Test 4: Infection Control

Question 1

What are the three elements necessary for human disease transmission?

Answer 1

1) A reservoir of infectious agent
2) Types of infectious disease microorganisms:
-Viruses, bacteria, fungi (most common)
-Parasitic organisms and prions
3) A susceptible human host

Question 2

What are the links in the chain of infection that are most susceptible to interventions?

Answer 2

-Controlling or eliminating the pathogen at its source
-protecting portals of entry
-supporting the host’s defenses

Question 3

What are Standard Precautions?

Answer 3

Basic level of infection control protocols that reduce the risk of disease transmission when providing patient care.
-Hand hygiene
-Personal protective equipment (PPE)
-Respiratory hygiene
-Safe injection practices
-Equipment and environmental cleaning, disinfection, and sterilization

Question 4

What are ways that healthcare workers can strengthen the links of the chain of infection?

Answer 4

-practicing frequent hand hygiene
-being up to date on vaccinations
-staying at home while sick
-following recommendations for standard and contact isolation
-utilizing appropriate personal protective equipment (PPE)
-cleaning and disinfecting the environment
-sterilizing medical equipment
-following safe injection practices

Question 5

What is Hand Hygiene?

Answer 5

The practice of removing microorganisms from hands.
-Significantly reduces the incidence of infection
-Gloves removed after contamination
-Alcohol-based sanitizer available in anesthetizing area
-Targeted cleaning anesthetizing area during/after each case

Question 6

What is PPE?

Answer 6

Specialized clothing or equipment worn for protection against contamination.
-Protects the patient and the healthcare provider
-N95 respirators should be fit-tested (Covid-19)
-Always perform hand hygiene prior to and after removing PPE (except for respirators)
-Guidelines on how to properly wear/remove/dispose of PPE

Question 7

What are the three categories of transmission-based precautions?

Answer 7

-Contact (direct or indirect)
-Droplet
-Airborne

Question 8

What is the purpose of Contact Precautions?

Answer 8

Prevents transmission of infectious agents spread by contact with the patient or environment.

Question 9

What is the purpose of Droplet Precautions?

Answer 9

Prevents transmission of infectious agents spread by close contact with respiratory secretions. (3 ft)
-Small liquid particles (>5 microns in size) of infected saliva or mucus expelled from an infected person’s mouth and/or nose during coughing or sneezing, which eventually are inhaled into the airway of an uninfected host, usually requiring close contact.

Question 10

What is the purpose of Airborne Precautions?

Answer 10

Prevents transmission of infectious agents suspended in the air. (N95 masks/respirator)
-Very fine (<5 microns in size) airborne particles
-distance of spread depends on the material exhaled by the infected person, air currents, and environmental conditions.

Question 11

What is Direct Contact transmission?

Answer 11

Transmission of an infectious microbe from an infected person to another person by direct contact with the body, or broken or damaged skin, or mucous membrane of the susceptible host, without any intermediary object.

Question 12

What are the defenses against direct contact transmission?

Answer 12

-Intact, nondamaged skin
-Mucosal surfaces (include immune system cells)
-Efficacy of these barriers is r/t the host’s immune system function

Question 13

What is Indirect Contact transmission?

Answer 13

An intermediary object serving as a connecting bridge between an infected human reservoir and susceptible host.
-Most commonly due to the contaminated hands of HCWs !!!!
-Occurs due to poor hand hygiene and not decontaminated equipment

Question 14

What is the most common bridge of indirect contact transmission?

Answer 14

The Contaminated hands of healthcare workers!!!

Question 15

What is respiratory hygiene?

Answer 15

Cough etiquette and the appropriate use of isolation precautions to prevent the spread of infection.
-Cover mouth and nose with a tissue when coughing or sneezing
-Dispose of tissue after use in the waste bin
-Perform hand hygiene following contact with respiratory secretions (with patients)
-Do not perform patient care when infected or ill.
-During times of elevated resp infection incidence, facemasks to patients and providers who are coughing.

Question 16

List some of the Safe Injection Practices.

Answer 16

-Avoid recapping of needles and discard used needles/syringes into a puncture resistant sharps container.
-Use syringes, needles, and needleless access devices only once, even for the same patient.
-Use infusion, pump syringe, and intravenous administration sets only once.
-Do not use bags or bottles of intravenous solution as a common source of diluent for multiple patients.
-Clean and process intravenous infusion and syringe pumps according to manufacturer recommendations between patients.
-Use 70 percent alcohol to clean the diaphragm prior to access when removing the cap from a new vial.
-Use single-dose vials for medications when possible.
-Dedicate multi-dose vials to a single patient when possible. Use a syringe or needle only once to withdraw medication from a multi-dose vial. Label the date on the multi-dose vial once opened and use/discard within 28 days of opening.

