Performance of aseptic technique during neuraxial analgesia for labor before and after the publication of international guidelines on aseptic technique.

BACKGROUND: Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap). METHODS: The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects. RESULTS: 135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups. CONCLUSION: Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.

Perioperative hyperoxygenation and wound site infection following surgery for acute appendicitis: a randomized, prospective, controlled trial.

OBJECTIVE: To assess the influence of hyperoxygenation on surgical site infection by using the most homogeneous study population. DESIGN: A randomized, prospective, controlled trial. SETTING: Department of surgery in a government hospital. PATIENTS: A total of 210 patients who underwent open surgery for acute appendicitis. In the study group, patients received 80% oxygen during anesthesia, followed by high-flow oxygen for 2 hours in the recovery room. The control group received 30% oxygen, as usual. INTERVENTION: Open appendectomy via incision in the right lower quadrant of the abdomen. MAIN OUTCOME MEASURES: Surgical site infection, mainly assessed by the ASEPSIS (additional treatment, serous discharge, erythema, purulent discharge, separation of deep tissues, isolation of bacteria, and stay in hospital prolonged >14 days) system score. RESULTS: Surgical site infections were recorded in 6 of 107 patients (5.6%) in the study group vs 14 of 103 patients (13.6%) in the control group (P = .04). Significant differences in the ASEPSIS score were also found. The mean hospital stay was longer in the control group (2.92 days) compared with the study group (2.51 days) (P = .01). CONCLUSION: The use of supplemental oxygen is advantageous in operations for acute appendicitis by reducing surgical site infection rate and hospital stay. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01002365.

The quality of the surgical field during functional endoscopic sinus surgery--the effect of the mode of ventilation--a randomized, prospective, double-blind study.

OBJECTIVES/HYPOTHESIS: The outcome of functional endoscopic sinus surgery (FESS) depends on a clean surgical field achieved by minimizing intraoperative bleeding. High frequency jet ventilation (HFJV), due to lower airway pressures, offers the benefit of improved venous return, less bleeding, and improved operating conditions. HFJV was compared to intermittent positive pressure ventilation (IPPV) by assessment of surgical conditions and measurement of intraoperative blood loss. STUDY DESIGN: Prospective, randomized, double-blind study. METHODS: A total of 22 patients undergoing FESS were randomly assigned to be ventilated during surgery under general anesthesia by either HFJV or IPPV. The quality of the surgical field was assessed and the total blood loss was measured. RESULTS: The mean airway pressure was significantly lower in the HFJV group than in the IPPV group (2.42 +/- 1.17 and 7.11 +/- 0.72, respectively, P < .0001). The total mean loss of blood in the HFJV group was 170 cc and in the IPPV group was 318.18 cc (P = .017). The quality of the surgical field as estimated by the surgeon was significantly better in the HFJV group. The mean point values on the Boezaart et al. scale for the IPPV and HFJV groups were 2.72 +/- 0.77 and 1.80 +/- 0.686, respectively (P = .012). CONCLUSIONS: HFJV significantly reduced the amount of intraoperative bleeding and thus significantly improved the quality of the surgical field. It is suggested that increased venous return due to lower intrathoracic pressures resulted in less bleeding and improved operating conditions. HFJV can be effectively used for FESS in order to improve endoscopic view with no adverse effects.

Reversal of adverse hemodynamic effects of pneumoperitoneum by pressure equilibration.

HYPOTHESIS: The creation of positive-pressure pneumoperitoneum during laparoscopic operations can lead to adverse hemodynamic changes, mainly decreased cardiac output. We hypothesized that pneumatic compression sleeves worn on the legs during pneumoperitoneum could abolish the pressure gradient between the abdominal cavity and the legs and so eliminate these adverse hemodynamic changes. DESIGN: Prospective, randomized, controlled clinical trial with an additional calibration group. SETTING: A regional referral center. PATIENTS: Forty-five consecutive patients undergoing laparoscopic cholecystectomy who developed hemodynamic changes on induction of positive-pressure pneumoperitoneum were randomized to 3 groups. INTERVENTIONS: Low-pressure, nonsequential pneumatic compression sleeves, wrapped around the legs, were used to equilibrate the pressure gradient in the study group and to gradually exceed it in the calibration group. In the control group, no sleeves were used. MAIN OUTCOME MEASURES: Transesophageal Doppler cardiac output, stroke volume, and systemic vascular resistance were monitored noninvasively. RESULTS: The creation of positive-pressure pneumoperitoneum caused a significant decrease of cardiac output and stroke volume and increased systemic vascular resistance. In the experimental groups of patients, pressurizing the sleeves to the pneumoperitoneal pressure caused a significant increase of cardiac output (from 4.82 to 6.74 L/min), increased stroke volume, and decreased systemic vascular resistance (P<.001). This was not seen in the control group. Additional gradual pressure increase in the sleeves of the calibration group produced no further improvement. Releasing the pressure abolished the hemodynamic advantages. CONCLUSIONS: Applying pressure on the legs equivalent to the positive-pressure pneumoperitoneum improves hemodynamic performance during pneumoperitoneum by nullifying the pressure gradient that is responsible for the adverse consequences. This might be of major practical value, especially for cardiac patients undergoing prolonged laparoscopic operations.