Anesthesiologists and patients are at risk for cross-contamination and cross-infection during routine clinical care (Clinical Anesthesia. 2017; Anesth Analg 2020;131:37-42; Curr Anesthesiol Rep 2020;10:233-41; J Anesth 2020;34:575-84). The SARS-CoV-2 pandemic emphasized the risk of such perioperative transmission (Anesth Analg 2020;131:37-42; Cardiothorac Vasc Anesth 2021;35:1503-8). In this article, we review practical considerations related to these hazards.

Hand hygiene, including hand washing, use of hand sanitizer, and appropriate use of gloves, reduces transmission of pathogens to patients and protects anesthesia providers from spread of disease via fomites, secretions, and blood (Clinical Anesthesia. 2017; Anesth Analg 2020;131:37-42; Curr Anesthesiol Rep 2020;10:233-41). Alcohol-based hand sanitizer, either body-worn or placed in proximity to the anesthesia machine, enhances compliance with hand hygiene protocols and reduces postoperative infection rates (Clinical Anesthesia. 2017; Anesth Analg 2020;131:37-42; Curr Anesthesiol Rep 2020;10:233-41).

Gloves are critical to hand hygiene, although many anesthesiologists do not use them while securing intravenous access (AANA J 2014;82:363-7; BMC Anesthesiol 2018;18:193). Double-gloving during induction reduces transmission of pathogens to the anesthesia workstation (Clinical Anesthesia. 2017; AANA J 2019;87:307-12; Anesth Analg 2015;120:848-52). Gloves should be removed and hand hygiene performed immediately after airway maneuvers to reduce cross-contamination (Infect Control Hosp Epidemiol 2019;40:1-17). After induction, contaminated equipment should be segregated and the work surface and other high-touch surfaces should be wiped with a germicidal solution (Am J Infect Control 2014;42:1223-5; JAMA Netw Open 2020;3:e201934).

Maintaining a clean workspace reduces cross-contamination (Anesth Analg 2020;131:37-42; Curr Anesthesiol Rep 2020;10:233-41; asamonitor.pub/3NXkrKQ). To promote efficient use of OR time, anesthesiologists often are expected to set up for subsequent patients while performing anesthesia. The risk of contamination during this process can be significantly reduced by envisioning the workspace as two zones: a contaminated area comprising the patient, the OR table, the I.V. pole, and the anesthesia machine, and a non-contaminated area comprising the anesthesia cart (Figure). Hand hygiene should be performed, and gloves need to be changed whenever the anesthesiologist crosses from the contaminated zone to the non-contaminated zone.

Figure: Contaminated and non-contaminated zones. The patient and their immediate environment, including the procedure table, anesthesia circuit, and anesthesia machine and proximate anesthesia workspace (inside the orange circle), should be treated as contaminated zones and potential sources of cross-transmission. The anesthesia cart (inside the green circle) contains clean equipment, drugs, and supplies that will be used with many patients. Thus, it should be treated as a non-contaminated zone outside the patient's environment. Copyright University of Utah Health; modified with permission.

Figure: Contaminated and non-contaminated zones. The patient and their immediate environment, including the procedure table, anesthesia circuit, and anesthesia machine and proximate anesthesia workspace (inside the orange circle), should be treated as contaminated zones and potential sources of cross-transmission. The anesthesia cart (inside the green circle) contains clean equipment, drugs, and supplies that will be used with many patients. Thus, it should be treated as a non-contaminated zone outside the patient's environment. Copyright University of Utah Health; modified with permission.

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Put another way, the anesthesia cart should only be accessed with sanitized hands and fresh gloves. Most anesthesiologists use the cart to set up for subsequent cases while a case is ongoing. By keeping the cart in the non-contaminated zone, subsequent cases can be set up without a risk of cross-contamination.

As a practical matter, during emergencies the cart is often accessed without changing gloves. While not ideal from the perspective of maintaining a non-contaminated area, in these circumstances, care of a patient requiring immediate resuscitation assumes priority. It is acceptable to apply hand hygiene directly to gloves (which should be easily available on the cart or anesthesia machine) in those circumstances to reduce contamination (Ann Lab Med 2018;38:83-4). Our recommendation is that after such cases it is important to recognize contaminated drug and equipment packaging and treat them accordingly. Furthermore, use of the anesthesia cart in this “dirty” fashion is permissible only during emergencies, not during periods of routine care.

Proper use of personal protective equipment, including masks, eye protection, and gloves, reduces perioperative cross-contamination (J Occup Environ Med 2021;63:e783-e91). Smoke evacuation devices have been demonstrated to reduce transmission of infectious pathogens, particularly human papilloma virus (J Anesth 2020;34:575-84). Minimizing the release of pneumoperitoneum into the OR atmosphere after laparoscopic surgery has similar preventive efficacy (BJU Int 2020;126:225-34).

Needle precautions, including use of blunt needles, needles with safety mechanisms, and not recapping sharp needles, reduce parenteral transmission of infectious disease from patients to clinicians.

Single-use disposable devices, including non-invasive blood pressure cuffs, laryngoscopes, and textiles, have proliferated in health care because of a misperception of reduced infection risk. This conclusion is not supported by evidence (Health Aff (Millwood) 2020;39:2088-97). Furthermore, life-cycle analysis has shown that disposables are more expensive and cause demonstrable environmental harm, offsetting any theoretical protection from infection (Health Aff (Millwood) 2020;39:2088-97; Anesth Analg 2018;127:576-9; APSF Newsletter 2020;35:1-32).

High-level disinfection of laryngoscope handles recently has been advocated, but low-level disinfection is sufficient except in cases of Creutzfeld-Jacob disease or Ebola infection (Infect Control Hosp Epidemiol 2019;40:1-17; Anesth Analg 2018;127:576-9; APSF Newsletter 2020;35:1-32).

Disposable surgical attire, including scrubs, masks, and head covers, reduces bacterial counts, but there is no evidence that its use decreases surgical site infections (J Bone Joint Surg Am 2014;96:1485-92). No studies suggest that shoe covers reduce infection, but soiled covers have been implicated as a possible source of cross-contamination (asamonitor.pub/3O8UZBW). Recommended practice is to have a dedicated pair of shoes worn only in the OR. If shoe covers are worn, they should be changed between cases.

Reduction in OR traffic does not appear to decrease significantly the frequency of surgical site infections (J Bone Joint Surg Am 2014;96:1485-92). A prospective cross-sectional study failed to demonstrate a statistically significant relationship in approximately 50 consecutive cardiac surgery operations between such traffic and wound infection (asamonitor.pub/3xtBQni).

Barry Swerdlow, MD, FASA, ASA Committee on Occupational Health, and Adjunct Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

Barry Swerdlow, MD, FASA, ASA Committee on Occupational Health, and Adjunct Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

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Harriet W. Hopf, MD, FUHM, FASA, ASA Committee on Occupational Health, Committee on Equipment and Facilities, Ad Hoc Committee on Environmental Health, Professor and Executive Director of Faculty Development and Academic Affairs, Department of Anesthesiology, and Adjunct Professor, Biomedical Engineering, University of Utah, Salt Lake City, Utah.

Harriet W. Hopf, MD, FUHM, FASA, ASA Committee on Occupational Health, Committee on Equipment and Facilities, Ad Hoc Committee on Environmental Health, Professor and Executive Director of Faculty Development and Academic Affairs, Department of Anesthesiology, and Adjunct Professor, Biomedical Engineering, University of Utah, Salt Lake City, Utah.

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