Infection Prevention and Control Guidelines for Anesthesia Care
Infection Prevention and Control Guidelines for Anesthesia Care
Introduction
According to the Centers for Disease Control and Prevention (CDC), on any given day, one in 31 hospital patients has at least one healthcare-associated infection (HAI), underscoring the urgent need for improvements in patient care practices across U.S. healthcare facilities.1 Despite recent progress, such as a 15% decline in central line-associated bloodstream infections (CLABSIs) between 2022 and 2023, HAIs remain a significant threat to patient safety, causing prolonged hospital stays, increased medical costs, and higher mortality rates.1-3
A major contributor to HAIs is inconsistent compliance with basic infection prevention techniques, including hand hygiene, aseptic procedures, and equipment sterilization.2,3 Unsafe practices such as improper reuse of needles or single-use devices further exacerbate the problem, alongside the growing challenge of multiple-drug resistant organisms (MDROs).2 These lapses have led to increased rates of surgical site infections (SSIs), catheterassociated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and other HAIs.1
Successful prevention of the transmission of infectious agents involves adherence to evidencebased practices by the anesthesia professional and the entire healthcare team. This is accomplished when facility leadership, clinicians, and other facility personnel collaborate to foster the culture of robust infection risk identification to continuously improve systems of prevention of harm.4-6 Adherence to infection control practices during routine anesthesia care is a priority that may become challenging when providing emergent, life sustaining care. During emergencies, the anesthesia provider focuses on the patient’s hemodynamic and ventilatory status to prevent immediate patient harm and collaborates with the healthcare team to address any related infection risk.4-7
While much progress has been made, more needs to be done. The American Association of Nurse Anesthesiology (AANA) Standards for Nurse Anesthesia Practice include infection control and prevention and AANA supports patient safety through the promotion of evidence-based infection prevention guidelines that minimize the risk of infection to patients, the CRNA, and other healthcare providers across all healthcare settings.4 Adherence to these universal practices is vital for reducing HAIs and their associated health and economic burdens.
Purpose
The purpose of these guidelines is to describe infection prevention and control best practices to increase awareness and reduce the risk of patients, Certified Registered Nurse Anesthetists (CRNAs), also referred to as nurse anesthesiologists and nurse anesthetists, and other healthcare providers transmitting and acquiring an HAI. These guidelines do not supersede federal, state or local statutes or regulations or facility policy but constitute minimum practice recommendations and considerations.
Audience
This resource is intended for Certified Registered Nurse Anesthetists (CRNAs), also known as nurse anesthesiologists or nurse anesthetists, resident registered nurse anesthetists, other anesthesia providers, members of the interdisciplinary team, administrators involved in policy developed and implementation, quality assurance professionals, and other interested stakeholders.
Guideline Chapters
1. Standard Precautions
• Hand Hygiene
• Personal Protective Equipment
• Transmission-Based Precautions
• Respiratory Hygiene
• Skin Preparation
• Aseptic Technique
• Airway Management: Considerations Specific to Anesthesia Professionals
2. Safe Medication Preparation and Injection Practices
• USP Chapter <797> Sterile Compounding
• Needle and Syringe Use
• Gels, Lubricants, and Ointments
3. Equipment and Environmental Cleaning, Disinfection, and Sterilization
• The Spaulding Disinfection and Sterilization Classification Scheme
• Single-Use Devices and Reprocessed Disposable Equipment
• The Anesthesia Machine and Breathing System
• Equipment Considerations for Special Patient Populations
• Environmental Surfaces
• Biohazardous Waste Management
4. Invasive Procedure Technique
• Considerations for Ultrasound-Guided Procedures
• Considerations for Epidural Catheters and Continuous Peripheral Nerve Block Catheters
• Considerations for Central Venous Catheter Maintenance and Procedures
• Considerations for Implanted Ports
• Considerations for Arterial Catheters and Pressure Monitoring Devices
5. Vaccinations, Post Exposure Prophylaxis, and Screening
• Seasonal Influenza (Flu) Vaccination
• Hepatitis B Vaccination
• SARS-CoV-2 Vaccination
• Post-Exposure Prophylaxis
6. Role of the CRNA in Reducing Ventilator-Associated Pneumonia and Surgical Site Infection
• Ventilator-Associated Pneumonia
• Surgical Site Infection
7. Pandemic Preparedness
• Preparedness Considerations
8. Infection Prevention and Control Glossary
References
1. Centers for Disease Control and Prevention. Current HAI Progress Report. Accessed March 12, 2025, https://www.cdc.gov/healthcare-associatedinfections/php/data/progress-report.html
2. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. Dec 2007;35(10 Suppl 2):S65-164. doi:10.1016/j.ajic.2007.10.007
3. Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections - an overview. Infect Drug Resist. 2018;11:2321-2333. doi:10.2147/idr.S177247
4. American Association of Nurse Anesthesiology. Standards for Nurse Anesthesia Practice. 2019. 2019;
5. Griffis CA, Reede L, O'Rourke M, Hledin V. Infection Control and Patient Safety: What Is Desirable and What Is Possible During Anesthesia? AANA J. 2017;Online Content(2):13-16.
6. Anderson M, Jeter L, Reede L, Everson M, Griffis C. Infection Control During Emergencies: Protecting the Patient. APSF Newsletter. Oct 2019 2019;34(2).
7. American Association of Nurse Anesthesiology. Code of Ethics for the Certified Registered Nurse Anesthetist. 2018.
Acknowledgement
Thank you to the AANA Infection Control Advisory Panel (ICAP) for the research, revision, and development that has gone into this guideline and ongoing efforts to improve infection control and prevention in anesthesia care delivery. ICAP members include Charles Griffis, PhD, CRNA, Elizabeth Bamgbose, PhD, CRNA, Sherry Bernardo, DNP, MHA, CRNA, Micheal Anderson, DNP, CRNA, ARNP, Leslie Jeter, DNP, CRNA, and Lynn Reede, DNP, MBA, CRNA, FNAP.
Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 1: Standard Precautions
Introduction
Standard precautions are the basic level of infection control protocols that reduce the risk of disease transmission when providing patient care.1,2 Basic standard precautions include, but are not limited to:
• Hand Hygiene
• Personal Protective Equipment
• Respiratory Hygiene
• Safe Injection Practices
• Equipment and Environmental Cleaning, Disinfection, and Sterilization
Anesthesia and other healthcare providers should always refer to their facility’s policy on infection control standard precautions.
Purpose
This chapter provides recommendations on critical infection prevention and control measures for anesthesia professionals. It covers core principles and protocols related to hand hygiene, use of personal protective equipment, application of transmission-based precautions, respiratory hygiene, skin preparation, aseptic technique, and airway management precautions. By adhering to these recommendations, healthcare facilities and providers can mitigate risks of healthcareassociated infections and support a safer environment for clinicians, ancillary staff, and patients.
Hand Hygiene
Hand hygiene is the practice of removing microorganisms from hands.2-9 Performing proper hand hygiene significantly reduces the incidence of infection.1-10 Hand hygiene is performed in a manner consistent with hospital infection control practices, policies, and procedures to maximize the prevention of infection and communicable disease.11 Table 1 describes when hand hygiene is indicated and Table 2 describes specific hand hygiene definitions and protocols.
• Contact with patient’s skin and immediate surroundings (e.g., bedside area).
• Contamination.
• Contact with blood, body fluids, excretions, mucous membranes, wound dressings, nonintact skin, or visibly contaminated surfaces.
• Contact with patient’s airway.
• Removing protective equipment (e.g., gloves).
• Contact with the floor or anything that has been in contact with the floor.
• Contact with inanimate objects, medical equipment, or monitors.
• Exiting the operating room.
• Using the restroom.
Table 2. Hand hygiene definitions and instructions.2,5,6,9,11-15
Term Definition Protocol
Antiseptic Handwashing
AlcoholBased Handrubbing
Washing hands with water and an antiseptic agent, (e.g., soap, hand rub).
Rubbing non-visibly soiled hands with a product that contains alcohol to decontaminate hands.
Surgical Hand Antisepsis
Washing hands with an antiseptic agent before a surgical procedure.
• Wet hands with water, apply antiseptic soap and rub hands together for at least 20 seconds.
• Apply manufacturer recommended amount to palm.
• Rub hands together covering all surfaces and fingernails until dry.
• Refrain from contact until hands are completely dry.
• Remove jewelry (e.g., rings, bracelets, wristwatches) prior to performing surgical hand hygiene.
• Follow manufacturer guidelines for scrub time.
• Clean under fingernails using a nail cleaner.
• Keep natural nail length to less than ¼ inch.
• Do not wear artificial nails or nail extenders.
Performing adequate hand hygiene while providing anesthesia care can be challenging due to the nature and intensity of care anesthesia professionals provide.16 Studies of anesthesia professionals in the operating room indicate that there are a high number of missed hand hygiene opportunities during patient care.16-18 Given the demands of anesthesia care and proportion of missed hand hygiene opportunities, aggressive strategies and education are needed to improve hand hygiene among anesthesia professionals.14,18,19 Recommended strategies include use of single and double gloving with glove removal after contamination, availability of alcohol-based hand sanitizers in the anesthesia work area, targeted environmental cleaning of the anesthesia area after each case, and ongoing research to design new methods to control bacterial transmission.5,14,16,17
Personal Protective Equipment
Personal protective equipment (PPE) is specialized clothing or equipment worn for protection against infectious materials and contamination.20 PPE protects the patient and the healthcare provider from transmitting and contracting infection.1,3,9,20 Always perform hand hygiene prior to applying PPE, after removing all PPE (except for respirators), and prior to exiting the operating or patient room. Avoid touching surfaces or face when possible, during the donning process to prevent contamination. Utilize the appropriate combinations for PPE based on clinical and patient needs. For example, during aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols wear a fit-tested N95 or higher respirator in addition to gloves, gown and face/eye protection.1 Table 3 offers examples of PPE and information on how to properly wear, remove, and dispose of the gear.
Disposable Gloves (NonSterile)
• Routine patient care.
• Shared patientprovider use of a difficult-to-clean device (e.g., computer keyboard).
• Remove and replace gloves promptly when contaminated or damaged. This helps keep anesthetizing locations and patient care areas clean.
• Remove gloves and perform hand hygiene after caring for a patient and between patients.
• Do not wear the same pair of gloves for more than one patient to prevent crosscontamination.
• Special considerations, such as pore size and glove composition (e.g. latex vs nonlatex), may apply based on patient, provider or procedure needs.
• Glove selection should account for potential allergies, procedures involving hazardous drugs, etc.
• Grasp outer edge of glove near wrist.
• Peel away from hand turning inside out.
• Hold removed glove in opposite gloved hand.
• Slide ungloved finger under wrist of gloved hand so finger is inside gloved area.
• Peel off the glove from inside creating a ‘bag’ for both gloves.
• Dispose of gloves in proper waste receptacles.
Disposable Gloves (Sterile)
• Surgical procedures.
• Vaginal deliveries.
• Invasive radiological procedures.
• Remove and replace gloves promptly when contaminated or damaged. This helps keep anesthetizing locations and patient care areas clean.
• Partially remove the first glove by peeling it back with fingers of the opposite hand (all five fingers should still be covered with the glove).
Table 3. PPE examples and guidelines.1,3,9,10,15,16,21-47
Double Gloves
• Performing vascular access and procedures.
• Preparing total parental nutrition and chemotherapeutic agents.
• Regional neuraxial techniques.
• Any invasive procedure risking sterile site or fluid exposure.
• High-risk wound dressings.
• Care of severely immunocompromised patients.
• Airway manipulation.
• Increased risk of complications from needle stick injuries (e.g., HIV, Hepatitis C contamination).
• Remove gloves and perform hand hygiene after caring for a patient and between patients.
• Do not wear the same pair of gloves for more than one patient to prevent crosscontamination.
• Special considerations, such as pore size and glove composition (e.g. latex vs nonlatex), may apply based on patient, provider or procedure needs.
• Remove the other glove completely, turning it inside out, only touching the outside of the glove with the covered fingers of the partially gloved hand.
• Remove the glove on the partially gloved hand completely, using the inside out removed glove.
• Skin is only contacted by the inner surface of the glove.
• Dispose of gloves in proper waste receptacles.
• After performing the planned intervention, immediately remove and safely dispose of the outer gloves.
• Remove and replace gloves promptly when contaminated or damaged. This helps keep anesthetizing locations and patient care areas clean
• Resume urgent patient care activities (e.g., patient ventilation) with clean, inner gloved hands.
• Remove gloves and perform hand hygiene after caring for a patient and between patients.
• Do not wear the same pair of gloves for more than one patient to prevent crosscontamination.
• First remove the outer glove by following the protocols for sterile glove removal.
• Remove other PPE equipment.
• Remove inner glove following the protocols for sterile glove removal.
• Perform hand hygiene.
Gowns (nonsterile)
Gowns (sterile)
• Risk of limb or torso contamination.
• Special considerations, such as pore size and glove composition (e.g. latex vs nonlatex), may apply based on patient, provider or procedure needs.
• Wear a gown that provides appropriate coverage.
• Secure gown in the back of the neck and waist.
• Discard after each use.
Eye Protection
• Insertion of pulmonary artery catheters and central venous catheters.
• Invasive procedures (e.g., surgery).
• Wear a gown that provides appropriate coverage.
• Secure gown in the back of the neck and waist.
• Discard after each use.
• Potential for contact with infectious material.
• Splash, spray, or droplet hazards.
• During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions (e.g., suctioning, endotracheal intubation).
• Select appropriate eye protection based on the type of hazard exposure, the duration of exposure, and the availability of other PPE.
• Pretest selected eye protection for suitability and appropriate fit.
• Clean and disinfect non-disposable eyewear prior to use (e.g., laser glasses, goggles, N95 respirator, face shields).
• Unfasten ties in back of neck and waist.
• Remove the gown touching only the inside of the gown.
• Roll or fold gown inside out.
• Dispose of gown in proper waste receptacle.
• If donning double gloves, dispose of outer glove following sterile glove removal protocol prior to removing gown.
• Follow removal protocol for non-sterile gowns.
• Dispose of gown in proper waste receptacle.
• If donning double gloves, dispose of outer glove following sterile glove removal protocol prior to removing eye protection.
• Lift head band or ear piece.
• Refrain from touching the face shield.
• Dispose of eye protection in proper receptacle for reprocessing or disposal.
Surgical Masks
• Invasive procedures (e.g., arterial and central venous access, regional anesthesia).
• Regional neuraxial technique.
• Potential for contact with infectious material.
