Summary of Content: Safe Injection Practices and Preventing the Contamination of Medication and Fluids

Needles and syringes

Infusions, administration sets or items in contact with the vascular system or other sterile body compartments

Hand hygiene guidelines

Anaesthetic equipment decontamination

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Needles and syringes

• Needles and syringes are sterile items, intended for singlepatient use only.
• A syringe and needle should be considered to be contaminated after contact with a patient, infusion bag or administration set, and must only be used for that patient. These include syringes used in infusion pumps.
• Medication should not be administered to different patients from the same syringe, even if a new sterile needle is used for each patient. Changing the needle, but not the syringe, is unacceptable practice.
• A syringe must not be reused, or a used syringe reinserted into a medication vial or solution bag or container, e.g. a saline, flush or phenylephrine bag, even if it is for use in the same patient.
• A used needle must not be reinserted into a multiple-dose vial or solution bag or container, e.g. a saline, flush or phenylephrine bag, even if it is for use on the same patient.
• The presence of a non-return valve (one-way valve) or the use of a syringe driver or infusion pump does not permit the reuse of syringes or their contents as it does not prevent the risk of blood contamination. The presence of a check valve (one-way valve or non-return valve) in the infusion set does not prevent blood contamination of syringes or needles.
• Before use, prepared syringes should be capped to avoid contamination.
• After use or at the end of the anaesthetic used syringes and needles should be discarded appropriately.
• Syringes must never be stored nor transported in clothing or pockets.

Preservative-free (single-dose) ampoules or vials

• Preservative-free (single-dose) ampoules or vials are singledose, single-patient items.
• Do not give drugs from preservative-free vials or ampoules to several patients or save the remaining contents for later use.
• Use of single-dose vials is preferred whenever possible over the use of multi-dose vials for parenteral medications.
• Single-dose vials must be disposed of after the drug dose has been drawn up, and not reused for other patients.
• Cleanse the vial’s rubber septum before entering, or the neck of glass ampoules before breaking, with an alcohol swab. Allow drying before entering or breaking the vial or ampoule.

Multi-dose vials

• Use of single-dose vials is preferred whenever possible over that of multi-dose vials for parenteral medications.
• If multi-dose vials must be used, then cleanse the vial’s rubber septum with an alcohol swab and allow it to dry before entering the vial. Even vials used for the first time should be cleaned as the cover does not guarantee sterility.
• A new sterile needle and syringe must be used each time the vial is entered.
• Discard a vial if there is suspicion that sterility has been compromised.
• Never leave a needle, cannula or spike device (even if it has a one-way valve) inserted into a medication vial rubber stopper because it leaves the vial vulnerable to contamination.

Infusions, administration sets or items in contact with the vascular system or other sterile body compartments

• These are for single-patient use. They should be discarded after use.
• Bags or bottles containing intravenous (IV) solution should never be used as a common source of supply for more than one patient, e.g. phenylephrine solutions and saline bags for flushing. The time between spiking the vacoliter and administration to the patient should be minimised.
• Never use cannulae or spiking devices, even with a non-return valve, to remove fluid from infusion bottles or bags for several uses or patients.
• Use single-dose, single-use containers for flush solutions.
• Aseptic techniques should be used when preparing infusions and breaks or taps in the lines kept to a minimum.
• Always clean IV injection ports or stopcocks with alcohol and allow to dry before use.
• IV cannula caps are not to be collected for reuse on other patients. These are single-patient, single-use items.
• Both the syringe and the needle or cannula must be sterile when any medication vial or solution is accessed.

Non-injectable items

• Examples include topical drugs, ointments and lubricating gels.
• Ideally, these items should be single-patient, single-use.
• If single-use practice is not possible, utmost care should be taken to avoid self-contamination of these items.
• If contamination is suspected or confirmed, the item should immediately be discarded.

Protecting clean supplies in the anaesthetic cart

• The anaesthetic cart should have its accessible outer surfaces wiped clean in between cases.
• Always perform hand hygiene before the drawers are opened and contents handled.
• The inside of the anaesthetic cart should be cleaned periodically.

Expiration time for drugs and intravenous solutions that are prepared by the anaesthetist

• Provider-prepared drug solutions should ideally be used within one hour of preparation.
• There is paucity on data to determine how long drawnup drugs or solutions can be used. In the absence of clear direction, provider-prepared drugs can be used to the end of the case. Drugs or solutions should be discarded at the end of the case, whether they were used or not.
• Propofol should be discarded after six hours of ampoule opening. For continuous IV infusions in the ICU, both the tubing, the container and any unused propofol must be discarded after 6–12 hours, as per the manufacturer’s recommendations, or when the container is changed.