Question 17

When should equipment be cleaned?

Answer 17

-The anesthesia work area and patient-specific equipment are cleaned between cases and terminally at the end of the day
-Need infection control policy and a method for monitoring compliance
-Minimize personal equipment brought into the OR and patient care areas

Question 18

How can you prevent the transferring of microbes from the anesthesia machine to the patient?

Answer 18

-Clean anesthesia machine surfaces/knobs with an appropriate germicide between cases and at the end of each day
-Take protective measures to prevent materials stored on the anesthesia machine from becoming inadvertently contaminated by airborne debris (e.g., blood)
-Remove equipment from drawers, clean and disinfect drawers regularly
-Place a clean covering on the top of the anesthesia cart at the beginning of each case

Question 19

In what two ways can contamination occur with the Anesthesia Delivery System (ADS)?

Answer 19

1) Pathogens can enter via the circuit and gas analysis sampling line
2) Pathogens can enter via the gas monitor

Question 20

How do you reduce the risk of contamination of the anesthesia machine and the gas sample line and protect the patient from ADS contamination?

Answer 20

-Single patient use of heat and moisture exchange filters (HMEFs) on the distal end of the anesthesia circuit
-Add another filter (ex: one with a viral filtration efficiency of 99.99%) on the expiratory limb to provide backup for any particles that may pass through the airway filter.

Question 21

What should you do if you suspect that the anesthesia machine is contaminated?

Answer 21

-Remove machine from use
-Consult manufacturer for cleaning and/or sterilization

Question 22

Is it ok to perform safety checks of equipment?

Answer 22

Performing safety checks is acceptable with proper hand hygiene and laryngoscope blade placed back in clean sleeve.

Question 23

What can you do as the anesthesia provider to reduce risk of infection?

Answer 23

-Put safety tested equipment back into clean sleeve
-Clean stethoscopes between use
-Clean reusable equipment per manufacturer’s guidelines
-Use disposable equipment when possible

Question 24

What takes priority over all issues?

Answer 24

Maintenance of oxygenation!!!

Question 25

How do you avoid the transmission of infection with airway manipulation/intubation?

Answer 25

Double glove for intubation, remove outer gloves after being in the mouth/airway, and then perform necessary actions for airway security and patency. -Ventilate manually, auscultate breath sounds, and monitor EtCO2. -Then, when the situation is stable, remove inner gloves, perform hand hygiene, and don clean gloves. -When it is challenging to change exam gloves or perform hand hygiene, using an Alcohol-Based Hand Rub/sanitizer directly on nonsterile nitrile gloves is an option -Targeted environmental cleaning of the anesthetizing area after each case

Question 26

What is the motto for safe injection practices?

Answer 26

1 needle, 1 syringe, only 1 time → prevents the spread of dz & protect providers from disciplinary action/legal recourse

Question 27

What are the 4 Categories of Aseptic Technique?

Answer 27

1) Equipment 2) Preparation 3) Environmental Controls 4) Contact

Question 28

What are the guidelines for Equipment precautions of Aseptic Technique?

Answer 28

May include some or all of the following items depending on the procedure: -Sterile gloves, gown, mask -Sterile drapes

Question 29

What are the guidelines for Preparation precautions of Aseptic Technique?

Answer 29

-Antiseptic skin preparation of patient prior to procedure -Consult manufacturer product instructions for directions and warnings regarding the proper use and application of specific skin antiseptics such as chlorhexidine-alcohol or povidone-iodine. -Confirm that all instruments, equipment, and devices are sterile.

Question 30

What are the guidelines for Environmental Control precautions of Aseptic Technique?

Answer 30

-Close doors during operative procedures. -Minimize unnecessary staff traffic in/out of operating room.

Question 31

What are the guidelines for Contact precautions of Aseptic Technique?

Answer 31

-Precautions should be taken to mitigate contact with nonsterile surfaces and objects.

Question 32

What makes an Ideal Skin Prep?

Answer 32

-Decreases microorganism count and inhibits rebound and regrowth of microorganisms -Activates quickly -Effective against a variety of microorganisms.

Question 33

What is the preferred skin prep?