• Wear to cover facial hair.
• The surgical mask should cover the mouth and nose and be secured in a manner that prevents venting at the sides of the mask.
• Remove and discard when wet or soiled, and at the end of a case or procedure.
• Perform hand hygiene immediately following mask removal and disposal.
• If donning double gloves, dispose of outer glove following sterile glove removal protocol prior to removing surgical mask.
• Undo the ties or grasp the elastics at the top and bottom of the mask and remove without touching the front of the mask.
• Dispose of mask in proper waste receptacle.
Hair Coverings
• Upon entry to semirestricted and restricted areas.
• Regional neuraxial technique.
• Cover hair, facial hair, sideburns and the back of the neck using a clean covering.
• Launder reusable cloth caps daily and when visibly soiled.
Shoe Coverings
• Risk of splash contamination.
• Slip coverings over shoes prior to donning gloves and other PPE.
• Shoe coverings must be changed each time a worker exits the area.
• If donning double gloves, dispose of outer glove following sterile glove removal protocol prior to removing surgical cap.
• Remove cap using gloves, refraining from contacting inner part of cap.
• Dispose of cap in proper waste receptacle.
• If donning double gloves, dispose of outer glove following sterile glove removal protocol prior to removing shoe covers.
• With already donned gloves, remove shoe coverings.
• Dispose of coverings in proper waste receptacle.
• Spray shoes with disinfectant if necessary.
Scrubs
• Follow facility policy regarding donning
• Wear a clean set of scrubs each day and change into clean scrubs if contaminated.
• Follow facility policy regarding removal of scrubs upon exiting
Cover Apparel (e.g., lab coats)
scrubs prior to entering restricted and semi-restricted areas.
• Scrubs should be laundered in a healthcareaccredited laundry facility after each daily use and when contaminated.
o If home laundering is unavoidable, the facility should provide clear instructions on optimal methods using appropriate water temperature, cycle time, disinfectant chemicals, mechanical agitation, and high heat drying
o Change out of contaminated scrubs promptly and have a process for containing and transporting soiled scrubs to avoid spreading contamination.
• Scrubs worn as general work clothes and not intended to function as protection against a hazard or expected to be contaminated by blood or other potentially infectious materials are not considered to be PPE. Therefore, these would nor need to be handled in the same manner as contaminated PPE.
restricted and semi-restricted areas.
• Follow facility policy regarding use of cover apparel.
• Cover apparel should be clean or singleuse.
• Lab coats are not recommended in the operating room, as they have the potential to become contaminated.
Transmission-Based Precautions
• Follow facility policy regarding removal of lab coats upon entering and exiting restricted and semi-restricted areas.
• Launder cover apparel after each daily usage and when contaminated.
In addition to standard precautions, transmission-based precautions should always be followed once a patient develops symptoms of an infection to reduce opportunities for disease transmission.1 The four categories of transmission-based precautions include contact, droplet, airborne, and bloodborne precautions. Because diagnostic tests are often required to confirm an infection and generally require several days for conclusive results, precautionary measures should be taken until the presence or absence of infection is confirmed.1 Some diseases have multiple routes of transmission, therefore multiple transmission-based precautions may be
necessary.1 Clinicians should also be vigilant and aware of the increasing incidence of vaccine-preventable disease and their impact on patient care and provider safety.48 Adherence to timely transmission-based precautions will mitigate opportunities for infections to spread, and in certain cases decrease the risk of community outbreaks of infectious diseases.49 Table 4 describes protocols and examples of transmission-based precautions.
Contact Prevents transmission of infectious agents spread by contact with the patient or environment.
• Use single-patient rooms when possible.
• Maintain ≥ three feet spatial separation between beds in rooms with more than one patient.
• Wear a gown and gloves for all contact with the patient or the patient’s environment.
• Wear PPE before entering the patient’s room and discard it before exiting the patient’s room.
• Use disposable single-use or patient-dedicated noncritical care equipment (e.g., blood pressure cuffs, stethoscopes).
Include, but not limited to:
• Clostridium difficile*
• Norovirus*
• Scabies
• Salmonella
• Shigella
• Poliomyelitis
• Patient with multidrug resistant organisms
Droplet Prevents transmission of infectious agents spread by close contact with respiratory secretions.
• Use single-patient rooms when possible.
• Use a private patient room, when possible. Maintain ≥ three feet spatial separation and a curtain between beds in rooms with more than one patient.
• Wear a gown, gloves, mask, and eye protection for all contact with the patient or the patient’s environment.
• Wear PPE before entering the patient’s room and discard it before exiting the patient’s room.
• Place a facemask on the patient during transport.
Include, but not limited to:
• Influenza
• Pertussis
• Mumps
• Rubella
• Neisseria meningitidis
• Diphtheria
• Respiratory syncytial virus
• SARS-CoV-2
Airborne Prevents transmission of infectious agents that can spread over longer distances when suspended in the air.
• Place patients in an airborne infection isolation room designed with monitored negative pressure, 12 air exchanges per hour, and air exhausted directly to the outside or recirculated through high-efficiency particulate air filtration.
Include, but not limited to:
• M. tuberculosis
• Measles
• Varicella
• SARS-CoV-2
• Smallpox
Bloodborne Prevents transmission of infectious agents in the blood.
• Facilities should establish a respiratory protection program.
• Isolate N95 or higher level masked patients in a private room when airborne precautions cannot be achieved.
• Healthcare workers should don gloves, gowns, and N95 mask upon entering an infectious patient’s room.
• As possible, clinical and non-clinical healthcare staff should maintain ≥ six feet special separation with patients who have or are at risk of infection,
• Place a facemask on the patient during transport.
• Healthcare workers with natural or acquired immunity are the preferred providers for infectious patients with airborne diseases.
• For anticipated exposure to sprays, splatters, and splashes, use additional PPE such as face masks, goggles, fluid-resistant gowns.
• Treat all blood and body fluids as potentially infectious.
• Immediately wash exposed skin or flush mucous membranes with water if exposure occurs.
• Report and seek medical evaluation for any potential bloodborne pathogen exposures.
• Properly handle and dispose of sharps (e.g., needles) in puncture-proof containers.
• Decontaminate equipment and surfaces exposed to blood or bodily fluids with EPA-approved disinfectants.
• Mpox
Include, but not limited to:
• HIV
• Hepatitis B virus
• Hepatitis C virus
High-risk bodily fluids include:
• Blood
• Semen, vaginal secretions
• Cerebrospinal fluid
• Synovial, amniotic, pericardial, and pleural fluid
Low-risk bodily fluids include**:
• Urine, feces
• Teams, saliva, vomitus
• Nasal secretions
*Facilities should consider use of a hypochlorite solution for environmental cleaning as an additional contact precaution.50
**Unless blood stained.15
During heightened periods of virulent and highly contagious infectious outbreaks (e.g., SARS-CoV-2, Ebola virus disease [EVD], Enterovirus), healthcare providers are encouraged to refer to the following resources for supplemental information regarding transmission-based precautions:
• AANA Practice Committee and Infection Control Advisory Panel (www.aana.com and practice@aana.com).
• Local and/or state health departments.
• Centers for Disease Control and Prevention (CDC) (www.cdc.gov).
• Society for Healthcare Epidemiology of America (www.shea-online.org).
• Association for Professionals in Infection Control and Epidemiology (www.apic.org).
• Infectious Diseases Society of America (www.idsociety.org).
Respiratory Hygiene
Respiratory hygiene includes cough etiquette and the appropriate use of isolation precautions to prevent the spread of infection.59
Perform the following measures for cough etiquette when afflicted with a respiratory disease:59
• 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.
• Do not perform patient care when infected or ill.
Healthcare providers should take droplet precautions and standard precautions, when caring for a patient with symptoms of a respiratory infection, particularly if fever is present.59 Maintain these precautions until it is determined that the cause of symptoms is not an infectious agent that requires droplet precautions.59
During periods of elevated respiratory infection incidence, facilities may offer facemasks to patients who are coughing and take additional transmission-based precautions, as necessary.59-61
Skin Preparation
Preparing the patient’s skin prior to performing any invasive procedures will reduce the risk of infection.15 Healthcare providers should follow manufacturer recommendations and facility policy for the proper use of skin prep agents.
An ideal skin prep agent should decrease microorganism count, inhibit rebound and regrowth of microorganisms, activate quickly, and be effective against a variety of microorganisms.62 Each prep agent has a specific mechanism of action along with specific advantages and disadvantages that should be weighed in all clinical situations.62 The patient’s allergies, skin condition, other
contraindications, and the procedure site should be considered prior to applying the agent. Table 5 provides examples of skin prep agents, their descriptions, and recommendations for use.
Table 5. Skin prep agent examples, descriptions and recommendations.62-70 Agent Description and Recommendations
Chlorhexidine gluconate
Povidone-iodine
• Preferred skin prep agent due to immediate action, residual activity, and persistent effectiveness against a wide range of microorganisms.62-64,66-69
• Available in a wide range of concentrations (0.5% - 4%) and formulations.66
• Strong tendency to bind to tissue, contributing to extended antimicrobial action.63
• Highly effective in the presence of blood and organic material. 32
• Addition of alcohol to the disinfectant provides more rapid and effective bacteriostatic germicidal activity.62-64
• Limited sporicidal activity.63
• Some fungistatic and fungicidal properties and can neutralize some viruses.69
• Not recommended for use on eyes, ears, brain and spinal tissues, mucus membranes, or genitalia.62
• Suitable alternative when chlorhexidine gluconate is contraindicated.63
• Highly effective against a broad range of microorganisms and acts immediately.62-64
• Safe to use on face, head, mucous membranes, vaginal area and during other neuraxial procedures.63-65
• Lower risk of tissue damage upon direct contact compered to chlorhexidine.66
• Minimally persistent compared to chlorhexidine.63
• Limited residual activity.62,64,66
• Decreased effectiveness in the presence of blood and organic material.62
• Transcutaneous iodine absorption can result in iatrogenic hyperthyroidism or hypothyroidism in adult and pediatric populations.66
Parachoroxylenol
Iodine-base with alcohol
• Less effective than chlorhexidine gluconate and povidone-iodine at eliminating microorganisms.62
• Moderately effective against a broad range of mircoorganisms.63
• Moderate persistent/residual activity.
• Nontoxic with no tissue contraindications.62
• Remains effective in the presence of blood and organic material and in the presence of saline solution.62
• Highly effective against a broad range of microorganisms.63
• Poor sporicidal activity.66
• Acts immediately.62,63
• Highly flammable.62
Fire Risk: Agents that are alcohol-based or have flammable properties have the potential to increase the risk of surgical fires.
Aseptic Technique
Aseptic technique requires multiple methods to prevent the transmission of microorganisms from the environment, healthcare provider, and patient. Table 6 refers to recommendations for aseptic procedure.
Table 6. Guidelines for aseptic technique.15,47
Precaution Guidelines
Equipment (Maximal sterile barriers)
Preparation
Environmental Controls
Contact
May include some or all of the following items depending on the procedure:
• Sterile gloves
• Sterile gowns
• Surgical masks
• Sterile drapes
• Antiseptic skin preparation of patient prior to procedure.
o Consult manufacturer product instructions for directions and warnings regarding the proper use and application of specific skin antiseptics such as chlorhexidine-alcohol or povidoneiodine.
• Ensure that all instruments, equipment, and devices are sterile.
• Recognize and avoid risks in the environment that may increase risk of infection.
• Close doors during operative procedures.
• Minimize unnecessary staff and traffic in/out of operating room.
• Precautions should be taken to mitigate contact with non-sterile surfaces and objects.
Airway Management: Considerations Specific to Anesthesia Professionals
Airway management poses unique challenges to anesthesia professionals in limiting or preventing environmental contamination. In order to mitigate disease transmission while ensuring the standard of care for proper airway management, the following practices are recommended:
• Oxygenation and ventilation are top priorities during airway manipulation, verifying that infection control and prevention measures are taken when possible.15,71,72
• Immediate ventilation is indicated prior to hand hygiene following airway device placement to oxygenate and assess airway patency.15,72
o CDC guidelines indicate the need to remove gloves, wash hands, and don new gloves, which would conflict with the standard of clinical care for airway instrumentation and maintenance. 1,15,72
• Following maneuvers to establish a patent airway, the patient should be ventilated manually, the breath sounds auscultated, and the expired breath examined for presence of expired carbon dioxide.
• It is recommended that anesthesia practitioners double glove prior to airway manipulation.25,73,74
o Following tube or device insertion, remove contaminated outer gloves and perform necessary actions to assure airway security and patency.
• When the situation is stable, remove the inner gloves, perform hand hygiene, and don clean gloves to continue with patient care.
• Decontamination of the anesthesia work area after each procedure is crucial to mitigate the risk of bacterial transmission. 16,17,75 Additionally, continuous research efforts are vital to develop innovative strategies that can further enhance infection prevention measures specific to the anesthetizing location and workflow.16,17,75
References
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22. Centers for Disease Control and Prevention. How to Remove Gloves Safely. Accessed Apr 8, 2025, https://www.cdc.gov/ebola/hcp/communication-resources/how-to-remove-glovessafely.html
23. Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques: An Updated Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2017;126(4):585-601. doi:10.1097/ALN.0000000000001521
24. National Institute for Occupational Safety and Health. How to Prevent Needlestick and Sharps Injuries. May 17, 2024, https://www.cdc.gov/niosh/docs/2012-123/default.html
25. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. Apr 2015;120(4):848-52. doi:10.1213/ane.0000000000000230
26. Occupational Safety and Health Administration. OSHA Technical Manual (OTM) Section VI: Chapter 1. Hospital Investigations: Health Hazards. Accessed May 17, 2024, https://www.osha.gov/otm/section-6-health-care-facilities/chapter-1
27. Jaffe G, Moriber N. Use of a Double Gloving Technique to Decrease Cross-Contamination by Anesthesia Providers. AANA J. Aug 2019;87(4):307-312.
