose antibiotic prophylaxis had significantlower levels of peripheral catheter-related infections (1.1%)compared to those without prophylaxis (2.4%, p < 0.001,nnT = 76). In patients with an epidural catheter, single-doseantibiotic prophylaxis reduced the incidence of infections(3.1%) in comparison to those without prophylaxis (5.2%,p < 0.001, nnT = 49). Administration of systemic antibioticswithin 24 hours postoperatively significantly decreases therisk of catheter colonization.98,123
Recommendations1 Single-dose antibiotic prophylaxis is associated with a
reduced risk of catheter-related infections for periph-eral and epidural catheters, and should therefore beperformed.98
2 Tunneling of long-term catheters is recommended in orderto reduce colonization of catheter tips.123
3 Handling short-term catheters should take place underaseptic technique with minimal handling of the catheterafter insertion, use of transparent dressings, and surveil-lance of the puncture site two to three times a day, andthe day following removal.
4 In case of inflammatory signs at the site, catheterremoval, catheter culture request and antibiotic treat-ment (ceftriaxone --- 2 g each 12 hours associated withvancomycin --- 1 g each 12 hours) are mandatory. Mag-netic resonance imaging should be ordered to guide futuredecisions.124
Reuse of materials in regional anesthesia
Are there materials that can be reprocessed forregional anesthesia practice (glass syringes,needles)?
Recycling or reuse of hospital supplies is one of the mostcontroversial issues discussed by health care systems world-
wide. Many industries are against reprocessing, claimingpossible dangers of reuse. Many health services are favorableto reprocessing, considering the economic and ecologicalimpacts. Several types of materials intended for health ser-Aaop
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ices are produced and labeled by manufacturers as foringle use, ensuring safety both for product operation andterilization, and avoiding any possibility of cross infec-ion. The items used for providing regional anesthesia areonsidered critical,125 and the current literature does notrovide sufficient evidence for practicing reprocessing,126
iven the risk of infection and other complications do notustify the adoption of this measure.125,127 Reprocessingan mechanically, thermally and chemically affect prod-cts, compromising their effective performance. Besides,he reprocessed item must have the safety equivalent tohe one provided by the manufacturer, so that the patients not exposed to any kind of risk.128,129
Thus, using reprocessed products offers a potential riskelated to improper cleaning, disinfection and/or steril-zation, which can result in chemical or microbiologicalontamination.130,131 There is evidence that using repro-essed products is related to transmission of diseases causedy viruses or by unconventional agents (Creutzfeldt-Jakobisease).131 After studying different reprocessed items, 11%f them had some type of malfunction, which compromisedheir safety use.132 Sterilization of reusable materials issually performed using ethylene oxide, mixed with steamnd formaldehyde, oxidizing gas (hydrogen peroxide), ozoner peracetic acid. Waste gases from the sterilization pro-ess can remain, compromising item safety and efficiency,specially if the item is reprocessed several times, andhus loses its biocompatibility.133 The presence of chemicalesidues that may remain after cleaning or by absorp-ion of the re-sterilized material is a latent and importantanger to be considered.134 The analysis from a question-aire that assessed doctor and patient perceptions regardingeprocessing of materials reported that more than 90% ofespondents considered that hospitals have the responsibil-ty to inform patients about the practice as part of theirare.135
Regarding the matter, the ANVISA RDC 156 defines clearriteria for reprocessing materials, with clear norms foreusing items that can be reused, including prohibiting theirommercialization.133
ecommendationaterials for use in regional anesthesia, such as needles,lass syringes or catheters should not be reprocessed.133
afety in the administration of drugs
ow to improve safety in the administration ofrugs in regional anesthesia?