Answer 33

Chlorhexidine gluconate. -Preferred skin prep agent due to immediate action, residual activity, and persistent effectiveness against a wide range of microorganisms

Question 34

Which skin prep is a suitable alternative when Chlorhexidine is contraindicated?

Answer 34

Povidone-iodine

Question 35

What is important regarding the use of Iodine-base with alcohol skin prep?

Answer 35

Highly effective against a broad range of microorganisms, acts immediately, but highly flammable!!! Fire Risk: Agents that are alcohol-based or have flammable properties have the potential to increase the risk of surgical fires.

Question 36

What is important to know regarding aseptic technique and invasive procedures?

Answer 36

-Patients and HCWs are at increased risk of exposure/infection during invasive procedures -Perform HH before assembling equipment, and before/after procedure -Follow facility policy -Take proper measures to prevent adverse events (SSIs, CLABSIs, CAUTIs)

Question 37

T/F: US guided procedures are associated with increased infection rates.

Answer 37

False; Ultrasound guidance for procedures such as vascular access and catheter placement has been shown to reduce infection rates and improve patient satisfaction.

Question 38

What mitigates risk of contamination with US guided procedures?

Answer 38

Hand hygiene -PPE -skin preparation and drape -sterile sheath -sterile probe covers -sterile ultrasound gel -Disinfect ultrasound probes between each procedure and patient per manufacturer's guidelines

Question 39

How can you prevent contamination during Epidural or Continuous PNB Catheter placement?

Answer 39

-Strict aseptic technique and single-use sterile gel -Maximal sterile barriers during procedure -Prepare patient skin with an appropriate agent -Dress the insertion site with a sterile transparent, occlusive dressing -Use chlorhexidine-impregnated dressings at insertion sites to reduce epidural skin entry-point colonization -Check the insertion site and overall patient status at least daily for early identification of infection (erythema, tenderness, itching; fever, weakness, HA) and sensory/motor status -Remove once no longer clinically indicated

Question 40

How can you prevent contamination during Central Venous Catheter placement?

Answer 40

-Consider the risks and benefits of placing a central line (site placement matters: femoral vs subclavian, peripheral, or jugular) -Perform hand hygiene, sterile gloves and gown, surgical cap and mask, and cover the patient with a large sterile drape prior to insertion -Prepare patient skin using appropriate agent -Use antibiotic-impregnated catheter if the catheter is to remain in place > 5 days -Replace catheter when adherence to aseptic technique cannot be ensured, otherwise do not routinely replace CVCs, and remove once no longer indicated

Question 41

What is important to know regarding accessing and maintenance of a CVC?

Answer 41

-Closed access systems preferred -Scrub the injection cap with appropriate antiseptic agent -Type, concentration/volume, and frequency of flush per manufacturer's guidelines/policy -Specimen collection maintains aseptic technique -Change injection port caps when signs of contamination/damage -Scrub cap and catheter hub with agent -CVCs in OR are dressed the same throughout facility

Question 42

What is important to know regarding minimizing infection risk with Arterial Lines?

Answer 42

-catheters that need to be in place for > five days should not be routinely changed if no evidence of infection is observed -Maintain sterility of stopcocks: cap when not in use: apply 70 percent alcohol prior to access -Maintain sterility of pressure monitoring devices -Minimize the number of manipulations and entries into the pressure monitoring device -When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, scrub the diaphragm with an appropriate antiseptic agent before accessing the system.

Question 43

What are the personal preventative measures associated with arterial catheters?

Answer 43

-Use of radial, brachial, or dorsalis pedis less infectious risk than femoral or axillary -Hand hygiene, surgical cap/ mask, sterile gloves, small sterile fenestrated drape -Use of closed flush systems and keep stopcocks free of blood/covered with sterile cap

Question 44

What are the personal preventative measures associated with CVCs?

Answer 44

-Maximum barriers, hand hygiene; chlorhexidine prep and Abx impregnated catheter -Topical Abx disc -Use R IJ or subclavian preferred site if possible

Question 45

What are the personal preventative measures associated with Regional Anesthesia?

Answer 45

-Meticulous aseptic technique: Jewelry removal, cap/mask, hand hygiene, sterile glove and drape -Skin preparation: 0.5% chlorhexidine with alcohol best choice followed by povidone-iodine with alcohol. Must allow time to dry -Barriers: Facemasks for all neuraxial procedures, Hand hygiene prior to sterile gloving, Gowns inconclusive (indwelling catheters) -Epidural Catheters: should be indwelling for the shortest amount of time.

Question 46

What is the definition of Surgical Site Infection?