28. Mane A. Double Gloving and Infection Control. AANA J. Jan 2020;88(1):2-3.
29. Zhang Z, Gao X, Ruan X, Zheng B. Effectiveness of double-gloving method on prevention of surgical glove perforations and blood contamination: A systematic review and metaanalysis. J Adv Nurs. Sep 2021;77(9):3630-3643. doi:10.1111/jan.14824
30. King KC, Strony R. Needlestick. StatPearls. 2023.
31. Roxburgh M, Gall P, Lee K. A cover up? Potential risks of wearing theatre clothing outside theatre. J Perioper Pract. Jan 2006;16(1):30-3, 35-41. doi:10.1177/175045890601600104
32. Food and Drug Adminstration. Medical Gowns. Accessed May 17, 2024, https://www.fda.gov/medical-devices/personal-protective-equipment-infectioncontrol/medical-gowns
33. Association of Surgical Technologists. Standards of Practice for Gowning and Gloving. July 2014 2014;
34. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JA. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth. Oct 1992;69(4):407-8. doi:10.1093/bja/69.4.407
36. Centers for Disease Control and Prevention. Infection Control Guidance: SARS-CoV-2. Accessed Apr 8, 2025, https://www.cdc.gov/covid/hcp/infectioncontrol/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-controlrecommendations.html
37. Yoshida H, Makino A, Yamaguchi A, et al. Droplets Adhesion to Surgical Masks during Standard Oral Surgery. Jpn J Infect Dis. Jan 24 2023;76(1):84-86. doi:10.7883/yoken.JJID.2022.184
38. Food and Drug Adminstration. N95 Respirators, Surgical Masks, Face Masks, and Barrier Face Coverings. Accessed May 18, 2024, https://www.fda.gov/medical-devices/personalprotective-equipment-infection-control/n95-respirators-surgical-masks-face-masks-andbarrier-face-coverings
39. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England). J Hosp Infect. Aug 2007;66(4):301-7. doi:10.1016/j.jhin.2007.03.026
40. Gerba CP, Kennedy D. Enteric virus survival during household laundering and impact of disinfection with sodium hypochlorite. Appl Environ Microbiol. Jul 2007;73(14):4425-8. doi:10.1128/AEM.00688-07
41. Annis K, Coates C, Renehan K, Ridgway B, Jasinski D. Examination of Hospital Policies Regarding Certified Registered Nurse Anesthetist Attire in the Operating Room. AANA J. Dec 2017;85(6):410-416.
42. Vera CM, Umadhay T, Fisher M. Laundering Methods for Reusable Surgical Scrubs: A Literature Review. AANA J. Aug 2016;84(4):246-52.
43. Nordstrom JM, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. Am J Infect Control. Aug 2012;40(6):539-43. doi:10.1016/j.ajic.2011.07.015
44. The Joint Commission. Laundering - Attire Including Surgical Scrubs and Uniforms. Does the Joint Commission require employers to launder surgical scrubs or other uniforms? Accessed May 18, 2024, https://www.jointcommission.org/standards/standardfaqs/ambulatory/infection-prevention-and-control-ic/000001460/
45. Occupational Safety and Health Administration. Compliance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030. Accessed May 18, 2024, https://www.osha.gov/laws-regs/standardinterpretations/2009-02-27
46. Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. Sep 2011;39(7):555-9. doi:10.1016/j.ajic.2010.12.016
47. Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 4 Aseptic Technique. Available from: https://www.ncbi.nlm.nih.gov/books/NBK596727/
48. Porteous GH, Hanson NA, Sueda LA, et al. Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications. Anesth Analg. May 2016;122(5):1450-73. doi:10.1213/ANE.0000000000001196
49. Zimmerman PA, Mason M, Elder E. A healthy degree of suspicion: A discussion of the implementation of transmission based precautions in the emergency department. Australas Emerg Nurs J. Aug 2016;19(3):149-52. doi:10.1016/j.aenj.2016.03.001
50. Virginia Department of Health. Transmission-based precautions. Accessed March 19, 2023. https://www.vdh.virginia.gov/haiar/ip/transmission-based-precautions/
51. Bahl P, Doolan C, de Silva C, Chughtai AA, Bourouiba L, MacIntyre CR. Airborne or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019? J Infect Dis. May 4 2022;225(9):1561-1568. doi:10.1093/infdis/jiaa189
52. Bowdle A, Jelacic S, Shishido S, Munoz-Price LS. Infection Prevention Precautions for Routine Anesthesia Care During the SARS-CoV-2 Pandemic. Anesth Analg. Nov 2020;131(5):1342-1354. doi:10.1213/ANE.0000000000005169
53. Wong TW, Lee CK, Tam W, et al. Cluster of SARS among medical students exposed to single patient, Hong Kong. Emerg Infect Dis. Feb 2004;10(2):269-76. doi:10.3201/eid1002.030452
54. Morawska L, Cao J. Airborne transmission of SARS-CoV-2: The world should face the reality. Environ Int. Jun 2020;139:105730. doi:10.1016/j.envint.2020.105730
55. Cook TM, El-Boghdadly K, Brown J, Pickering AE. The safety of anaesthetists and intensivists during the first COVID-19 surge supports extension of use of airborne protection PPE to ward staff. Clin Med (Lond). Mar 2021;21(2):e137-e139. doi:10.7861/clinmed.20200983
57. Centers for Disease Control and Prevention. Transmission-Based Precautions Accessed Apr 8, 2025, https://www.cdc.gov/infection-control/hcp/basics/transmission-basedprecautions.html
58. Occupational Safety and Health Administration. Bloodborne Pathogens and Needlestick Prevention. Accessed May 18, 2024, https://www.osha.gov/bloodborne-pathogens
59. Respiratory hygiene/cough etiquette in healthcare settings. Centers for Disease Control and Prevention. Accessed March 19, 2023. www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
60. Choi JS, Kim KM. Predictors of respiratory hygiene/cough etiquette in a large community in Korea: A descriptive study. Am J Infect Control. Nov 1 2016;44(11):e271-e273. doi:10.1016/j.ajic.2016.04.226
61. Fox GJ, Redwood L, Chang V, Ho J. The Effectiveness of Individual and Environmental Infection Control Measures in Reducing the Transmission of Mycobacterium tuberculosis: A Systematic Review. Clin Infect Dis. Jan 23 2021;72(1):15-26. doi:10.1093/cid/ciaa719
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Infection Prevention and Control Guidelines for Anesthesia Care
Introduction
Chapter 2: Safe Medication Preparation and Injection Practices
Improper injection practices put patients and healthcare providers at risk of infection from bloodborne pathogens, which can lead to the spread of healthcare-associated infections (HAIs).1-5 Following safe injection practices and appropriate medication preparation techniques can prevent the spread of disease. These measures can also protect providers from disciplinary action and legal recourse.2,6,7
Purpose
The purpose of this chapter is to describe evidence-based safe medication management and compounding of anesthetic drugs, safe injection practices for needle and syringe use, and infection control safety considerations for gels, lubricants, and ointments. This chapter includes content described in U.S. Pharmacopeial Convention (USP) Chapter <797> on compounding of sterile preparations.
USP Chapter <797> Sterile Compounding
The USP is a scientific nonprofit organization responsible for defining standards for the identity, strength, quality, and purity of drugs and compounds used in clinical practice.8 USP standards are developed with input from various stakeholders, undergo rigorous scientific evaluation, and are presented for public input before being finalized.8
USP Chapter <797>, Pharmaceutical Compounding - Sterile Preparations,describes conditions and practices for preparing compounding sterile preparations (CSPs) in healthcare settings.9 These standards apply to all healthcare providers preparing and administering CSPs within an institution when that institution has adopted USP <797>. USP <797> was most recently revised effective November 1, 2023.10
USP <797> is not law but is an accepted standard and may be incorporated into federal, state, and local statutes, regulations, and facility accreditation standards.11 Anesthesia professionals should comply with applicable statutes, regulations, facility accreditation requirements, and facility policies in the preparation of CSPs.
The following summarizes USP <797> as it applies to anesthesia professionals:9
• USP <797> distinguishes three categories of CSPs: Category 1, Category 2, and Category 3, primarily based on the state of environmental control under which they are compounded, the probability of microbial growth during the storage time, and the time in which they must be used.
o Category 1 is a CSP that is assigned a beyond-use date (BUD) of 12 hours or less at a controlled room temperature or 24 hours or less refrigerated.
o Category 2 is a CSP that may be assigned a BUD of greater than 12 hours at a controlled room temperature or greater than 24 hours refrigerated.
o Category 3 is a CSP that has a BUD up to 90 days at a controlled room temperature or 120 days refrigerated.
• When all the following conditions are met, compounding of “immediate use” CSPs for direct and immediate administration is not subject to the requirements of Category 1, Category 2, or Category 3 CSPs:9
o Aseptic techniques, processes, and procedures are followed, and written standard operating procedures (SOPs) are in place to minimize contact with nonsterile surfaces, introduction of biological fluids or particulate matter, and mixups with other CSPs or manufactured products.
o Personnel are trained and demonstrate competency in aseptic processes as they relate to the facility’s SOPs and assigned tasks.
o The preparation is performed according to evidence-based information for physical and chemical compatibility of the drugs.
o Preparation involves not more than 3 different sterile products.
o Any unused starting component from a single-dose container must be discarded upon completion of preparation. Single-dose containers may not be used for more than one patient.
o Administration must begin within 4 hours following the start of preparation. If administration does not begin with 4 hours following the start of preparation, it must be appropriately and promptly safely discarded.
o Unless directly administered by the person who prepared it or administration is witnessed by the preparer, the CSP must have proper labeling with the names and amounts of all the active ingredients, the name or initials of the preparer, and the 4-hour time period within which the administration must begin.
• All labeling must be in compliance with laws and regulations of the applicable regulatory jurisdiction.9
Proprietary Bag and Vial Systems
Docking and activation of proprietary bag and vial systems in accordance with the manufacturer’s labeling for “immediate” administration to an individual is not considered compounding and may be performed outside of an International Organization for Standardization (ISO) Class 5 environment.9
Conventionally Manufactured Single-Dose and Multi-Dose Containers
A manufactured single-dose container is a container closure system that holds sterile products for injection or infusion that is not required to abide by antimicrobial effectiveness testing requirements.9
If a product is manufactured in a multiple-dose container, it is intended to contain more than one dose of a product. Once it has been initially opened, the multiple-dose container must be used within 28 days, unless specified by the manufacturer’s label.9
Compounded Multiple-Dose CSPs
Multiple-dose CSPs contain more than one dose of a sterile preparation, which is intended to be opened and closed multiple times, since the vile normally contains a preservative. Multiple-dose CSPs require the criteria for antimicrobial effectiveness testing.9 They must be stored under the conditions on which their BUD is based. After being opened, the multiple-dose CSP must not be used longer than the assigned BUD or 28 days, whichever is shorter. The time limit for opening or closing is not supposed to restrict the BUD of the final CSP.9
All personnel involved in compounding should understand how they may contribute to the risk of CSP contamination during preparation. To decrease the risk of contamination, many hospital pharmacies commonly prepare medications used in anesthesia care delivery (e.g., phenylephrine) or buy ready-to-use, prefilled medications (e.g., fentanyl).
See the glossary at the end of this document for definitions of USP Chapter <797> terms used in this section.
Needle and Syringe Use
AANA Safe Injection Guidelines for Needle and Syringe Use address aspects of anesthesia care which involve the use of needles and syringes when administering injectable medications.4 In addition to AANA guidance, CRNAs are advised to refer to CDC recommendations for safe injection practicefor additional guidance.12 The following statements reflect current safe practices for needle and syringe use.
• Never administer medications from the same syringe to multiple patients, even if the needle is changed 1,13-15
• Never reuse a needle,2,13,16-19 or needleless access device even on the same patient. Once a needle or access device has been used, it is considered contaminated and must be discarded in an appropriately identified sharps container.20 Access devices are single- use devices.1,2
• Never refill a syringe once it has been used, even for the same patient. Syringes are single-use devices.2,17,18,21 Once the plunger of a syringe has been completely depressed in order to expel the syringe contents (i.e., intravenous medication), the internal barrel of the syringe is considered contaminated and must be discarded in an appropriate fashion. A syringe must only be used once to draw up medication, and must not be used again even to draw up the same medication from the same vial for the same patient.21-24 In recognizing the needs of anesthesia care workflow, one syringe may contain medication to be administered over a period of time in incremental doses. The syringe tip should be protected with a sterile cap at all times when not being actively used to administer an incremental dose of medication.1 For medication administration, the sterile cap should be removed and the injection port should be cleansed with 70% alcohol prior to injection of medication.1,25 Following medication injection, the sterile cap should be reattached, being careful not to contaminate the syringe tip.1
CRNAs should weigh the risks of possible syringe contamination (e.g., from anesthesia workspace contamination26-31 that may occur when repeatedly connecting and disconnecting a medication-filled syringe from an intravenous infusion set or other administration systems.
• Never use an infusion or intravenous administration tubing set for more than one patient. 1 Infusion and intravenous sets are single-patient use items and must be used according to applicable policies and guidelines. These devices are to be used on one patient only and must never be used between patients.
• Never reuse a syringe or needle to withdraw medication from a multidose vial (MDV) 2,32-34 A new sterile syringe and needle or access device are required each time an MDV is accessed.2,17,33-35
• Avoid use of MDV for more than one patient. Practitioners should avoid using MDVs if at all possible 17,33,34,36 If MDV must be used, the practitioner should consider using that MDV on only one patient.14,18,37,38 Although MDVs contain a preservative, they still may become contaminated with infectious agents due to unsafe practices that are
not evident.
• Do not access an MDV in the immediate patient treatment area unless the MDV is dedicated to a single patient and discarded immediately thereafter.1,34,39
• Never reenter a single-dose medication vial, ampoule or intravenous infusion bag 14,32,39,40 It is not appropriate to prepare multiple intravenous flush syringes for single or multiple patients from the same single-dose intravenous solution bag or bottle (e.g., normal saline).2,18,41 It is not appropriate to prepare multiple fentanyl, midazolam, or propofol syringes for the same or multiple patients from the same single-dose medication vial, ampoule, or solution. Do not store a single-dose medication vial for future use. Do not reenter a single-dose medication vial, even for the same patient
• When accessing medication vials, complete hand hygiene, don clean gloves, use a new sterile needle, and cleanse the access diaphragm with 70% alcohol prior to needle insertion.25,42
Gels, Lubricants, and Ointments
Gels, ointments, and lubricants require proper handling and use as they can potentially serve as vehicles for the transmission of pathogens if not managed appropriately. Handle and use these products in a way that mitigates the risk of cross-contamination and subsequent infections.1
• Dedicate ointments, gels, and lubricants to a single patient when possible.
• Use sterile skin prep agents when indicated.
Chapter Glossary
Administration: The direct application of a sterile product or preparation to a single patient by injecting, infusing, or otherwise providing a sterile product or preparation in its final form.
Beyond-use date (BUD): The date, or hour and the date, after which a CSP must not be used, stored, or transported. The date is determined from the date and time the preparation is compounded.
Compounded sterile preparation (CSP): A preparation intended to be sterile that is created by combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug product or bulk drug substance.