wide range of drugs is used during regional anesthe-ia techniques,136 and currently, medication administrationrrors are considered a worldwide epidemic, resulting inhousands of deaths annually. The incidence of the eventas increased over the years, generating human fatalitiesnd significant financial losses.137
The medication error is characterized, according to
NVISA’s definition, as any preventable event that can,ctually or potentially, lead to incorrect administrationf medication. The event may be related to professionalractice and to healthcare products, procedures, commu-
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ication issues (prescription, labeling, packaging, naming),reparation, dispensing, distribution, administration, edu-ation, monitoring and use of medications.138
Following, we describe some measures for reducingrrors in medication administration. The measures havetrong evidence for recommendation, such as carefully read-ng the label of every drug, ampoule or syringe before use,ouble checked by a second person;139---142 using ampoulesnd syringes that have a clear identification label andollow standards defined by the pertaining agency;142---149
outine identification of syringes;141 systematic organiza-ion of drugs routinely used during anesthesia;139,142,143
eview of drug administration error incidents during anes-hesia, registered at the organization;145 drug handlingechnique focused on minimizing the possibility of admin-stration error;142---145 avoid handling drugs that have similarresentations;139 and using drug color identification basedn drug class, complying with national recommendations ornternational standards.139,142
There are essential and necessary elements to improveafety and avoid drug administration errors,146 such as theevelopment of a safety culture among team members;ogistical support to the team, encouraging the report ofdverse events; integration between areas (anesthesiol-gy, pharmacy, organization risk management); encouragingomprehensive report of the facts by professionals involved;nd sharing safety lessons among team members.5
The Brazilian norms on this matter are described inNVISA Resolutions, which establish criteria for labels andags for Small Volume Parenteral Solutions (SPPV). Theorms were established by collegiate resolutions RDC no 9,f January 2, 2001. In 2009, a new resolution, RDC no 71, onrug Labeling was published. Among the innovations incor-orated by this RDC, one in particular was very well receivedy companies that own the brands of reference products.ccording to article 17, item V, of this resolution, ‘‘using
abels with a layout (packaging) similar to that of a pharma-eutical with the same active ingredient, pharmaceuticalorm and concentration, previously registered by anotherompany, is prohibited’’. An improvement in the identifica-ion of pharmaceuticals and, consequently increase in safetys expected.138---147
ecommendationdopt a safety routine (preferably with the development of
culture of institutional safety) to avoid accidents during aegional anesthesia procedure, such as detailed reading ofny medication label before administration; regular reviewf label legibility on packaging or ampoules of drugs; iden-ification of syringes filled with drugs; formal organizationf drugs routinely used; medication double checking by aecond person; and, if possible, use of drugs dispensed inre-filled and pre-labeled syringes139---149
oes using solutions in vials or ampoules in sterileackaging for regional anesthesia seem to be safer?
o test the likelihood of contamination of the local anes-hetic dispensed in ampoules, a swab with S. epidermidisas rubbed on the neck of 16 1% lidocaine ampoules; theecks of half of these ampoules (eight) were subsequently
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leaned with prepackaged alcohol pads, and all ampoulesere opened in the supine position with sterile gauze. The
esults described that none of the alcohol-cleaned ampouleshowed bacterial growth, while three of eight lidocainempoules not cleaned with alcohol showed strong bacte-ial growth.149 A survey performed in the UK, reported thatnly 21% of anesthesiologists claimed that they cleaned theeck of non-sterile ampoules with alcohol.34 It is argued thathe risk of contamination of solutions stored in ampoulesuring handling and opening is small, but should not be over-ooked. Possible answers for the contamination of solutionshile opening ampoules should include changing medica-
ion packaging into different formats, such as single-usempoules sealed with a rubber septum; cleaning the neckf ampoules with alcohol before opening; or sterilizing theutside of glass ampoules and subsequent sterile packag-ng, as is already the case of some ampoules for spinal andpidural anesthesia.149
Regarding bacterial contamination, no differences werebserved between withdrawing fentanyl solution afterleaning the ampoule neck with isopropyl alcohol, or whenhe solution was withdrawn aspirated with a needle with anntibacterial filter.150
When sterility and microbial (bacteria and fungi) load onhe outside of ampoules and vials of hyperbaric bupivacainerom conventional or sterile packaging were compared, these of sterile packaging reduced the microbial load, andecreased the possibility of potential anesthetic solutionontamination.151
ecommendations
Cleaning glass ampoule necks with alcohol before open-ing or withdrawing drugs using antibacterial filter needlesshould be part of the anesthesiologist‘s routine.149,150
Sterile packaging is recommended as a way of increas-ing safety and reducing bacterial contamination of thesolutions used in regional anesthesia.149,151
s there cost-effectiveness in handling andreparation of sterile solutions foratient-controlled analgesia in the out-of-hospitalnvironment?