Answer 46

A SSI is acquired by a patient in a health care facility following surgery, which was not present or incubating at the time of admission. The infection occurs at or near the surgical site within 30 days of the procedure or within 90 days of a prosthetic implantation.

Question 47

What is Creutzfeldt-Jakob Disease?

Answer 47

A fatal neurodegenerative disease due to accumulation of pathologic proteins (prions). -Also called transmissible spongiform encephalopathy -Prions are resistant to sterilization

Question 48

What are equipment concerns when caring for a patient with CJD?

Answer 48

-Use disposable equipment when possible for patients with CJD; incinerate equipment after use -Destroy laryngoscopes and supraglottic devices used on patients with CJD -Safely discard devices that are difficult or impossible to clean -Clean and perform steam sterilization of instruments for 30 to 60 minutes at 132° C -Perform steam sterilization for 18 minutes at 134° C-138° C when using a prevacuum sterilizer -Immerse instruments in 1N sodium hydroxide solution for one hour at room temperature followed by steam sterilization for 30 minutes at 121° C as an alternative to the prevacuum sterilizer -Disinfect noncritical items and environmental surfaces with bleach or 1N sodium hydroxide for 15 minutes at room temperature -Consult the CDC recommendations for best infection control practices when working with patients with CJD.

Question 49

What is iatrogenic transmission?

Answer 49

The spread of a pathogen, (bacteria or virus) through a medical procedure or treatment such as a blood transfusion, reuse of needles or IV sets, or by touching a wound on an infected patient and then touching another patient.

Question 50

What is Tuberculosis?

Answer 50

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. -Usually attack lungs, but can attack kidney, spine, brain, etc. -Latent vs active disease

Question 51

What are the S/Sx of TB?

Answer 51

-Cough that lasts 3 weeks or longer -Pain in the chest -Coughing up blood or sputum (phlegm from deep inside the lungs) -Fatigue, weight loss, lack of appetite, fever, night sweats

Question 52

How do you prevent the spread of TB?

Answer 52

-Place a high-efficiency particulate air (HEPA) filter between the breathing system and the patient!!!! -Sterilize or perform high-level disinfection on equipment used on patients with cases of suspected or confirmed Tuberculosis -Culturing anesthesia equipment is not required.

Question 53

What is a hypersensitivity reaction?

Answer 53

An immune system response to a foreign, environmental antigen that causes an altered T cell and antibody response upon reexposure to the antigen. -Requires prior sensitization -Immediate or delayed onset of symptoms -Common antigens: environmental (grass, pollen, animal dander), topical (latex), food (gluten), and medications. -I-V classification system

Question 54

What is a Type 1 Hypersensitivity Reaction?

Answer 54

-Immediate hypersensitivity (IgE mediated) -15-30 minutes of exposure to antigen -S/Sx: Mild cutaneous, GI, bronchospasm, CP collapse -Tx: Antihistamines, bronchodilators, Cromolyn sodium to inhibit mast cell degranulation, leukotriene receptor blockers, COX inhibitors -60-70% of anesthesia related reactions -Usually NMBAs: 50-70% of rxns

Question 55

Order the NMBAs from highest to lowest in terms of causing a Type 1 Hypersensitivity Reaction?

Answer 55

Succinylcholine Vecuronium/Rocuronium Atracurium Pancuronium Mivacurium Cisatracurium

Question 56

Describe Type 2 (Cytotoxic) Hypersensitivity

Answer 56

-IgG/IgM/Complement mediated -Rxn to cell surface or tissue antigen -Antigen-Antibody complex activates complement and destroys target cell -Transfusion rxns, Myasthenia gravis

Question 57

Describe Type 3 (Immune Complex) Hypersensitivity?

Answer 57

-IgG/IgM/Compliment/Neutrophils -Antigen-Antibody complexes are deposited in tissue, stimulating inflammation -SLE and RA

Question 58

What is the treatment plan for intraoperative anaphylaxis? (Know this)

Answer 58

-D/c triggering agent -Tburg to offset vasodilation -FiO2 100% -Epinephrine -Fluids (NS/LR) Secondary tx: -Vaso or NE if unresponsive to Epi -Albuterol or Ipratropium if Bronchospasm -Glucagon if they are Beta Blockaded -ALWAYS give antihistamines and corticosteroids Post resuscitation: -Serum Tryptase < 120 minutes -24-hour monitoring for recurrence -Patient/family notification of reaction -Referral to allergist

Question 59

What surgery and anesthesia factors contribute to a state of immunosuppression?