Compounding: The process of combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug product or bulk drug substance to create a sterile preparation.
Compounding record: Documents the compounding of each CSP.
Repackaging: The act of removing a sterile product or preparation from its original primary container and placing it into another primary container, usually of smaller size without further manipulation.
References
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25. World Health Organization Guidelines Best Practices for Injections and Related Procedures Toolkit. Geneva: World Health Organization; 2010 Mar 2, Best Practices for Injection. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138495/
26. Baillie JK, Sultan P, Graveling E, Forrest C, Lafong C. Contamination of anaesthetic machines with pathogenic organisms. Anaesthesia. Dec 2007;62(12):1257-61. doi:10.1111/j.1365-2044.2007.05261.x
27. Jeske HC, Tiefenthaler W, Hohlrieder M, Hinterberger G, Benzer A. Bacterial contamination of anaesthetists' hands by personal mobile phone and fixed phone use in the operating theatre. Anaesthesia. Sep 2007;62(9):904-6. doi:10.1111/j.13652044.2007.05172.x
28. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. Sep 2008;109(3):399-407. doi:10.1097/ALN.0b013e318182c855
29. Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg. Jan 2011;112(1):98-105. doi:10.1213/ANE.0b013e3181e7ce18
30. Kawakami Y, Tagami T. Pumping infusions with a syringe may cause contamination of the fluid in the syringe. Sci Rep. Jul 29 2021;11(1):15421. doi:10.1038/s41598-02194740-1
31. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. Jan 2019;40(1):1-17. doi:10.1017/ice.2018.303
32. Branch-Elliman W, Weiss D, Balter S, Bornschlegel K, Phillips M. Hepatitis C transmission due to contamination of multidose medication vials: summary of an outbreak and a call to action. Am J Infect Control. Jan 2013;41(1):92-4. doi:10.1016/j.ajic.2012.01.022
33. Folkema A, Wang HL, Wright K, et al. An outbreak of hepatitis C virus attributed to the use of multi-dose vials at a colonoscopy clinic, Waterloo Region, Ontario. Can Commun Dis Rep. May 7 2021;47(4):224-231. doi:10.14745/ccdr.v47i04a07
34. Miller DC, Smith C. The Safe Use of Multidose and Single-Dose Vials. Pain Med. May 1 2019;20(5):1047-1048. doi:10.1093/pm/pny314
35. Arrington ME, Gabbert KC, Mazgaj PW, Wolf MT. Multidose vial contamination in anesthesia. AANA J. Dec 1990;58(6):462-6.
36. Rehan HS, Chopra D, Sah RK, Chawla T, Agarwal A, Sharma GK. Injection practices of healthcare professionals in a Tertiary Care Hospital. J Infect Public Health. Apr 2012;5(2):177-81. doi:10.1016/j.jiph.2012.01.001
37. Perez F, Deshpande A, Kundrapu S, Hujer AM, Bonomo RA, Donskey CJ. Pseudooutbreak of Klebsiella oxytoca spontaneous bacterial peritonitis attributed to contamination of multidose vials of culture medium supplement. Infect Control Hosp Epidemiol. Feb 2014;35(2):139-43. doi:10.1086/674857
38. Bhatia M, Mishra B, Loomba PS, Dogra V. A pilot study for evaluation of knowledge and common practises of nursing staff regarding use of multidose injection vials and their microbial contamination rate in a super-specialty hospital. J Educ Health Promot 2018;7:120. doi:10.4103/jehp.jehp_73_18
39. Silberzweig JE, Khorsandi AS, Dixon RG, Gross K, Nikolic B. Society of Interventional Radiology position statement on injection safety: improper use of single-dose/single-use vials. J Vasc Interv Radiol. Jan 2013;24(1):111-2. doi:10.1016/j.jvir.2012.09.031
40. Centers for Disease Control and Prevention. Infection control requirements for dialysis facilities and clarification regarding guidance on parenteral medication vials. MMWR Morb Mortal Wkly Rep. Aug 15 2008;57(32):875-6.
41. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control. Oct 2011;39(8):663-670. doi:10.1016/j.ajic.2010.11.011
42. The Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert. Jun 16 2014;(52):1-6.
Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 3: Equipment and Environmental Cleaning, Disinfection, and Sterilization
Introduction
The following guidelines outline essential practices for equipment and environmental cleaning, disinfection, and sterilization in healthcare settings. This information is not exhaustive; for comprehensive guidance, refer to the CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, as well as applicable federal, state, and local law and regulations, manufacturer recommendations, and facility policies and procedures.1
The following are general considerations for equipment and environmental cleaning and should not substitute review and adherence to previous referenced resources:
• Policy Development: Facilities should establish infection control policies specific to disinfection and sterilization of anesthesia equipment and monitor compliance regularly.16
• Disinfectant Selection: Use U.S. Environmental Protection Agency (EPA)-registered disinfectants according to manufacturer instructions regarding concentration, contact time, disposal, and safety.7,8
• Cleaning Protocols: Anesthesia equipment should be adequately cleaned prior to disinfection and sterilization.3,5,6,8
• Staff Training: Ensure staff are trained in proper cleaning and disinfection techniques, with regular competency assessments.
• Environmental Practices: Minimize personal equipment (e.g., stethoscopes) and belongings (e.g., jackets, backpacks, bags, purses, personal electronic devices) in the operating room and/or patient care areas to reduce contamination risks.9
Purpose
To provide guidance on disinfection, sterilization, and waste management practices in healthcare settings, with a focus on anesthesia-related equipment and procedures.
The Spaulding Disinfection and Sterilization Classification Scheme
The Spaulding scheme classifies disinfection and sterilization methods for medical equipment by the risk of infection involved.1,2,10,11 View the details of the classification scheme in Table 1.
Table 1. Spaulding Disinfection and Sterilization Classification Scheme. Device
Classification Device Example(s) Process Recommendation
Critical Devices that enter sterile tissue, the vascular system, or through which blood flows.
Surgical instruments, cardiac and urinary catheters, implants, and ultrasound probes used in sterile body cavities1,11
Sterilization1,3,4,8,1012
• Sterilize between each patient use.
• Use sterilization methods that destroy all vegetative bacteria, nonlipid viruses and bacterial spores.
• Ensure thorough cleaning before sterilization.
• Medical devices can be sterilized using chemical or
physical properties depending on degree of contact with the patient.
• Rinse with sterile water after chemical sterilization.3
• Chemical germicides should be used rationally and in accordance with manufacturer recommendations and facility policy.
Laryngoscope blades1,11,13-23
High-level disinfection1,3,4,8,1013
• Clean thoroughly before disinfection.
• Use FDA-approved high-level disinfectants that destroy all vegetative bacteria, mycobacteria, fungi, and viruses.
• Rinse with sterile water after chemical disinfection.
• Dry equipment using forced air or hanging to air dry to prevent recontamination
• Dry all equipment surfaces to prevent humidity from encouraging microorganism growth.
• Follow manufacturer's instructions for disinfectant concentration and contact time.
• Store in a clean, dry area to prevent recontamination.
• Perform high-level disinfection between patient uses.
• Wrap laryngoscope blades individually.
• If high-level disinfection is used, a closed plastic bag may be used for storage. If steam sterilized, a peel pack may be used for storage.
• Partially remove the blade from the package, attach to light source without touching blade surface, and test. Manipulation of the blade onto the light source/handle can be tested without actually removing the blade from the bag or pack
Non-critical Contact intact skin.
Laryngoscope handles1,11,13,14,1821,23
without touching the blade itself.
• Following testing, insert the blade back into the package and return to a clean, dry area to prevent recontamination.
• Apply this protocol to both reusable and disposable blades.
• At a minimum, use intermediate-level disinfection with EPA-registered hospital disinfectant to wipe the handle after use.
• Ensure adequate contact time as specified by the disinfectant manufacturer.
• After disinfection, store in a clean, dry area to prevent recontamination.
• Apply this protocol to both reusable and disposable handles.
• Follow facility-specific policies and procedures for handle reprocessing. Some facilities may opt for high-level disinfection or sterilization based on risk assessment.
Patient Care Items: Electronic devices, stethoscopes, blood pressure cuffs, arm board, nametags, pulse oximeter sensors, head straps, monitor cables, blood warmers, medication administration pumps, carts, beds and monitors.1,11
Intermediate or low-level disinfection1,11,12,24
• Clean and disinfect between patients and when visibly soiled in accordance with manufacturer recommendations and facility policy.
o Low and intermediate-level disinfection differs by disinfectant type, concentration, and exposure to pathogen.
• Use EPA-registered hospital disinfectants appropriate for the item.
• Stethoscopes may be cleaned with soap and water, then disinfected with 70% isopropyl alcohol.
• Use protective covering for noncritical surfaces that are difficult to clean (e.g., keyboard covers).
Environmental Surfaces: Bed rails, food utensils, bedside furniture, computer keyboards, floors, mobile devices.1,11
• Hydrogen peroxide gas decontamination is an effective sterilization method for reusable items that are difficult to clean.
• Clean and disinfect between patients and when visibly soiled in accordance with manufacturer recommendations and facility policy.
• Use EPA-registered hospital disinfectants appropriate for the item.
• Use protective covering for noncritical surfaces that are difficult to clean (e.g., keyboard covers).
Single-Use Devices and Reprocessed Disposable Equipment
• A single-use device (SUD) is a medical device intended for use on one patient during a single procedure. It is not designed or validated for reuse.25,26 Studies have linked outbreaks of infection to improperly reprocessed medical devices.1,27-30
• Reuse of single-use devices may expose healthcare providers and facilities to additional liability.31
• The reprocessing of SUDs is regulated by the FDA. Only FDA-registered third-party reprocessors or healthcare facilities that comply with FDA regulations may reprocess SUDs.25,26 Refer to the FDA for guidance and information on reprocessed single-use devices.1,25,26
To mitigate the incidence of outbreaks, it is recommended that healthcare facilities:
• Develop and implement policies to verify the cleanliness and functionality of reprocessed disposable equipment prior to use.25,26
• Disassemble, clean, dry, reassemble, repackage, and disinfect or sterilize reprocessed, disposable equipment prior to use as appropriate.25,26
• Train staff on the proper handling and use of reprocessed SUDs.
The Anesthesia Machine and Breathing System
Although there is no direct contact between the anesthesia workspace, anesthesia machine controls and the patient, microorganisms can be transferred between the machine and patient by the healthcare provider.23,32-36 Refer to federal, state or local law and regulations and facility policies as well as specific manufacturer instructions for guidance concerning:3,8
• Cleaning and disinfecting the anesthesia machine.
• Pasteurizing or autoclaving of valves.
• Disassembling and disinfecting adjustable pressure-limiting valves.
Anesthesia Machine Surfaces and
Carts3,8,23,32-34,36-39
• Clean and disinfect anesthesia machine surfaces, knobs, and touchscreens between cases and at the end of each day using an EPA-registered hospital-grade disinfectant appropriate for the surface material.
• Implement measures to protect materials stored on the anesthesia machine from inadvertent contamination by airborne debris or fluids (e.g., blood).
• Regularly remove equipment from drawers, clean and disinfect the drawer interiors according to manufacturer's instructions
• Replace or clean the covering on the top of the anesthesia cart at the beginning of each case to maintain a clean work surface
• For small surfaces that are not visibly soiled, 70% isopropyl alcohol can be used for intermediate-level disinfection. However, for surfaces with visible contamination, use an EPA-registered disinfectant appropriate for the type of contamination.
• Clean carbon dioxide and soda lime absorbent canisters when changing the absorbent. Remove debris from screens and follow manufacturer's instructions for cleaning and maintenance.
Anesthesia Breathing System
Consult the manufacturer's user manual for specific cleaning recommendations for the breathing system.
Filters3,8,12,40-42
Breathing system filters are single-use items evaluated by their bacterial filtration efficiency (BFE) and viral filtration efficiency (VFE).8,41 Bacterial filtration is generally more effective than viral filtration.3,8 Filters may prove problematic during spontaneous respiration due to increased resistance to air flow.3 While routine use of breathing system filters is not recommended due to inconclusive data on infection risk reduction, they should be used for patients with known respiratory infections (e.g., Myobacterium. tuberculosis infection).3,12
• Consider placing high-efficiency filters on both inspiratory and expiratory limbs of the breathing circuit to protect both the patient and the anesthesia machine
• Filters may be placed between the endotracheal tube and the Y-piece.
• Use circuit filters and perform post-anesthesia machine disinfection after caring for patients with known pulmonary infections or trauma.
Carbon Dioxide Absorbers3,8,40,42
• Follow manufacturer instructions for disassembly, cleaning, and sterilization of carbon dioxide absorbers.
• Clean canisters when changing the absorbent and remove debris from screens.
• Discard disposable plastic canisters after use.
• Periodically clean and disinfect bellows, unidirectional valves, and carbon dioxide absorbers.
Circuits1,3,8,41
Anesthesia circuits may be single-patient use or multiple-patient use. For multiple-patient use circuits, place a new breathing system filter between the Y-piece and endotracheal tube after sterilization or high-level disinfection. Anesthesia professionals should pay close attention to anesthesia circuit product labeling.
• At a minimum, provide high-level disinfection for multiple-patient use breathing circuits.
o If available, ultrasonic cleaning is effective.
• Disinfect the outer surface of the circuit between each use.
• Change end-tidal carbon dioxide tubing between patients.
• After anesthesia care for a patient with pulmonary infection or trauma, disinfect both internal and external components of the anesthesia machine's respiratory system.
Heat and Moisture Exchangers41,43-45
• Heat and moisture exchangers alone are not effective in preventing microorganism transmission to the anesthesia breathing system.
Supraglottic Airway Devices21,46-52
• If possible, use disposable single-use laryngeal mask airways (LMAs) due to the difficulty in completely removing protein deposits from reusable LMAs.
• If using reusable LMAs, rinse and soak in enzymatic detergent before autoclaving to remove occult blood.
o Numerous studies have demonstrated that protein deposits are extremely difficult to eradicate completely from reusable LMAs.
• Consult manufacturer instructions for cleaning and sterilizing supraglottic airway devices.
Equipment Considerations for Special Patient Populations
Creutzfeldt-Jakob Disease3,12,53-62
Creutzfeldt-Jakob Disease (CJD) is caused by prions, which are highly resistant to conventional sterilization methods. To properly disinfect equipment, consult the following recommendations:
• If lumbar puncture is being performed, limit the number of clinicians in the room to those who are essential.
• Attach a HEPA grade filter directly to the endotracheal tube.