lthough not widely reported, contamination of solutionsan cause serious infectious complications in regional anes-hesia. The adoption of handling practices that minimizeontamination should be a priority for anesthesiologists,specially when such solutions are infused in unmoni-ored patients in settings outside the hospital environment.ecause continuous infusion during several days is con-idered of medium risk, solutions must be purchased asre-made sterile products, or handled according to USP---797uidelines.152 It is recommended that all sterile solutionse prepared in a laminar flow environment, with particleounts between 0 and 46,262 per cubic meter (class ISSO---6). Therefore, they must be prepared outside operating
ooms and by qualified pharmacy personnel.153A study assessing cost-effectiveness of solutions (localnesthetic or opioids) for epidural administration viaatheter, all prepared in the pharmacy department using
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aseptic technique and horizontal laminar airflow, found bac-terial growth in five of the 115 samples prepared, and itwas associated with handling contamination during sam-ple collection, since most of the identified microorganismssupported this assumption. Based on these findings, it isrecommended that for solution mixtures prepared withopioid, local anesthetic/opioid or only local anesthetic,both the infusion system replacement and solution handlingshould not be more frequent than every 72 hours. This is aclear pharmacoeconomic-oriented recommendation, espe-cially for services that routinely adopt continuous epiduralanalgesia for postoperative acute pain treatment.154
However, as replacement of the infusion solution bagrequires disconnection of the catheter, it is preferable touse larger volume bags, to minimize contamination risk.76
Evaluating the sterile viability of local anesthetic and opi-oid solutions to be used in continuous infusion for chronicpain home treatment, solutions were stored in a regularhome refrigerator and no bacterial growth in the solutionswas observed after seven months from preparation. It is rec-ommended, in selected patients undertaking out-of-hospitalbasis treatment, and being followed up at home and with along-term epidural catheter in situ, to use solutions pre-pared with a sterile technique, stored in a regular homerefrigerator, for a period not exceeding 14 days.155
Regarding the compatibility between different solutions,ropivacaine associated with morphine, sufentanil, fentanylor clonidine was studied in plastic bag commercially avail-able solutions of 0.2% ropivacaine with 214 mL. The bagswere diluted once again with 0.9% saline using controlledaseptic technique to result in a 1 mg.mL-1 solution. Thenew dilution was later associated with different concentra-tions of opioids and clonidine.125 Solutions were stored for 30days, at 30 ◦C and relative humidity of 40%. The mixtures of1---2 mg.mL-1 of ropivacaine, with 20---100 �g.mL-1 of mor-phine sulfate, 0.4---4 �g.mL-1 of sufentanil, 1---10 �g.mL-1of fentanyl or 5---50 �g.mL-1 of clonidine were observed tobe chemically and physically compatible and stable for 30days after preparation when stored in plastic bags keptat 30 ◦C.156 A levobupivacaine solution mixed with sufen-tanil and sodium chloride to produce a concentration of1 �g.mL-1 of sufentanil and 1 mg.mL-1 of levobupivacaine,was stored in polypropylene syringes, protected from lightfor 30 days. The results of the microbiology and chemicalstability analysis showed that the solution can be stored at4 ◦C or 21 ◦C. It should not be stored at 36 ◦C due to thepotential bacterial growth.157 The stability in PVC infusionbags of the mixture of sufentanil citrate (500 �g) with lev-obupivacaine hydrochloride (625 mg) in 500 mL 0.9% sodiumchloride solution, enables the solution to be prepared inadvance by a specialized service, in sterile conditions,and stored for 58 days at a temperature of 4 ◦C, withoutchanges in the concentration of the product.158 The stabil-ity of pre-manufactured solutions of 0.1% bupivacaine in PVCinfusion bags containing 2 �g.mL-1 of fentanyl citrate andepinephrine (1 mg) allows us to conclude that this epiduralinfusion solution is stable when stored at temperatures of4 ◦C and 22 ◦C for 184 days, with refrigeration as the pre-
ferred storage condition.159Several recommendations can also be made regardingthe duration of regional anesthetic infusions. Evidencesuggests that when the local anesthetic or the mixture
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f local anesthetic with opioids is prepared under ster-le conditions, microbiological stability is maintained for2 hours.153
ecommendations
It is recommended to prepare the solution in a sterileenvironment.152 The solution can be stored at low tem-peratures (4 ◦C or 21 ◦C) for several days, as it retainsits physical-chemical characteristics without bacterialcontamination.157---159
It is recommended to replace the analgesic solution after72 hour infusion.154
are while using ultrasound-guided regionalnesthesia technique
recautions regarding ultrasound-guided regionalnesthesia