Answer 59

-Surgery -Blood transfusion -Hyperglycemia -Hypothermia -General anesthesia -Opioids Can result in a reduced resistance to infection, development of postoperative septic complications, and tumor metastasis.

Question 60

What can happen with surgical excision of tumors?

Answer 60

May stimulate proliferation and metastasis of tumor cells -Disrupts blood vessels supplying tumor, allowing tumor cells to enter systemic circulation -Angiogenesis is increased postop to promote tissue repair, but also contributes to tumor growth and metastasis. -Catecholamines promote angiogenesis

Question 61

What is the effect of Blood Transfusion on the immune system?

Answer 61

-Associated with depression of the immune system, increased incidence SSI, and earlier recurrence of CA -Irradiated or leukocyte-depleted blood products recommended for CA patients -Use of intraoperative cell savers may contribute to CA recurrence

Question 62

What is the effect of DM/Hyperglycemia on the immune system?

Answer 62

-Inc susceptibility to infection r/t depression of both innate and adaptive immune systems -Inc SSIs, Poor patient outcomes -BG level of 100-150 mg/dL can attenuate immune system effects

Question 63

What is the effect of Hypothermia on the immune system?

Answer 63

-Hypothermia occurs in 70% of patients -Increased SSIs, increased blood loss, impaired wound healing, decreased immune function -Inc need for blood transfusions (bad)

Question 64

What is the effect of Anesthesia on the immune system?

Answer 64

-Depressed function of NK cells, neutrophils, macrophages, DCs, and T cells -Uncontrolled postop pain contributes to immune suppression and amplifies tumor promoting effects of surgery. Need multimodal approach.

Question 65

What is the effect of opioids on the immune system/cancer?

Answer 65

-Suppress NK Cells (which are vital for eradication of tumor cells/viruses) -Promotes angiogenesis -Suppresses Apoptosis Promote cancer progression and reduce long-term survival. Promote cancer cell growth, inhibit cellular immunity, enhance angiogenesis and tumor cell signalling pathways; inhibit natural killer cell functionality.

Question 66

What is the effect of Regional Anesthesia on immune response?

Answer 66

Regional anesthesia attenuates surgical stress response and preserves normal immune function!!! -Associated with decreased cortisol levels and normal NK cell function -Decreases opioid and volatile inhalation agent usage -Amide LAs have cytotoxic effects on CA cells -Lower incidence SSIs

Question 67

What is the effect of Volatile Anesthetics on the Immune system?

Answer 67

Conflicting evidence; some in vitro studies suggest enhanced expression of tumorigenic markers, migration of cancer cells, angiogenesis and metastasis in tumors. Insufficient evidence exists to avoid in cancer surgery

Question 68

What is the effect of N2O on the Immune system?

Answer 68

No impact on cancer recurrence

Question 69

What is the effect of Local Anesthetics on the Immune system?

Answer 69

Reduced cancer recurrence and metastasis secondary to anti-inflammatory actions and direct effects on the proliferation and migration of cancer cells

Question 70

What is the effect of Neuraxial Anesthesia on the Immune system?

Answer 70

Conflicting results but generally thought to reduce cancer recurrence and metastasis by attenuating the immunosuppressive consequences of the stress response and possibly an opiate sparing effect.

Question 71

What is the effect of NSAIDs on the Immune system?

Answer 71

Acute or chronic use associated with tumor regression presumably via cyclo-oxygenase-2 (COX 2) and prostaglandin inhibition in cancer cells. Beneficial choice as analgesics in cancer patients

Question 72

What is the effect of ASA on the Immune system?

Answer 72

Reduces cancer metastasis

Question 73

What is the effect of Supplemental O2 on the Immune system?

Answer 73

Patients given 80% oxygen postoperatively have a shorter cancer free survival period. Has an angiogenic effect on micrometastasis

Question 74

What is the effect of Dexamethasone on the Immune system?

Answer 74

No effect on cancer survival

Question 75

Describe anesthetic management of the Immunocompromised patient.

Answer 75

-Strict aseptic technique and maximum barrier precautions -Scrub the Hub!!! (Needleless connectors responsible for 50% of infections) -Neuraxial can blunt SNS response that suppresses immune system -Prophylactic ABX administered 30 min before incision -Active warming measures to avoid hypothermia -Perioperative management of blood glucose to avoid hyperglycemia -Leukocyte poor and irradiated blood products should be used when transfusion unavoidable -Postoperative pain control: multimodal approach including a combination regional anesthesia and nonopioid agents (control SNS Stimulation)