• The gas sampling line leading to the respired gas analyzer should be connected only to the sampling port on the circuit side of the HEPA filter.
• Use disposable, single-use equipment whenever possible for patients with known or suspected CJD. Incinerate this equipment after use.
• For reusable equipment:
o Destroy or quarantine laryngoscopes, supraglottic airway devices, and other instruments that have come into contact with high-risk tissues (e.g., spinal cord, eye).
o Safely discard devices that are difficult or impossible to clean thoroughly.
• For instruments that must be reprocessed:
o Clean thoroughly to remove visible contamination before sterilization.
o Steam sterilize using one of the following methods:
▪ Gravity displacement sterilizer: 132°C for 60 minutes
▪ Prevacuum sterilizer: 134°C for 18 minutes
▪ Alternative method for heat-sensitive instruments:
• Immerse in 1N sodium hydroxide for 1 hour at room temperature, rinse with water, then autoclave at 121°C for 30 minutes
• For noncritical items and environmental surfaces:
o Decontaminate with 1N sodium hydroxide or sodium hypochlorite (i.e. bleach) at room temperature for 1 hour.
• Anesthesia machines used for CJD patients should undergo thorough decontamination, including disposal of the breathing circuit and carbon dioxide absorbent.
• Consult the CDC recommendations for best infection control practices when working with patients with CJD.
Tuberculosis3,63-67
• Wear N95 respirators or higher-level respiratory protection.
• Place a HEPA filter between the breathing circuit Y-piece and patient's airway device.
• Perform high-level disinfection or sterilization on reusable equipment contacting patient's respiratory tract. Follow manufacturer's cleaning and sterilization instructions.
• Replace breathing circuit, reservoir bag, and carbon dioxide absorber after use.
• Routine anesthesia equipment culturing not recommended.
Environmental Surfaces
Healthcare facilities should establish and implement a comprehensive environmental cleaning and disinfection policy. This policy should specify:2,68-73
• Frequency and level of disinfection (e.g., high-level, low-level)
• List of EPA-registered disinfectants approved for use in the facility
• Staff training on proper cleaning and disinfection techniques
• Procedures for monitoring compliance and performance improvement
Cleaning and disinfection practices:2,68,69,71-74
• Procedures for monitoring compliance and performance improvement
• Clean and disinfect environmental surfaces to reduce transmission of HAIs from surfaces to providers and patients.
• Clean and disinfect anesthetizing locations and equipment surfaces (e.g., IV pumps, monitors, point-of-care devices, fluid warmers, forced air warmers) between patient cases and at the end of each day in accordance with facility policy.
• Follow manufacturer's recommendations for disinfectant use, contact time, and disposal.
• Place items that may be used during the next case on clean surfaces.
Product selection and use:68,69,71-74
• Use EPA-registered hospital-grade disinfectants appropriate for the surface and suspected pathogens.
• Ensure proper contact time is maintained for effective disinfection.
Follow CDC recommendations for Standard Precautions and Transmission-Based Precautions.69,75
76-78
Linens and Disposable Drapes
• Handle linens and disposable drapes in a manner that minimizes the transfer of blood and microorganisms.
• Handle contaminated laundry as little as possible. Avoid unnecessary agitation of used linens to prevent aerosolization of pathogens.
• Place and transport the laundry in labeled or color-coded bags or containers.
• Do not sort or rinse contaminated laundry in patient care areas. Avoid body contact with soiled items; use appropriate PPE.
• Place and transport contaminated laundry in leak-resistant bags or containers.
• When using Standard Precautions, alternative labeling or color-coding is acceptable if it allows all personnel to recognize the containers as requiring compliance with precautions
• Store clean, laundered items in a clean, dry area to prevent contamination
Biohazardous Waste Management69,79-84
Biohazardous waste refers to any item that is contaminated with infectious or potentially infectious materials. Sharps disposal is of particular concern due to the potential for injury when handling (e.g., needles, scalpel blades, drill bits, glass items).
• Dispose of all regulated waste in specified biohazard waste receptacles following federal, state, and local law and regulations.
• If a biohazardous waste container becomes contaminated, place the container inside of another biohazardous waste container.
• Consult relevant EPA and OSHA documents for specific guidance.
Single-Use Items
• Discard disposable single-use devices (e.g., breathing circuits, airway devices, orogastric tubes) in a biohazardous bag/container immediately after use.
Reprocessed Items
• Place items for reprocessing in a designated container immediately after use.
• Close containers before removing from the anesthetizing location.
Sharps Management
• Sharps include any device that may puncture skin (e.g., needles, syringes, scalpels, lancets, blades, glass).
• Use safety-engineered devices when possible.
• Do not bend or recap contaminated needles. If recapping is absolutely necessary, use a one-handed technique or mechanical device.
• Discard sharps immediately in a closeable, puncture-resistant, leak-proof container.
Drug Disposal
• Follow facility policy and applicable federal, state, and local law and regulations for disposal of partially remaining drugs in vials, ampules, syringes, and IV bags.
• Consider using EPA-registered pharmaceutical waste containers for certain medications.
References
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45. Hallo-Carrasco A, Gruenbaum BF, Gruenbaum SE. Heat and Moisture Exchanger Occlusion Leading to Sudden Increased Airway Pressure: A Case Report Using ChatGPT as a Personal Writing Assistant. Cureus. Apr 2023;15(4):e37306. doi:10.7759/cureus.37306
46. Brimacombe J, Stone T, Keller C. Supplementary cleaning does not remove protein deposits from re-usable laryngeal mask devices. Can J Anaesth. Mar 2004;51(3):254-7. doi:10.1007/BF03019106
47. Clery G, Brimacombe J, Stone T, Keller C, Curtis S. Routine cleaning and autoclaving does not remove protein deposits from reusable laryngeal mask devices. Anesth Analg Oct 2003;97(4):1189-1191. doi:10.1213/01.ANE.0000080154.76349.5B
48. Miller DM, Youkhana I, Karunaratne WU, Pearce A. Presence of protein deposits on 'cleaned' re-usable anaesthetic equipment. Anaesthesia. Nov 2001;56(11):1069-72. doi:10.1046/j.1365-2044.2001.02277.x
49. Coetzee GJ. Eliminating protein from reusable laryngeal mask airways. A study comparing routinely cleaned masks with three alternative cleaning methods. Anaesthesia. Apr 2003;58(4):346-53. doi:10.1046/j.1365-2044.2003.03084.x
50. Greenwood J, Green N, Power G. Protein contamination of the Laryngeal Mask Airway and its relationship to re-use. Anaesth Intensive Care. Jun 2006;34(3):343-6. doi:10.1177/0310057X0603400312
51. Bannon L, Brimacombe J, Nixon T, Keller C. Repeat autoclaving does not remove protein deposits from the classic laryngeal mask airway. Eur J Anaesthesiol. Jul 2005;22(7):515-7. doi:10.1017/s0265021505000888
52. Richards E, Brimacombe J, Laupau W, Keller C. Protein cross-contamination during batch cleaning and autoclaving of the ProSeal laryngeal mask airway. Anaesthesia. May 2006;61(5):431-3. doi:10.1111/j.1365-2044.2006.04550.x
53. Rutala WA, Weber DJ. Creutzfeldt-Jakob disease: recommendations for disinfection and sterilization. Clin Infect Dis. May 1 2001;32(9):1348-56. doi:10.1086/319997
54. Weber DJ, Rutala WA. Managing the risk of nosocomial transmission of prion diseases. Curr Opin Infect Dis. Aug 2002;15(4):421-5. doi:10.1097/00001432-200208000-00011
55. Centers for Disease Control and Prevention. Infection Control for CJD. Updated May 13, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/creutzfeldt-jakob/hcp/infectioncontrol/index.html
56. Brown P, Brandel JP, Sato T, et al. Iatrogenic Creutzfeldt-Jakob disease, final assessment. Emerg Infect Dis. Jun 2012;18(6):901-7. doi:10.3201/eid1806.120116
57. Washington State Department of Health. Human Prion Disease Infection Control Key Points. . Accessed Nov 16, 2024, https://doh.wa.gov/sites/default/files/legacy/Documents/5100/420-162PrionInfectionControl.pdf
58. Belay ED, Blase J, Sehulster LM, Maddox RA, Schonberger LB. Management of neurosurgical instruments and patients exposed to Creutzfeldt-Jakob disease. Infect Control Hosp Epidemiol. Dec 2013;34(12):1272-80. doi:10.1086/673986
59. World Health Organization Guidelines Guidelines on Transmissible Spongiform Encephalopathies in relation to Biological and Pharmaceutical Products. Accessed Nov 16, 2024, https://www.who.int/publications/m/item/who-guidelines-on-transmissiblespongiform-encephalopathies
60. Commonwealth of Australia. Department of Health and Aged Care. Creutzfeldt–Jakob disease – Infection control guidelines. Updated Jan 16, 2013. Accessed Apr 8, 2025, https://www.health.gov.au/resources/publications/creutzfeldt-jakob-disease-infectioncontrol-guidelines
61. UCSF Medical Center. Policies and Procedures for Patients with Suspected or Confirmed Human Prion DIsease (e.g., Creutzfeldt-Jakob Disease [CJD]). Updated Mar, 2022. Accessed Nov 16, 2024, https://infectioncontrol.ucsfmedicalcenter.org/sites/g/files/tkssra4681/f/Sec%204.2%20H uman%20Prion%20Policy_FINAL%2003-2022.pdf
62. Johnston L, Conly J. Creutzfeldt-Jakob disease and infection control. Can J Infect Dis Nov 2001;12(6):332-6. doi:10.1155/2001/786564
63. Centers for Disease Control and Prevention. Tuberculosis Infection Control. Updated Dec 15, 2023. Accessed Apr 8, 2025, https://www.cdc.gov/tb-healthcaresettings/hcp/infection-control/index.html
64. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. Dec 30 2005;54(Rr-17):1-141.
65. Krueger P, Klos C, Paulsen AW, et al. Cross-Contamination Via Anesthesia Equipment? Anesthesia Patient Safety Institute. 2009;24(1)
66. University of Texas Medical Branch. 01.21 – Tuberculosis (TB) Control Program. Updated Nov 20, 2023. Accessed Nov 17, 2024, https://www.utmb.edu/policies_and_procedures/NonIHOP/Healthcare_Epidemiology/01.21%20%20Tuberculosis%20(TB)%20Control%20Program.pdf
67. UNC Medical Center. Tuberculosis Control Plan. Updated Oct, 2022. Accessed Nov 17, 2024, https://spice.unc.edu/wp-content/uploads/2022/12/Tuberculosis-Control-Plan.pdf
68. Rutala WA, Weber DJ. Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach. Am J Infect Control Jun 2019;47s:A96-a105. doi:10.1016/j.ajic.2019.01.014
69. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. Dec 2007;35(10 Suppl 2):S65-164. doi:10.1016/j.ajic.2007.10.007
70. Centeleghe I, Norville P, Maillard JY, Hughes L. Infection prevention control in practice: a survey of healthcare professionals' knowledge and experiences. Infect Prev Pract. Jun 2024;6(2):100357. doi:10.1016/j.infpip.2024.100357
71. Link T. Guidelines in Practice: Environmental Cleaning. AORN J. May 2021;113(5):487499. doi:10.1002/aorn.13376
72. Facciolà A, Pellicanò GF, Visalli G, et al. The role of the hospital environment in the healthcare-associated infections: a general review of the literature. Eur Rev Med Pharmacol Sci. Feb 2019;23(3):1266-1278. doi:10.26355/eurrev_201902_17020
73. Dallolio L, Raggi A, Sanna T, et al. Surveillance of Environmental and Procedural Measures of Infection Control in the Operating Theatre Setting. Int J Environ Res Public Health. Dec 28 2017;15(1)doi:10.3390/ijerph15010046
74. Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcareassociated infections. Curr Opin Infect Dis. Aug 2013;26(4):338-44. doi:10.1097/QCO.0b013e3283630f04
75. Centers for Disease Control and Prevention. Transmission-Based Precautions Updated May 13, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/infectioncontrol/hcp/basics/transmission-based-precautions.html
76. Centers for Disease Control and Prevention. Appendix D - Linen and laundry management. Updated Mar 19, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendixd.html
77. Centers for Disease Control and Prevention. G. Laundry and Bedding. Updated Jan 8, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/infection-control/hcp/environmentalcontrol/laundry-bedding.html
78. Association of Surgical Technologists. AST Standards of Practice for Surgical Drapes. 2008;
79. Occupational Safety and Health Administration 1910.1030 - Bloodborne Pathogens (2019).
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81. Occupational Safety and Health Administration. Bloodborne Pathogens and Needlestick Prevention General Guidance. Accessed Apr 8, 2025, https://www.osha.gov/bloodbornepathogens/general
Infection Prevention and Control Guidelines for Anesthesia Care
Introduction
Chapter 4: Invasive Procedure Technique
Invasive procedures, such as catheter insertion, often expose patients and healthcare providers to heightened risk of infection transmission.1 Ensuring that proper measures are taken prior to performing invasive procedures helps prevent adverse events such as surgical site infections, central line-associated bloodstream infections, and catheter-associated urinary tract infections. Healthcare providers should perform hand hygiene immediately before patient contact, after contact with the patient or their surroundings, and before assembling equipment. All invasive procedures should be performed using appropriate aseptic or sterile technique, with proper personal protective equipment, and in accordance with facility policy. Patient education is a key component in care delivery, including providing information on the need for the device, the procedure, insertion, management, signs and symptoms of complications, risk of infection, and removal.2-4
Purpose
To outline evidence-based best practices in infection prevention and control, maintenance of sterility, and proper handling of invasive devices. By adhering to these recommendations, clinicians can minimize the risk of catheter-related bloodstream infections and ultimately improve patient outcomes and patient safety in acute and critical care settings.
Considerations for Ultrasound-Guided Procedures
Ultrasound guidance for procedures such as vascular access and catheter placement has been shown to reduce infection rates and improve patient satisfaction.5,6
• Site selection should consider factors such as vessel size, depth, course, surrounding structures, and adjacent pathology prior to access.5
• Prepare patient skin with an appropriate antiseptic agent.5,7,8
o Use single-use containers or sachets, as multi-use bottles can result in bacterial contamination.9
• Use a sterile sheath, sterile probe covers, and sterile ultrasound gel to mitigate the risk of contamination.7,8
• Disinfect ultrasound probes between each procedure and patient according to manufacturer directions.5,7,8,10-13
o Direct application of non-manufacturer-approved cleaning solutions to the transducer may result in damage.