Hand hygiene guidelines

• Hand washing is one of the most effective infection control practices.
• Gloves do not fully protect against contamination.
• Indications for hand hygiene:
  • Before and after direct patient contact.
  • Before putting on sterile gloves.
  • Contact with body fluids, mucous membranes, open skin and wound dressings.
  • Before making contact with a clean site after touching a contaminated site.
  • After touching a high-touch environmental surface/ equipment near the patient.
  • After removing gloves.
  • Before eating or drinking.
  • After using the bathroom.
• Plain soap (non-antimicrobial): Used for routine handwashing when hands look dirty. It will only remove loosely adherent transient bacteria through mechanical friction. It will not decontaminate the hands.
• Antimicrobial soap: Used if there has been visible hand contamination with blood or body fluids. Chlorhexidine has adequate cover against Gram-positive, Gram-negative organisms and viruses but poor cover against mycobacterium and fungi. Iodine compounds have a slightly decreased action against fungi and good cover against all the other microorganism groups. Both chlorhexidine and iodine compounds have an intermediate onset of action and thus need adequate contact time. Chlorhexidine retains its efficacy in the presence of blood and has a lower incidence of adverse skin reactions.
• Alcohol-based hand rubs can be used provided the hands are not obviously dirty or contaminated with proteinaceous material. If an alcohol hand rub is used, it is important to keep the hands and forearms wet during the whole procedure. Using inadequate volumes of alcohol-based rub (0.2– 0.5 ml) is as efficient as washing with plain soap and water. Approximately 15 ml of alcohol-based rub is required. Roughly one minute should be spent rubbing the forearm. Thereafter, hands and fingers should be rubbed in the same manner as for handwashing. Alcohol has a good cover against Grampositive and Gram-negative organisms and also against mycobacteria and viruses. It also has a fast onset of action and should be allowed to evaporate. It has virtually no activity against spores and protozoal oozytes. Physical handwashing with antimicrobial soap and vigorous washing and rinsing is important for spore-forming organisms, such as Clostridium difficile and Bacillus anthracis.
• Nails: Artificial nails and nail polish should not be used in the operating rooms or ICU. Fingernails should be kept short and clean. Avoid using nail brushes during hand washing as they damage the skin and therefore increase the risk of contamination by microorganisms.
• Non-sterile gloves should be worn whenever contact with blood, body fluid, mucous membranes, non-intact skin and potentially infectious materials is anticipated. They need to be removed as soon as possible and therefore be changed between different procedures on the same patient. They should not be reused. Gloves must be removed before touching equipment if they were in contact with the patient. Curtains, clinical notes, pens, computer keyboards, and cellular and landline telephones must not be touched with contaminated gloves.
• Alcohol-based hand rubs used on gloved hands can be considered in settings with inadequate supply of gloves to meet the above requirements. This practice may potentially degrade the quality of the gloves, making them prone to leakage.
• Bare below the elbow: Different societies have conflicting recommendations with regards to coverage of the arms. This contentious issue has led to multiple guideline changes. Unfortunately, studies have had conflicting results. The proponents of “bare below the elbow” argue that garments have a high risk of being contaminated and by removing them as far away as possible from the hands will decrease the risk of contamination of the hands and increase the efficacy of handwashing. Opponents to “bare below the elbow” argue that the skin sheds millions of squamous cells every day that contain both normal skin flora and pathogenic microorganisms. By covering up the arms to the wrists, the load of squamous cells entering the environment will be decreased. False nails, nail polish, wristwatches and stoned rings should not be worn.

Anaesthetic equipment decontamination

Management of reusable equipment:

• Reprocessing refers to infection control procedures for removing and inactivating microorganisms on reusable patient-care equipment.
• Reprocessing of reusable patient-care equipment includes cleaning, disinfection, and sterilisation.
• The choice of reprocessing method must consider the instument manufacturer’s recommendations.
• Factors that need to be considered are compatibility among equipment components and materials, chemicals to be used, heat and pressure tolerance of the equipment, and time and temperature requirements of the reprocessing methods.

Spaulding classification

Spaulding developed a classification of instruments into “critical”, “semi-critical” and “non-critical”. This classification is more than 50 years old and is used to determine the level of disinfection for equipment items.

Critical instruments

• Critical instruments have a high risk of contamination.
• These include those instruments that are in contact with sterile sites within the body or the intravascular system.
• Critical instruments should be subjected to sterilisation such as pressurised steam or low temperature methods such as ethylene oxide gas.