ltrasound has revolutionized the way we approach regionalnesthesia. Nonetheless, consistent evidence supporting theffectiveness of ultrasound-guided regional anesthesia ineducing the incidence in local anesthetic systemic toxicity,ascular injury, hemi diaphragmatic paralysis and pneu-othorax, and its impact on patient safety remains under
tudy.160,161 There is no solid evidence that ultrasound guid-nce significantly affects the incidence of peripheral nervenjury associated with regional anesthesia.162 It is importanto note that safety does not depend on a single technol-gy. During the performance of regional anesthesia, safety iselated to the level of training of the professional, and to theechnique chosen, patient anatomy, and equipment.160,162
Regional anesthesia is also becoming increasingly fre-uent in pediatric anesthesiology. In this scenario, differenttudies have shown that regional anesthesia, when prop-rly performed, has low morbidity in infants and children,resenting itself as a promising tool to increase regionalnesthesia safety.163
The occurrence of infection related to ultrasound-guidedlocks has already been reported, with serious associatedomplications.164
Given regional anesthesia requires a sterile techniquend that the USG device and probe (or transducer) areeusable Medical Devices (RMD), every precaution muste taken to avoid patient cross-infection transmission vialood or other body fluids. Although studies often men-ion that ultrasound-guided blockades should be carried outnder aseptic conditions, the way they should be performedwith both protective cover and conductive gel sterile) haseen neglected. Due to the lack of specific studies on useuring regional anesthesia, general recommendations forntraoperative ultrasound use can be adopted. Thus, theeneral recommendations used for disinfecting RMD are usu-lly adopted to USG device care. 165
According to the use and risk of infection transmission,
nd based on the Spaulding classification, RMD are dividednto:166Critical: Devices that penetrate tissue, sterile cavity orascular system (high risk of infection). Invasive surgical
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evices require sterility or high-level disinfection. Example:ltrasound probe used by the surgeon during the surgery.
Semi-critical: Devices in contact with intact mucosa oron-intact skin (medium risk of infection). Disinfection muste of intermediate level and is achieved by immersion inisinfectant solution after cleaning. Example: endovaginalnd transesophageal probes.
Non-critical: Devices that do not have direct contact withhe patient or come into contact with intact skin (low riskf infection). They require low level disinfection. Transcu-aneous ultrasonic probes fall into this category.
The USG probe is usually placed on healthy, prepped,isinfected skin and does not penetrate the tissue. Thus,t could be considered a non-critical device according tohe Spaulding classification,166 and, therefore, subject toow-level disinfection.
The guideline of the Center for Disease Control andrevention (CDC) for disinfection and sterilization of health-are facilities defines cleaning as removal of visible grimefor example, organic and inorganic material) from theransducer surface, and it is usually done manually orechanically using water with detergents or enzyme prod-
cts. Disinfection is described as the process that eliminatesany or all pathogenic microorganisms, except bacterial
pores. Cleaning should always be carried out before dis-nfection, as the inorganic and organic materials that mayemain on the surface of devices can interfere with theffectiveness of the process.167
To provide appropriate USG probe care after regionallockades one should know if the device was contaminatedy body fluids, if it was kept in a sterile environment, andf device components allow sterilization or disinfection.168
herefore, care requirements for the USG probe for regionalnesthesia match those of the camera used in video-assistedurgeries. Disinfection of the camera is performed by clean-ng it with a disinfectant detergent solution with the goalf minimizing the number of microorganisms present on itsurface. A sterile cover is subsequently applied before usinghe camera in the surgical field.169
A recent recommendation by the American College ofmergency Physicians established some principles for clean-ng transducers, which include the disinfection based on theathogens possibly found in each patient and on the empha-is on initial cleaning (including carefully removing gel) anderforming the correct level of disinfection. The levels ofisinfection range from low (destroys most bacteria, someiruses and some fungi by using soap and water and quater-ary ammonia sprays) to high (removes all microorganisms,xcept bacterial spores by using chemical/germicidal steril-zers or by physical sterilization). According to the Americanollege of Emergency Physicians,170 the following precau-ions should be followed:
a) Transducers (linear or curved) placed on clean andintact skin (for example, when scanning structureswithout performing puncture) are considered non-critical devices and require low level cleaning aftereach use.