Considerations for Epidural Catheters and Continuous Peripheral Nerve Block Catheters
• Perform thorough hand hygiene immediately before the procedure and prior to any catheter manipulation.14,15
• Adhere to strict aseptic technique and use single-use sterile ultrasound probe gel to prevent contamination during catheter placement.14-16
• Don appropriate personal protective equipment, including surgical masks, and consider sterile gowning, gloves, and caps during the procedure.14,15,17,18
• Prepare patient skin with an appropriate agent.15,19-25
• Dress the insertion site with a sterile transparent, occlusive dressing.15,16,22
o Use chlorhexidine-impregnated dressings at insertion sites to reduce epidural skin entry-point colonization.26-35
• Check the insertion site and overall patient status at least daily for:16,36,37
o Early signs of superficial infection (e.g., erythema, tenderness, itching at the site).
o Symptoms of deep infection (e.g., fever, back pain, lower limb weakness, headache).
o Changes in sensory or motor status.
• Maintain a closed system and minimize disconnections to reduce contamination risk.
• Change dressings according to facility policy or immediately if the dressing becomes damp, loosened, or visibly soiled.
• Remove the catheter once no longer clinically indicated according to institutional protocol.
Disconnected Catheters
Prolonged use of epidural catheters increases the risk of disconnection from the insertion site, significantly elevating the risk of infection.38-40 When a disconnected catheter is discovered, it is crucial to assess the situation immediately by considering the duration of disconnection, if known, the extent of fluid movement along the catheter, potential contamination, and the potential risk to the patient.40-42 The decision to reconnect or remove the catheter should be made by the anesthesia professional, or as addressed in facility policy.
If reconnection is considered, strict aseptic technique must be used so both the catheter and surrounding area remain sterile.18,42 Remove the catheter if there is any doubt about maintained sterility, visible contamination is present, or if static fluid has moved more than 5 inches from the disconnected end, or a distance defined in facility policy.41,43
Considerations for Central Venous Catheter Maintenance and Procedures
Central venous catheters (CVCs), also known as central lines, are used for rapid administration of fluids, blood products, and vasoactive medications.44,45 They also allow for hemodynamic monitoring and can be crucial for perioperative management.44,45 Strict adherence to evidencebased insertion techniques, maintenance protocols, and infection prevention strategies is crucial when inserting CVCs. This includes following manufacturer recommendations and facility policies for CVC care, encompassing sterile insertion techniques, proper site care, regular assessment for complications, and prompt removal when no longer clinically necessary.44,45 Table 8 describes the different types of CVCs.
Table 8. Examples and descriptions of Central Venous Catheters (CVCs).6,15,44-47
Catheter Type
Tunneled catheter (e.g., Hickman, Groshong®)
Non-tunneled catheter (e.g., Quinton)
Duration Description
Months to years
Peripherally-Inserted
Central Catheter (PICC)
Days to weeks, longer if needed
Weeks to months
• Surgically inserted, tunneled under skin
• Catheter and attachments emerge from underneath the skin.
• Lower infection risk than non-tunneled CVCs.
• Suitable for long-term therapy.
• Percutaneously inserted directly into central vein.
• Catheter attachments protrude directly.
• Common in critical care settings.
• Higher infection risk than tunneled CVCs.
• Inserted into peripheral vein in arm, threaded to central vein.
• Lower risk of insertion complications.
Implanted Port Years
• Suitable for intermediate to long-term therapy.
• Surgically implanted entirely under the skin.
• Inserted entirely under the skin.
• Medications administered through blunt needle (e.g., Huber needle) placed through the skin to the catheter.
Central Venous Catheter Insertion
In order to reduce the incidence of infections such as central line-associated bloodstream infections, the following is recommended for the proper insertion of a central line:
• Consider the risks and benefits of different insertion sites (e.g., subclavian, internal jugular, or femoral veins). Whenever possible, avoid using the femoral vein for central venous access in adult patients due to the higher risk of infection and other complications associated with this site.15,48,49
• Use a subclavian site, rather than a jugular or femoral site, in adult patients to minimize infection risk for non-tunneled CVC placement.15
• Perform hand hygiene. Use full barrier precautions, and don sterile gloves, sterile gown, surgical cap, and surgical mask.6,15,50-52 Cover the patient's entire body with a large sterile drape prior to insertion.6,15,50-52
• Prepare patient skin using appropriate agent.6,15,48,50-52
• Use ultrasound guidance for catheter insertion, following appropriate infection control technique with sterile sheathe and ultrasound gel.6,48,53-56
• Use antibiotic-impregnated catheters in patients whose catheter is expected to remain in place for more than five days.15
• Replace catheter promptly when safe to do so, when adherence to aseptic technique cannot be ensured (e.g., catheters inserted during a medical emergency). Do not routinely replace CVCs.15
• Remove any intravascular catheter promptly, according to institutional protocol, once it is no longer clinically indicated.15,52,56-59
• Perform surveillance for central line-associated bloodstream infection (CLABSI).6,50,56,6062
• For complete guidance, refer to the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections. 15
Central Venous Catheter Access
When accessing CVCs, closed access systems are preferred in addition to the following recommendations:
• Perform hand hygiene before accessing the catheter.
• Scrub the injection cap (e.g., needleless connector) with an appropriate antiseptic agent and allow to dry according to manufacturer recommendation.19,52,63
o For patients ≥2 months old, use 70% alcohol, povidone iodine, or >0.5% chlorhexidine with alcohol.29,31-33,35,48,64-66
o For patients <2 months old, povidone-iodine remains a recommended option.29,3133,35,48,64,65
• Access the injection port with a sterile syringe or intravenous tubing.63
o If necessary, open the clamp.63
• Maintain aseptic technique throughout the procedure.
Flushing Technique
Refer to the manufacturer instructions for the catheter and the needleless connector for the appropriate technique to use. Unless otherwise specified, perform the following:
• Perform hand hygiene before accessing the catheter and maintain aseptic technique throughout the flushing procedure.
• The type of flush (e.g., saline, heparin, dilute heparin), concentration, volume, and frequency of flushing should be determined in accordance with manufacturer indications for use and facility policy and per the treating clinician’s orders. Individualized patient needs should also be considered.63,67-71
• Use a single-use flushing system (e.g., single-dose vials, prefilled syringes) to reduce the risk of contamination.63,71
o Use a minimum of a 10 mL syringe to prevent excessive pressure that could damage the catheter.72,73
• Flush the catheter using a pulsatile or "push-pause" technique to create turbulence within the catheter lumen, which helps dislodge any adherent particles.63,71,72
• Maintain positive pressure at the end of the flush to prevent reflux of blood into the catheter tip.63,71,72
Positive Pressure Technique
The positive pressure technique is crucial for maintaining catheter patency and preventing blood reflux.63,71,72 However, its application may vary depending on the type of needleless connector used.74
For catheters with clamps:
• Flush the catheter using a pulsatile or "push-pause" technique to create turbulence within the catheter lumen, which helps dislodge any adherent particles.63,72
• Continue to hold the plunger of the syringe while closing the clamp on the catheter.
• Disconnect the syringe while maintaining positive pressure.63
For catheters without clamps:
• Withdraw the syringe as the last 0.5-1 mL of fluid is flushed to create a positive pressure effect.63
For neutral or positive displacement needleless connectors:
• Follow manufacturer-specific instructions, as these devices may have built-in mechanisms to prevent reflux.
Heparin Flushes
• Flushing CVCs with heparin solutions is a recommended practice despite the lack of conclusive evidence of efficacy and safety compared with 0.9% normal saline.63,67-70,75,76
• The choice between heparin and normal saline should be based on catheter type, patient factors, and institutional protocols.
• Heparin flushes are appropriate for maintaining patency of CVCs for dialysis.75
o For dialysis CVCs, heparin flushes are still commonly used, with higher concentrations sometimes employed for patients with evidence of occlusion or thrombosis.63,75
o The injected volume of the heparin flush should not exceed the internal volume of the catheter.75
Assessing Placement and Patency
• Aspirate catheter for blood return to initially assess correct placement within the vein, indicated by blood return in syringe.73,77,78
• After aspiration, immediately flush the catheter with saline using a pulsatile technique to:73,77,78
o Clear the catheter of blood to prevent clotting
o Assess patency
o Detect any resistance that might indicate catheter malposition or thrombosis
• Chest x-ray is recommended following any central line placement. For central venous catheters inserted in the internal jugular or subclavian veins, obtain a chest x-ray to confirm proper tip placement and rule out complications such as pneumothorax.6,44,45,79
Specimen Collection
• Access the catheter as outlined above, maintaining aseptic technique.
• Draw the first 3-5 mL of blood, dispose in an appropriate biohazardous waste receptacle, or return to the patient in accordance with the procedure or as indicated by patient’s medical status and institutional protocol.63
• Before specimen is collected, flush catheter in accordance with facility policy and per the treating clinician’s orders.
• Discard 1.5-2 times the volume of the internal catheter lumen before drawing the specimen.
• Collect the specimen using appropriate specimen tubes, blood culture bottles or syringes.63
• After specimen collection, flush the catheter as directed by facility policy and the treating clinician's orders.
• Assure the line ports and injection caps are tightly fastened and any clamps secured as flushing is completed and promptly dispose of used syringes.
Changing the Injection Cap (e.g., needleless connector)
• Change the injection cap immediately when there are signs of contamination (e.g., blood, precipitate) or damage (e.g., leaks, septum destruction). Otherwise, change the cap at least every 7 days or according to manufacturer recommendations and facility policy.63,80
• Scrub the injection cap and catheter hub with an appropriate antiseptic agent (e.g., 2% chlorhexidine in 70% isopropyl alcohol) and allow it to dry completely before accessing.63,73,80,81
• If necessary, clamp the catheter, or lower the patient to supine position, as the cap is removed to prevent air embolism or blood reflux.63,81
• Attach a new sterile cap to the catheter hub using aseptic technique.80,81
Site Dressing
• Use single-use, sterile supplies for site cleansing and dressing.63,80,81
o Refer to manufacturer recommendations to ensure compatibility with catheter material.
• Perform hand hygiene and wear sterile gloves for dressing changes.63,80
• Prepare patient skin with appropriate agent.
o When replacing the dressing, remove the existing dressing, visually inspect the site, and document findings before skin preparation.63,81
• Do not apply topical antibiotic ointment or cream to the catheter site, except for hemodialysis catheters, where povidone-iodine or bacitracin/gramicidin/polymyxin B ointment may be used.63,80,82
• Cover the site with either sterile gauze or a sterile, transparent, semipermeable dressing.63,80,81
• Replace or change dressing when indicated.63,80,81
Considerations for Implanted Ports
The following considerations outline high-level steps for managing implanted ports, located below the intact skin surface, emphasizing proper access, de-access, and maintenance procedures to minimize infection risks and maximize device longevity.
Additionally, patient education is an important step in implanted port management, as it significantly improves patients' knowledge, confidence, and ability to participate in their care, ultimately leading to better outcomes and reduced complications.2,83
Port Access Procedure
• Pre-Procedure Assessment63,84-88
o Perform hand hygiene and don clean gloves.
o Consider using local anesthetic for patient comfort.
o Examine the port site for complications such as swelling, erythema, drainage, leakage, pain, or tenderness.
o Palpate the outline of the port to identify the insertion diaphragm.
▪ Mark location on patient skin for blunt needle insertion.
• Preparation63,84-88
o Remove gloves, perform hand hygiene, and don new sterile gloves.
o Prepare a sterile field with necessary supplies.
o Clean the port site with an appropriate antiseptic solution (e.g., chlorhexidine-alcohol) and allow it to dry.
• Port Access63,84-88
o Stabilize port with one hand and insert a non-coring needle (e.g., sterile Huber needle) until the needle contacts the back of the port. Gently push the needle through the diaphragm.
o Aspirate blood to confirm proper placement and patency.
• Post-Access Care63,84-88
o Flush the port with 10-20 mL of normal saline using a pulsatile technique.
o Secure the needle with a sterile transparent dressing or tape.
o Stabilize needle/port with tape, securement device, or stabilization device.
o For short-term use (e.g., outpatient treatment), apply gauze and tape.
Port De-access Procedure63,84-89
• Perform hand hygiene and don clean gloves.
• Flush the port catheter in accordance with facility policy and per the treating clinician’s orders.
• Remove the dressing.
• Stabilize port with one hand and remove needle with the other hand.
• Maintain positive pressure while de-accessing by flushing the catheter while withdrawing the needle from the septum.
• Apply dressing.
Port Maintenance and Care63,83-88
• For short-term use in outpatient settings, a sterile transparent dressing or gauze may be used in place of an occlusive dressing during the infusion.
• Ensure the needle is secure in the portal septum as described above.
• When not in use, implanted ports should be flushed every four to eight weeks to maintain patency.
Considerations for Arterial Catheters and Pressure Monitoring Devices
• Catheters that need to be in place for > five days should not be routinely changed if no evidence of infection is observed.15
• Maintain sterility of stopcocks: cap when not in use: apply 70 percent alcohol prior to access.15
• Maintain the sterility of the entire monitoring system, including pressure transducers and flush solution
• Minimize the number of manipulations and entries into the pressure monitoring system.
• 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.
o Use sterile devices to access the pressure monitoring system through a diaphragm.
• Sterilize reusable transducers according to the manufacturers' instructions if used.
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23. Birnbach DJ, Meadows W, Stein DJ, Murray O, Thys DM, Sordillo EM. Comparison of povidone iodine and DuraPrep, an iodophor-in-isopropyl alcohol solution, for skin disinfection prior to epidural catheter insertion in parturients. Anesthesiology. Jan 2003;98(1):164-9. doi:10.1097/00000542-200301000-00026
24. Kinirons B, Mimoz O, Lafendi L, Naas T, Meunier J, Nordmann P. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anesthesiology. Feb 2001;94(2):239-44. doi:10.1097/00000542-200102000-00012
25. Krobbuaban B, Diregpoke S, Prasan S, Thanomsat M, Kumkeaw S. Alcohol-based chlorhexidine vs. povidone iodine in reducing skin colonization prior to regional anesthesia procedures. J Med Assoc Thai. Jul 2011;94(7):807-12.
