masks for neuraxial anesthesia?

[midazme]

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hi everyone:

i'm wondering what your thoughts are on infection control procedures for neuraxial anesthesia. a quick review of the literature is pretty ambivalent about it.

what are your hospital's practices on OB neuraxial analgesia? on the OB floor at my hospital, the anesthesiology attending and resident wear hat and masks. the resident washes hands and wears sterile gloves. we also have the patient wear a hat, and the pt's partner needs to wear a hat and mask if they're in the room.

there's discussion of moving from handwashing, sterile gloves, hat and mask to full gowns. i don't know if this is going to happen, though, as some of the nurses on the OB floor are already up in arms over the patient's partner having to wear a hat and mask.

 

[Precedex]

There was a practice advisory published this year in Anesthesiology. I include some quotes below.


"Use of aseptic techniques: The literature is insufficient regarding
the efficacy of aseptic techniques during neuraxial
procedures (e.g., removal of jewelry, hand washing, and
"wearing of caps, masks, and sterile gloves) in reducing
infectious complications (Category D evidence). Studies
with observational findings indicate that infections occur
even when aseptic techniques are used (Category B2 evidence),
38–40 and case reports indicate similar outcomes
(Category B3 evidence).12,19,25–27,30,41– 64"

"Both consultants and ASA members strongly agree that
aseptic techniques should always be used during the placement
of neuraxial needles and catheters, including hand
washing, wearing of sterile gloves, wearing of caps, wearing of
masks covering both the mouth and nose, use of individual
packets of skin preparation, and sterile draping of the patient.
In addition, both consultants and ASA members agree that
aseptic techniques should include removal of jewelry, and
they are equivocal regarding the wearing of gowns. Finally,
consultants agree and ASA members are uncertain regarding
whether aseptic techniques should include changing masks
before each new case."

 

[sevoflurane]

Masks for every neuraxial. Some places mask and gown for epidurals. Where I trained, we masked and gowned for PNB's (catheters) and Epidurals.

 

[midazme]

Masks for every neuraxial. Some places mask and gown for epidurals. Where I trained, we masked and gowned for PNB's (catheters) and Epidurals.

i agree. we mask and gown for PNBs here, but only mask/hat/gloves for neuraxial.

what about masks/hats for other people in the room? how about for the patient? we have the patient wear hats to keep the hair from falling into the field, and my argument for having the support person wear a mask is that they're facing the patient (and therefore, me) and talking, which risks contaminating my field. the reason i bring this up is because a nurse today told me: "having the partner wear a mask just makes it seem like more medicalization of labor", to which i replied "the medicalization of epidural abscesses is a lot worse than the medicalization of labor". needless to say, i didn't make any friends with that one.

if anyone could find any evidence behind my logic, i'd love to see it. i've looked but can't find any actual published evidence.

 

[BLADEMDA]

hi everyone:

i'm wondering what your thoughts are on infection control procedures for neuraxial anesthesia. a quick review of the literature is pretty ambivalent about it.

what are your hospital's practices on OB neuraxial analgesia? on the OB floor at my hospital, the anesthesiology attending and resident wear hat and masks. the resident washes hands and wears sterile gloves. we also have the patient wear a hat, and the pt's partner needs to wear a hat and mask if they're in the room.

there's discussion of moving from handwashing, sterile gloves, hat and mask to full gowns. i don't know if this is going to happen, though, as some of the nurses on the OB floor are already up in arms over the patient's partner having to wear a hat and mask.

Wearing a mask is the standard of care. There have been cases of serious infections from Neuraxial anesthesia. Always wash your hands, sterile gloves and wear a mask. I don't fully gown for blocks or epidurals/spinals.

If the Ob Nurse is in the room opposite the patient do you make her wear a mask?

 

[BLADEMDA]

Besides the obvious mask, gloves, hand wash, etc. don't forget the prep and prep solution may make a huge difference in preventing an infection:


http://www.ncbi.nlm.nih.gov/pubmed/20054046

New England Journal of Medicine


CONCLUSIONS: Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.) 2010 Massachusetts Medical Society

 

[BLADEMDA]

http://cucrash.com/Handouts09/Hawkins%20What's%20New%20from%202008.pdf

A nice review of OB.

​

Technique is something we often take for granted when performing neuraxial techniques. An interesting study of videos taken of CA-2 anesthesia residents over 6 months found a strong correlation between increasing experience and manual skills.22 However, there was almost no correlation between the aseptic technique checklist score and number of epidurals performed. Most of the time residents did not recognize breaches in sterile technique and therefore did not correct them. Clearly this is an area we could teach more effectively.
• A troubling conflict in recommended technique for neuraxial anesthesia is the use of chlorhexidine prep. The ASRA guidelines state it is the antiseptic of choice for regional techniques23, but the package of the Chloraprep applicator states that the solution should not be used when working in proximity to meningeal structures. An article in the Anesthesia Patient Safety Foundation (APSF) newsletter notes that the FDA has no prospective evaluation of chlorhexidine in the setting of epidural and spinal anesthesia that would support a change their labeling.24 The expense for the manufacturer to seek a label change is prohibitive. No resolution of that problem is in sight.

 

[Licoricestick]

Labour ward: Gown, gloves, mask, +/- hat (usually only if we didn't take it off after leaving theatre). No hat/mask for anyone else in the room.

For spinals in theatre we normally gown, but if we have to call the boss for a hand they'll often just put on gloves. For CSE/epidural - they'll gown

PNBs - really variable