b) Transducers that are used during percutaneous pro-cedures (vascular access, lumbar puncture, regionalanesthesia and other procedures) should be coveredwith a sterile single-use probe cover during the pro-
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cedure, and then cleaned with low level disinfectionbetween uses.
c) Internal transducers (probes for intraoral proceduresand transesophageal probes) are semi-critical devicesthat must be covered with a single-use cover and sub-jected to high-level disinfection between cases. Whenremoving the probe cover, care must be taken to avoidprobe contamination with patient fluids. Upon com-pletion of the examination, the operator must performadequate hand hygiene. Operators should be awareof hospital procedures for high-level disinfection andworkflow that may include communicating with sup-ply technicians, adopting equipment covers or probetracking systems.
Therefore, during the procedure, probes used duringegional anesthesia must be covered with a sterile single-userobe cover, and then cleaned with low-level disinfectionetween cases.170
There is only one study that deals with the direct rela-ionship between ultrasound, and regional anesthesia andnesthetic injections. Alakkad et al. examined 7,476 medi-al charts of patients who underwent peripheral nervelockade with a single injection guided by ultrasound. Aow-level disinfection technique was used in combinationith a transparent sterile barrier protection glove to cover
he ultrasound transducer. Results showed no evidence ofnfection related to the blockade. Thus, the authors sug-ested that the low-level disinfection technique associatedith a sterile transparent film barrier dressing to cover theltrasound transducer result in an extremely low infectionate.171
For single shot or continuous peripheral nerve blocks,terile gel and a sterile probe cover are required. Ideally, aelescope plastic cover should be used, secured in place by aterile rubber band instead of an adhesive tape, which poses
greater risk of tearing during removal and, therefore,ffering a real possibility of soiling probes. Between twoatients, probes must at least undergo low-level disinfectionit is a non-critical device). Using sterile gel for ultrasound isecommended, as non-sterile gel has already been linked toosocomial infection outbreaks. If non-sterile gel is used,are should be taken to dispose multiple-dose recipientshen empty (that is, avoid replenishment) and avoid directontact between gel container/tube and surface of theransducer or the skin. Once opened, gel containers muste discarded after 28 days. Gel used on a patient should note reused. Sterile single-use gel packs should be used fornvasive procedures that involve skin puncture, for examina-ions performed on non-intact skin or near sites with surgicalcars.170
The protective barriers used during venipuncture andegional anesthesia are medical gloves and probe cov-rs. Covers with pore sizes < 30 nm are recommendedecause they block most viruses, including HPV, whichs 50 nm in size. Sterile adhesive film dressings (e.g.,egaderm®, OPSITE®) are considered effective barriers
gainst microorganisms larger than 27 nm in size. One mustudge on a case-by-case basis and observe the manufac-urer’s recommendations when contact with non-intact skins necessary.170 Even if the cover is intact after removal, the
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probe must be cleaned with detergent, rinsed, dried andmaintained in a clean environment. 167
In case of damage to the protective cover, the transducermust undergo higher level disinfection. Most manufactur-ers do not offer probes and cables that can be completelysubmerged in disinfectant products. The material of thetransducer can be previously disinfected with detergent,but not always with a disinfectant, such as peracetic acid.The manufacturer must provide information on alternativemethods for the disinfection process, which may be auto-mated rapid disinfection devices, such as ultraviolet C light(physical disinfection) or hydrogen peroxide (chemical dis-infection). The pre-cleaning process is important to assureeffective disinfection.172