26. Shapiro JM, Bond EL, Garman JK. Use of a chlorhexidine dressing to reduce microbial colonization of epidural catheters. Anesthesiology. Oct 1990;73(4):625-31. doi:10.1097/00000542-199010000-00007
27. Masferrer E, Riera-Rodríguez L, Farré-Alins V, Vilà de Muga S, Arroyo-Muñoz FJ, González-Caro MD. Randomized controlled trial on healthy volunteers of
pharmacokinetic and antimicrobial activity of a novel hydrogel-containing chlorhexidine dressing to prevent catheter-related bloodstream infection. Front Med (Lausanne). 2023;10:1335364. doi:10.3389/fmed.2023.1335364
28. Arvaniti K, Lathyris D, Clouva-Molyvdas P, et al. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: a multicenter, randomized, controlled study. Crit Care Med. Feb 2012;40(2):420-9. doi:10.1097/CCM.0b013e31822f0d4b
29. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol. Mar 2009;88(3):267-72. doi:10.1007/s00277-008-0568-7
30. Timsit JF, Mimoz O, Mourvillier B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med. Dec 15 2012;186(12):1272-8. doi:10.1164/rccm.201206-1038OC
31. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA. Mar 25 2009;301(12):1231-41.
doi:10.1001/jama.2009.376
32. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics. Jun 2001;107(6):1431-6. doi:10.1542/peds.107.6.1431
33. Levy I, Katz J, Solter E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J. Aug 2005;24(8):676-9. doi:10.1097/01.inf.0000172934.98865.14
34. Düzkaya DS, Sahiner NC, Uysal G, Yakut T, Çitak A. Chlorhexidine-Impregnated Dressings and Prevention of Catheter-Associated Bloodstream Infections in a Pediatric Intensive Care Unit. Crit Care Nurse. Dec 2016;36(6):e1-e7. doi:10.4037/ccn2016561
35. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother. Aug 2006;58(2):281-7. doi:10.1093/jac/dkl234
36. Holt HM, Andersen SS, Andersen O, Gahrn-Hansen B, Siboni K. Infections following epidural catheterization. J Hosp Infect. Aug 1995;30(4):253-60. doi:10.1016/01956701(95)90259-7
37. Helander EM, Kaye AJ, Eng MR, et al. Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review. Curr Pain Headache Rep. May 23 2019;23(6):43. doi:10.1007/s11916-019-0782-0
38. Ishida Y, Homma Y, Kawamura T, Sagawa M, Toba Y. Accidental epidural catheter removal rates and strength required for disconnection: a retrospective cohort and laboratory study. BMC Anesthesiol. Jun 16 2022;22(1):185. doi:10.1186/s12871-02201728-z
39. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med. Jul-Aug 2006;31(4):311-23. doi:10.1016/j.rapm.2006.04.004
40. Fragneto RY. The broken epidural catheter: an anesthesiologist's dilemma. J Clin Anesth. Jun 2007;19(4):243-4. doi:10.1016/j.jclinane.2007.01.002
41. Langevin PB, Gravenstein N, Langevin SO, Gulig PA. Epidural catheter reconnection. Safe and unsafe practice. Anesthesiology. Oct 1996;85(4):883-8. doi:10.1097/00000542-199610000-00025
42. Scholle D, Kipp F, Reich A, Freise H. Influence of protective measures after epidural catheter disconnection on catheter lumen colonization: an in vitro study. J Hosp Infect Feb 2014;86(2):133-7. doi:10.1016/j.jhin.2013.12.001
43. Parry G. What do we do with a disconnected epidural catheter? Can J Anaesth. May 2003;50(5):523. doi:10.1007/bf03021070
44. Kolikof J, Peterson K, Baker AM. Central Venous Catheter. [Updated 2023 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557798/
45. Leib AD, England BS, Kiel J. Central Line. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519511/
46. Centers for Disease Control and Prevention. Background Information: Catheter Types. Updated Apr 12, 2022. Accessed Apr 8, 2025, https://www.cdc.gov/infectioncontrol/hcp/intravascular-catheter-related-infection/table-1-catheter-types.html
47. Gonzalez R, Cassaro S. Percutaneous Central Catheter. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459338/
48. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. May 2022;43(5):553-569. doi:10.1017/ice.2022.87
49. de Grooth HJ, Hagel S, Mimoz O. Central venous catheter insertion site and infection prevention in 2024. Intensive Care Med. Sep 30 2024;doi:10.1007/s00134-024-07664-5
50. Centers for Disease Control and Prevention. National Healthcare Safety Network. Central Line Insertion Practices (CLIP) Adherence Monitoring. Updated Jan 2024. Accessed Apr 8, 2025, https://www.cdc.gov/nhsn/pdfs/pscmanual/5psc_clipcurrent.pdf
51. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. Jan 2020;132(1):8-43. doi:10.1097/aln.0000000000002864
52. Centers for Disease Control and Prevention. Checklist for Prevention of Central Line Associated Blood Stream Infections. Accessed Apr 8, 2025, https://www.cdc.gov/healthcare-associated-infections/media/pdfs/checklist-for-CLABSIP.pdf
53. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162. doi:10.1186/cc5101
54. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. Aug 16 2003;327(7411):361. doi:10.1136/bmj.327.7411.361
55. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. Jan 9 2015;1(1):Cd006962. doi:10.1002/14651858.CD006962.pub2
56. Buetti N, Mimoz O, Mermel L, et al. Ultrasound Guidance and Risk for Central Venous Catheter-Related Infections in the Intensive Care Unit: A Post Hoc Analysis of Individual Data of 3 Multicenter Randomized Trials. Clin Infect Dis. Sep 7 2021;73(5):e1054e1061. doi:10.1093/cid/ciaa1817
57. van der Kooi T, Sax H, Pittet D, et al. Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Med. Jan 2018;44(1):48-60. doi:10.1007/s00134-017-5007-6
58. Cload B, Day AG, Ilan R. Evaluation of unnecessary central venous catheters in critically ill patients: a prospective observational study. Can J Anaesth. Sep 2010;57(9):830-5. doi:10.1007/s12630-010-9348-7
59. Rotz S, Sopirala MM. Assessment beyond central line bundle: audits for line necessity in infected central lines in a surgical intensive care unit. Am J Infect Control. Feb 2012;40(1):88-9. doi:10.1016/j.ajic.2011.06.004
60. Marschall J, Leone C, Jones M, Nihill D, Fraser VJ, Warren DK. Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study. Infect Control Hosp Epidemiol. Aug 2007;28(8):905-9. doi:10.1086/519206
61. Gastmeier P, Geffers C, Brandt C, et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect. Sep 2006;64(1):16-22. doi:10.1016/j.jhin.2006.04.017
62. Zingg W, Sax H, Inan C, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. J Hosp Infect. Sep 2009;73(1):41-6. doi:10.1016/j.jhin.2009.05.015
63. Centers for Disease Control and Prevention. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings. Updated Apr 15, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/healthcare-associated-infections/hcp/preventionhealthcare/infection-control-outpatient-oncology.html
64. Ullman AJ, Cooke ML, Mitchell M, et al. Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review. Int J Nurs Stud. Jul 2016;59:177-96. doi:10.1016/j.ijnurstu.2016.04.003
65. Puig-Asensio M, Marra AR, Childs CA, Kukla ME, Perencevich EN, Schweizer ML. Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol. Dec 2020;41(12):1388-1395. doi:10.1017/ice.2020.356
66. Jones K. Centers for Disease Control and Prevention. Maintenance and Removal of Central Venous Catheters. Accessed Apr 8, 2025, https://www.cdc.gov/infectioncontrol/media/pdfs/Strive-CLABSI104-508.pdf
67. Nascimento APD, de Medeiros KS, Costa APF, et al. Heparin versus 0.9% sodium chloride intermittent flushing for preventing occlusion in newborns with peripherally inserted central catheters: A systematic review protocol. PLoS One. 2022;17(12):e0278068. doi:10.1371/journal.pone.0278068
68. Bradford NK, Edwards RM, Chan RJ. Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children. Cochrane Database Syst Rev. Apr 30 2020;4(4):Cd010996. doi:10.1002/14651858.CD010996.pub3
69. Bradford NK, Edwards RM, Chan RJ. Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children. Cochrane Database Syst Rev. Nov 23 2015;(11):Cd010996. doi:10.1002/14651858.CD010996.pub2
70. López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Martí S, Carbonell Sanchis R. Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults. Cochrane Database Syst Rev 2022;(7)doi:10.1002/14651858.CD008462.pub4
71. Cullinane C. Right Management and Flushing. In: Moureau NL, ed. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer International Publishing; 2019:243-261.
72. Goossens GA. Flushing and Locking of Venous Catheters: Available Evidence and Evidence Deficit. Nurs Res Pract. 2015;2015:985686. doi:10.1155/2015/985686
74. Cancer Nurses Society of Australia. Needleless Connector & Patency. Accessed Oct 13, 2024, https://www.cnsa.org.au/practiceresources/vascular-accessguidelines/needleless-connector-and-patency
75. Moran JE, Ash SR. Locking solutions for hemodialysis catheters; heparin and citrate a position paper by ASDIN. Semin Dial. Sep-Oct 2008;21(5):490-2. doi:10.1111/j.1525139X.2008.00466.x
76. Sharma SK, Mudgal SK, Gaur R, Sharma R, Sharma M, Thakur K. Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis. J Family Med Prim Care. Sep 2019;8(9):2779-2792. doi:10.4103/jfmpc.jfmpc_669_19
77. Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 4 Aseptic Technique. Available from: https://www.ncbi.nlm.nih.gov/books/NBK596727/
78. Weston V. Assessment for Catheter Function, Dressing Adherence and Device Necessity. In: Moureau NL, ed. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer International Publishing; 2019:219-233:chap 17.
79. Tse A, Schick MA. Central Line Placement. [Updated 2022 Dec 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470286/.
80. Ball M, Singh A. Care of a Central Line. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564398/.
81. Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Advanced Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 4 Manage Central Lines. Available from: https://www.ncbi.nlm.nih.gov/books/NBK594495/.
82. Centers for Disease Control and Prevention. Best Practices for Bloodstream Infection Prevention in Dialysis Setting. Updated Mar 29, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/dialysis-safety/hcp/clinical-safety/
83. Piredda M, Migliozzi A, Biagioli V, Carassiti M, De Marinis MG. Written Information Improves Patient Knowledge About Implanted Ports. Clin J Oncol Nurs. Apr 2016;20(2):E28-33. doi:10.1188/16.Cjon.E28-e33
84. Vanderbilt University Medical Center. Clinical Skills Implanted Venous Port: Access, Deaccess, and Care. Accessed Oct 22, 2024, www.vumc.org/periopservices/sites/default/files/public_files/Implanted-venous-port.pdf
85. pfm medical gmbh. Nursing Guide Port Care and Port Access Procedure. Accessed Oct 22, 2024, https://www.pfmmedical.com/fileadmin/redaktion/documents/marketingmaterial/ica/broch ures/PB2010EN_Nursing_Guide.pdf
86. Interdisciplinary Clinical Practice Manual, Infection Control, Vascular Access Device (VAD) Policy, Adult. Appendix L: Accessing/Deaccessing Implanted Central Venous
Access Port. Accessed Oct 22, 2024, https://safercare.s3.amazonaws.com/support_media/docs/clabsi/VAD_APPX/Appendix_ L-Accessing_Deaccessing_Implanted_Central_Venous_Access_Port.pdf
87. Access Device Guidelines: Recommendations for Nursing Practice and Education. 4th ed. Oncology Nursing Society; 2023.
88. Chou PL, Fu JY, Cheng CH, et al. Current port maintenance strategies are insufficient: View based on actual presentations of implanted ports. Medicine (Baltimore). Nov 2019;98(44):e17757. doi:10.1097/md.0000000000017757
89. CarePro Health Services. Accessing and Flushing an Implanted Port Removal of Noncoring Needle. Accessed Oct 22, 2024, https://www.careprohs.com/handlers/securedocument-handler.php?file=02cbc61369181fdc2f314b1b82a12390.pdf
Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 5: Vaccinations, Post Exposure Prophylaxis, and Screening
Introduction
Preventive measures like vaccinations, prophylaxis, and screening tests are important for protecting healthcare providers from contracting and spreading infectious diseases in healthcare settings.1 Healthcare facilities may establish policies requiring certain vaccinations for their healthcare personnel, which has been shown to increase vaccination coverage rates among providers.1-4 However, when implementing vaccination policies, facilities must comply with applicable local, state, and federal laws and regulations, as well as accreditation standards.2 Facilities should provide reasonable accommodations for personnel who are exempt from mandatory vaccination.5 For specific clinical guidance on dosing, contraindications, and other details for each vaccine, healthcare providers should consult the package inserts and recommendations provided by the vaccine manufacturers.
Purpose
This chapter outlines preventive measures to protect healthcare providers from occupational exposures to infectious diseases like influenza, hepatitis B, SARS-CoV-2, and tuberculosis. It covers recommended vaccinations, post-exposure protocols, screening tests, and guidance for healthcare facilities to establish effective policies and maintain compliance with regulations.
Seasonal Influenza (Flu) Vaccination
The CDC recommends that all healthcare providers receive an annual influenza vaccine.1,3,6-8 Facilities may encourage healthcare providers to obtain required vaccinations through interventions such as making vaccine available at no cost at the workplace along with active promotion of vaccination to increase vaccination rates among healthcare provider.1 Healthcare personnel who receive the live attenuated influenza vaccine (LAIV4) should avoid contact with severely immunosuppressed patients for 7 days after vaccination.9 If a healthcare provider is unable to obtain the influenza vaccine, facility policy should be consulted regarding patient care.
Hepatitis B Vaccination
The risk of HBV transmission to healthcare professionals is 3-5 times higher than to the general public.6,10-12 Healthcare providers who perform tasks that may involve exposure to blood or body fluids should consider receiving a three-dose series of hepatitis B vaccine at 0-, 1-, and 6-month intervals, as appropriate for the vaccine brand.10,13,14 Test for hepatitis B surface antibody (antiHBs) to document immunity 1-2 months after the third dose.10 Positive results for anti-HBs equal to or >10 mIU/mL confirm immunization.9,10,14
SARS-CoV-2 Vaccination
Healthcare workers have an increased risk of exposure to SARS-CoV-2 and studies show COVID-19 vaccines are effective at preventing transmission in real-world conditions.15,16 The AANA supports offering COVID-19 vaccinations to frontline healthcare personnel, including CRNAs and nurse anesthesiology students. The AANA strongly encourages healthcare personnel to be vaccinated to protect their patients, colleagues, families, and themselves. While vaccine hesitancy exists among some patients and healthcare providers, AANA encourages education and review of scientific evidence about the vaccine and its impact on infection prevention, patient care, infection spread, and herd immunity.