Table II: Definitions and classifications used in infection control practices*

Decontamination	A process of removing pathogenic microorganisms from an object or surface so that it is no longer capable of transmitting infectious particles. It is a combination of the processes of cleaning, disinfection, and/or sterilisation.
Cleaning	Cleaning is the removal of foreign material (e.g., soil, organic or inorganic material) from objects and is normally accomplished using water with detergents or enzymatic products (depending on the type of instrument/device/surface that needs to be “cleaned”; surface will be a chemical and instrument will be an enzymatic detergent). Thorough cleaning is required before high-level disinfection and sterilisation because inorganic and organic materials that remain on the surfaces of instruments/devices interfere with the effectiveness of these processes. Cleaning is considered the most important step in the reprocessing process of an instrument/device or equipment
Disinfection	The disinfection process reduces the number of pathogenic microorganisms on the instruments significantly by removing and/or killing them. Bacterial spores are not necessarily killed by disinfection; however, the number may be reduced as a result of the cleaning process. Disinfection may involve chemical or thermal means. Chemical disinfection Chemical disinfection is used for equipment that cannot be disinfected in the washer-disinfector and it is used for skin and surfaces. Microorganisms present a range of resistance to chemical disinfectants and no single disinfectant is effective in all situations. Examples of chemical disinfectants are chlorine compounds, alcohol, iodine vapour, and chlorhexidine. Thermal disinfection Thermal disinfection of instruments/equipment is achieved with moist heat, either with water or steam. To determine which temperature to disinfect in and for how long, the standard ISO 15883 for washer-disinfectors has specified a so-called A0-value. A0 value explains the relationship between time and temperature, in short, high temperature = less time, and low temperature = more time. High-level disinfection (HLD) Destroys all microorganisms (mycobacteria, vegetative bacteria, viruses and fungal spores), except large numbers of bacterial spores in a relatively short exposure time. Examples of disinfectants: Glutaraldehyde, ortho-phthalaldehyde, hydrogen peroxide and peracetic acid. Used for semi-critical instrument decontamination. Intermediate-level disinfection (ILD) Destroys mycobacteria, vegetative bacteria, most viruses, and most fungi, but does not kill bacterial spores. Examples of disinfectants: 70% isopropyl alcohol, iodophor and phenolic compounds, concentrated quaternary ammonium compounds, e.g. hospital cleaners and disinfectants with a tuberculocidal claim. Used for non-critical instruments and environmental surfaces when a tuberculocidal agent is necessary. Low-level disinfection (LLD) Destroys lipid or medium-sized viruses, some fungal spores and vegetative bacteria. Examples of disinfectants: Diluted quaternary ammonium compounds, e.g. hospital cleaners and disinfectants without a tuberculocidal claim. Used for non-critical items and surfaces when a tuberculocidal agent is not needed.
Sterilisation	A process whereby all types of microorganisms, e.g. mycobacteria, vegetative bacteria, viruses and fungal spores, including bacterial endospores, are eliminated. To be effective, sterilisation must be preceded by cleaning, the removal of all foreign material from the item, and disinfection, the reduction of pathogen microorganisms to a level that is not harmful to health. Examples of methods include pressurised steam (autoclaves) or low-temperature sterilisation methods, e.g. ethylene oxide gas and hydrogen peroxide plasma, as well as hot air ovens. It is used for critical instrument decontamination.

*Reproduced with permission² 

• Examples include surgical instruments, implants and sterile catheters.
• With the advent of multidrug-resistant and aldehyde-resistant organisms there was a call to also include other semi-critical instruments into the category of critical instruments. One such an item is endoscopes. The design is flawed with lots of crevices that may retain microorganisms. A study by Ofstead showed that almost 50% of endoscopes retained moisture that can aid in the development of a biofilm. In addition, 71% of endoscopes showed microbial growth and cultured organisms such as Stenotrophomonas maltophilia and Citrobacter freundii.
• Other items that are relevant to the anaesthetist include airway instruments such as laryngoscope blades and handles as well as forceps. Airway instrumentation is often associated with trauma to the mucosa. Several studies have demonstrated occult blood on these items. These instruments thus meet the criteria for critical instruments. These items require cleaning and disinfection followed by sterilisation as required and as per manufacturer’s recommendations.

Semi-critical instruments

• Semi-critical instruments have an intermediate risk of contamination.
• These instruments only come into contact with intact mucosa and intact skin.
• Examples given under this category include endoscopes, respiratory equipment and cystoscopes. It is, however, interesting to note that most of these items are now being considered “critical instruments”

 Non-critical instruments

• Non-critical equipment has a low risk of contamination.
• These instruments only come into contact with intact skin.
• Divided into patient non-critical items such as blood pressure cuffs and oximetry probes and environmental non-critical items such as cot sides, theatre trolleys and uncontaminated floors.
• Cleaning and drying are usually adequate.

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South African Society of Anaesthesiologists (SASA) Guidelines for Infection Control and Prevention in Anaesthesia in South Africa 2021