Due to the chance of protective cover perforation ofaround 10%, some protocols recommend that high-level dis-infection should be routinely performed.167 As USG probesare not resistant to high temperatures, it is not possi-ble to autoclave them. An alternative to obtain high-leveldisinfection is Ultraviolet C (UV-C) light, currently avail-able in Brazil. One study evaluated the effectiveness ofUV-C disinfection after previous probe infection (48 hoursbefore) with gel contaminated with Staphylococcus aureus,Escherichia coli and Enterococcus faecalis. As the UV-C dis-infection protocol requires performing a primary cleaningstep before disinfection, according to the study protocol,transducers were first cleaned with dry paper to removegel, and then with paper impregnated with disinfectant.The results found showed that, after 5 to 7 minutes of expo-sure to the inoculated gel, all probes were infected (> 150CFU --- Colony Forming Units). All were considered sterile (<10 CFU) after the disinfection protocol. Ultraviolet C lightappears to offer a triple advantage over conventional tech-niques. First, it provides high-level disinfection. Second, itallows the use of the ultrasound probe without a protectivecover, which can simplify US-guided techniques and improveechogenicity. In addition, it is a quick process (cycle lasts 90seconds).173
After using the transducer cover, it must be removedand discarded with common waste. If it contains body flu-ids, the cover must be discarded as biological waste. Gelresidues should be removed (e.g., wipe with a lint-free clothmoistened with running water), and probe and cable shouldbe inspected and disconnected from the device to clean.After cleaning, probes must be stored dry and protected. Itis recommended that they be stored in a closed and ven-tilated space outside the procedure room. The entire unit(keyboards and carts) should be cleaned regularly.167,170
Protocols for cleaning and disinfection of the materialsinvolved must be developed and monitored. Neverthe-less, recently, a study that evaluated the cleaning ofultrasound equipment in five institutions in Australia withdefined protocols,174 concluded that for more than 90%of the devices, cleaning standards could be significantlyimproved.175
Anesthesiologists have varying levels of interpretation inrelation to care after use. In research evaluating the riskof infection in regional anesthesia, cross-transmission was
considered low, moderate or high by 43%, 48% and 9% ofanesthesiologists, respectively. Regarding the use of probegel, sterile single-dose packets were reported in 83% ofcases, while a non-sterile, multi-dose plastic bottle, used for413
ore than 24 hours after opening, was used by 13% of thoseurveyed. There was no protocol for skin disinfection in 73%f cases. Regarding probe protection, 68% of respondentseported using nonspecific protective covers, 52% reportedsing semi-permeable transparent occlusive dressing (e.g.,PSITE®) and 5% did not use any type of covering. Still, only7% believed they were using appropriate protective covers.robe decontamination between two patients was reportedy 86% of professionals. The multiplicity of precaution mea-ures taken reflects the imperative need for studies andhe establishment of specific recommendations by specialtyocieties,176 because, although the use of sterile and self-dhesive ultrasound films is useful in daily clinical practice,here is still no scientific and economic evidence regardingts efficacy in regional anesthesia.177
ecommendationst is recommended that aseptic measures be taken for theltrasound probe used in regional blockades. For simpler continuous peripheral nerve blocks, sterile gel and aterile transducer covers are required. Ideally, a telescopicover should be used and secured in place by sterile rubberand. Between two patients, the transducer must undergoow-level disinfection (non-critical device). The entire unithould be cleaned regularly.162,164,167,172,173
Ultrasound probes used for external use on intact skinfor diagnosis only (without punctures for injections) andwithout contamination of blood or body fluids, should becleaned with low-level disinfection.167,170,172
Ultrasound probes used externally for percutaneous pro-cedures must be covered with single-use protective coversand sterile gel applied. Subsequently, they should becleaned with low-level disinfection.167,170,172
Ultrasound probes used internally in mucous membranesand internal orifices must be covered with a single-usesterile cover for each examination, followed by high-leveldisinfection between each use.167,170,172
If available, ultraviolet C light seems to offer anadvantage over conventional techniques, as it provideshigh-level disinfection, it is a quick process (90 secondcycle) and allows US probe use without a protective cover(which improves echogenicity).173
onflicts of interest
he authors declare no conflicts of interest.
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