Post-Exposure Prophylaxis (PEP)
In the event of a high-risk exposure, such as needlestick injury, to hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), or Mycobacterium tuberculosis (TB), healthcare providers should immediately review and follow their facility's policies and procedures.
PEP for HIV
• PEP for HIV should be initiated as soon as possible, ideally within 2 hours but no later than 72 hours after potential exposure, and consists of a 28-day course of two or three antiretroviral medications.17-20
• Following PEP administration, healthcare providers should follow up with HIV testing at baseline, 4-6 weeks, 3 months, and 6 months post-exposure, and should be educated about the importance of adherence to the full 28-day regimen, potential side effects, and the need for additional precautions to prevent HIV transmission during the follow-up period.17-20
Tuberculosis Screening
• Healthcare providers who may have occupational exposure should receive annual TB skin testing (Mantoux tuberculin skin test) or blood tests, as well as post-exposure testing.
o A positive TB skin test (Mantoux tuberculin skin test) or TB blood test only indicates that a person has been infected with TB bacteria. It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB disease.21-23
o Other tests, such as a chest x-ray and a sample of sputum, determine the presence of active TB disease, in accordance with symptoms such as fever, weight loss, and night sweats.22,23
• Review facility policy for specific guidelines for identification, reporting, and management of an active TB case.
o Facility policies should be implemented in accordance with Occupational Safety and Health Administration (OSHA) and state health department standards.24
o Refer to the Equipment and Environmental Cleaning, Disinfection, and Sterilization chapter for information regarding the use of filters and appropriate cleaning procedures for the anesthesia machine following a suspected case of active TB.
References
1. Lu PJ, O'Halloran AC, Ding H, Williams WW, Black CL. Influenza Vaccination of Healthcare Personnel by Work Setting and Occupation-U.S., 2014. Am J Prev Med. Dec 2016;51(6):1015-1026. doi:10.1016/j.amepre.2016.08.038
2. Lindley MC, Mu Y, Hoss A, et al. Association of State Laws With Influenza Vaccination of Hospital Personnel. Am J Prev Med. Jun 2019;56(6):e177-e183. doi:10.1016/j.amepre.2019.01.011
3. Frederick J, Brown AC, Cummings DA, et al. Protecting Healthcare Personnel in Outpatient Settings: The Influence of Mandatory Versus Nonmandatory Influenza Vaccination Policies on Workplace Absenteeism During Multiple Respiratory Virus Seasons. Infect Control Hosp Epidemiol. Apr 2018;39(4):452-461. doi:10.1017/ice.2018.9
4. Lee JT, Sean Hu S, Zhou T, et al. Employer requirements and COVID-19 vaccination and attitudes among healthcare personnel in the U.S.: Findings from National
Immunization Survey Adult COVID Module, August - September 2021. Vaccine. Dec 5 2022;40(51):7476-7482. doi:10.1016/j.vaccine.2022.06.069
5. U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. Updated May 15, 2023. Accessed Sept 15, 2023, https://www.eeoc.gov/wysk/what-you-should-knowabout-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws
6. Centers for Disease Control and Prevention. What Vaccines are Recommended for You. Updated Sept 8, 2023. Accessed Sept 15, 2023, https://www.cdc.gov/vaccines/adults/rec-vac/index.html
7. Grohskopf LA, Blanton LH, Ferdinands JM, Chung JR, Broder KR, Talbot HK. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, 2023–24 Influenza Season. MMWR Recomm Rep. 2023;72(No. RR-2):1–25. doi:http://dx.doi.org/10.15585/mmwr.rr7202a1
8. Centers for Disease Control and Prevention. 2023-2024 CDC Flu Vaccination Recommendations Adopted. Updated Jun 29, 2023. Accessed Apr 8, 2025, https://www.cdc.gov/flu/spotlights/2022-2023/flu-vaccination-recommendationsadopted.htm
9. Centers for Disease Control and Prevention. Summary: ‘Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) United States, 2023-24’. Updated Aug 23, 2023. Accessed Sept 15, 2023, https://www.cdc.gov/flu/professionals/acip/summary/summaryrecommendations.htm
10. de Geus JL, Koch LFA, Kintopp C, et al. Are healthcare workers immunized after receiving hepatitis B vaccination according to recommended guidelines? A systematic review and meta-analysis. Int J Health Sci (Qassim). Jan-Feb 2021;15(1):35-42.
11. Byrd KK, Lu PJ, Murphy TV. Hepatitis B vaccination coverage among health-care personnel in the United States. Public Health Rep. Nov-Dec 2013;128(6):498-509. doi:10.1177/003335491312800609
12. Nikolopoulou GB, Tzoutzas I, Tsakris A, Maltezou HC. Hepatitis B in Healthcare Personnel: An Update on the Global Landscape. Viruses. Dec 18 2023;15(12)doi:10.3390/v15122454
13. Weng MK, Doshani M, Khan MA, et al. Universal Hepatitis B Vaccination in Adults Aged 19-59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep. Apr 1 2022;71(13):477483. doi:10.15585/mmwr.mm7113a1
15. Centers for Disease Control and Prevention. Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2. Updated March 18, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/covid/hcp/infection-control/guidancerisk-assesment-hcp.html?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019ncov/hcp/guidance-risk-assesment-hcp.html
16. Centers for Disease Control and Prevention. CDC Real-World Study Confirms Protective Benefits of mRNA COVID-19 Vaccines. Updated Mar 21, 2021. Accessed Apr 8, 2025, 2021. https://archive.cdc.gov/www_cdc_gov/media/releases/2021/p0329-COVID-19Vaccines.html
17. Centers for Disease Control and Prevention. Post-Exposure Prophylaxis (PEP). Updated Aug 24, 2022. Accessed Jul 9, 2024, https://www.cdc.gov/hiv/risk/pep/index.html
18. DeHaan E, McGowan JP, Fine SM, et al. Johns Hopkins University. PEP to Prevent HIV Infection. Accessed Jul 9, 2024, https://www.ncbi.nlm.nih.gov/books/NBK562734/table/nycgpep.tab21/
19. National Clinician Consultation Center. PEP Quick Guide for Occupational Exposures. Updated Jun 18, 2021. Accessed Jul 9, 2024, https://nccc.ucsf.edu/clinicalresources/pep-resources/pep-quick-guide-for-occupational-exposures/
20. Markelz AE. Postexposure HIV Prophylaxis in Physicians and Medical Personnel. Medscape. Updated Nov 18, 2022. Accessed Jul 9, 2024, https://emedicine.medscape.com/article/1991375-overview
21. Centers for Disease Control and Prevention. Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test. Updated Jan 31, 2025. Accessed Apr 8, 2025, https://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm
22. Centers for Disease Control and Prevention. Testing for Tuberculosis. Updated June 17, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/TB/TOPIC/testing/default.htm
23. Centers for Disease Control and Prevention. Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. Updated Apr 2, 2024. Accessed May 14, 2024, https://www.cdc.gov/tb/hcp/education/latent-tb-infection-guide-primary-careproviders.html?CDC_AAref_Val=https://www.cdc.gov/tb/publications/ltbi/default.htm
24. Occupational Safety and Health Administration. Tuberculosis. Accessed May 14, 2024, https://www.osha.gov/tuberculosis
Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 6: Role of the CRNA in Reducing Ventilator-Associated Pneumonia and Surgical Site Infection
Introduction
Ventilator-Associated Pneumonia (VAP) and Surgical Site Infection (SSI) are two significant healthcare-associated infections (HAIs) that can lead to increased morbidity, mortality, and healthcare costs. There are other HAIs that may pose a risk to patients, this chapter will focus on VAP and SSI as these infections are ones that anesthesia providers can directly mitigate. The following section outlines key prevention strategies for anesthesia professionals to mitigate the risk of these adverse events.
Purpose
The purpose of this chapter is to outline key prevention strategies for anesthesia professionals to mitigate the risk of VAP and SSI.
Ventilator-Associated Pneumonia
VAP is hospital-acquired pneumonia that develops 48 hours or longer in patients who have been mechanically ventilated by endotracheal tube (ETT) or tracheostomy.1-3 VAP is reported to affect 5 to 40% of patients receiving invasive mechanical ventilation for more than 2 days, with large variations depending upon the country, ICU type, and criteria used to identify VAP.1,2 VAP is a serious healthcare-associated infection that can lead to significant morbidity, mortality, and increased healthcare costs.4-9 Clinical signs of VAP include purulent tracheal discharge, fevers, and respiratory distress in the presence of microorganisms.10 Studies have attempted to quantify the economic burden of VAP and have reported costs ranging from $10,000 to $40,000 per patient treated.4,5,7-9
Implementing the following ventilator bundle compliance prevention strategies may reduce the burden of VAP and improve patient outcomes.2,11-22
• Practice hand hygiene before and after patient care.
• Use noninvasive ventilation when possible to avoid intubation and associated risks.
• Extubate as early as possible to minimize duration of invasive ventilation.
• Prevent aspiration by:
o Maintaining semirecumbent position (30-40 degrees) if possible.
o Avoiding gastric overdistention.
o Avoiding unplanned extubation and reintubation.
o Using cuffed endotracheal tubes with subglottic suctioning.
o Maintaining cuff pressure of ≥ 20cm H2O.
• Avoid nasotracheal intubation.
• Avoid acid suppressive therapy (i.e., H2 blockers, proton pump inhibitors), if possible, due to risk of increasing bacterial colonization of the aerodigestive tract. If clinically indicated, use the lowest possible dose and duration of acid suppressive therapy to reduce risk of bacterial colonization.
• Perform regular oral care with an antiseptic solution.
• Eliminate potential contamination risk to equipment:
o Using sterile water to rinse reusable equipment.
o Removing condensate from ventilator circuits.
o Changing circuits only when visibly soiled.
o Using sterile suction catheters.
Surgical Site Infection
SSI is an infection occurring at or near the surgical site within 30 days of the surgical procedure or within 90 days of implantation of prosthetic materials.23 SSIs can be classified as superficial or deep, involving tissues beneath the skin, surrounding organs, or implanted materials.23 SSIs can be caused by a myriad of bacteria, including the patient’s own endogenous flora. SSIs are costly and pose a risk to patient safety. SSIs account for 20% or more of all HAIs and affect up to 3% of all surgical patients, with variation based on type of surgery, patient co-morbidities, length of operation, increasing mortality 2- to 10-fold.24-29 SSIs are the most costly HAI with an estimated annual cost of $3.3 billion, and extend hospital length of stay by 9.7 days, with cost of hospitalization increased by more than $20,000 per admission.7,26,27,29
It is estimated that over half of SSIs are preventable by the use of evidence-based measures.30 CRNAs can play an active role in SSI mitigation by deploying an SSI prevention bundle, which includes performing enhanced SSI surveillance to determine the source, extent, and potential solutions to the problem.
Hand Hygiene
Hand hygiene interrupts the transmission of pathogens between healthcare providers, patients, and contaminated surfaces/fomites in the patient's environment.31-34 While studies demonstrate that hand hygiene plays an important role in reducing healthcare acquired infections, compliance rates among anesthesia professionals is poor.32,3537 Strategic placement of alcohol-based hand sanitizer dispensers near the anesthesia work area is recommended to improve hand hygiene compliance and facilitate SSI prevention.38,39
Equipment and Environment Cleaning
Cross-transmission of bacteria can occur in the anesthesia work area on surfaces like equipment (e.g., IV poles), anesthesia carts, anesthesia machines, and computers.34,40,41 Proper cleaning, disinfection, and sterilization, as appropriate, of anesthesia equipment and the anesthesia machine are important to prevent SSIs.40,41 Recommended precautions include:
• Cleaning and then disinfecting anesthesia machine surfaces, knobs, and high-touch areas like keyboards between cases and at the end of the day with an appropriate germicide.
• Taking protective measures to prevent contamination of materials stored on the anesthesia machine from becoming inadvertently contaminated by airborne debris (e.g., blood).40
Maintenance of Normothermia
Perioperative hypothermia is defined as the reduction in body temperature to less than 36°C in the perioperative period.42 Prevention of intraoperative hypothermia has been shown to significantly reduce the incidence of SSIs.43-45 Hypothermia triggers vasoconstriction and tissue hypoxia, which can impair wound healing and increase SSI risk.43 Hypothermia can also impair the function of neutrophils, further reducing the body’s protection against infection.46,47
CRNAs should maintain normothermia for the patient during surgery.43-45 The method of maintaining normothermia is patient and procedure dependent, and may include passive warming measures (e.g., blankets, surgical drapes) or active warming measures (e.g. forced air warming devices, underbody warming mattresses, fluid warmers for intravenous and irrigation fluids, radiant warmers). There continues to be debate regarding forced air warming and its relationship to SSIs, therefore each anesthesia professional must determine what is more appropriate for their patient and follow relevant facility policies and protocols for patient warming.48-66
Document measures taken to maintain patient normothermia, including the warming method used, warming device identifier, and temperature settings when applicable.67
Strict Glycemic Control
Hyperglycemia is associated with a higher risk of developing SSIs.44,68-70 Surgical stress triggers the release cortisol, leading to hyperglycemia and insulin resistance.70 Hyperglycemia impairs neutrophil function and immune response, increasing susceptibility to infections.71,72 During the perioperative period, short-term strict glycemic control has been shown to be more important than long-term glycemic management in reducing SSI risk.27,68-70,73 Recommendations range from blood glucose levels less than 200 mg/dL to as low as 110-150 mg/dL.27,30,68-71,74-76 For cardiac patients, the target is less than 180 mg/dL or lower.71,77-79
More information about perioperative glycemic control can be found in the AANA Enhanced Recovery After Surgery, Considerations for Pathway Development and Implementation
Fluid Management – Normovolemia
Perioperative fluid therapy helps maintain adequate tissue perfusion and oxygenation, which is important for wound healing and preventing SSIs.71,80,81 Both hypovolemia and hypervolemia can impair wound healing and increase SSI risk.80-83 Specifically, hypovolemia can cause vasoconstriction and a reduction in perfusion, resulting in decreased oxygen delivery to organs and peripheral tissues.80,81,84 Hypervolemia results in tissue edema, local inflammation, and impaired collagen synthesis, which can lead to infection and wound dehiscence.80,81,84
Current recommendations include adherence to goal-directed fluid therapy (GDFT) protocols rather than standard fluid management calculations.81,83,85,86 To decrease variability in fluid administration during surgery and to improve outcomes, it is important to tailor GDFT protocols to each patient’s unique surgical and patient risk factors.85 This can be achieved with an individualized patient and procedure fluid management plan. GDFT maintains intraoperative normovolemia by monitoring stroke volume, cardiac output, and/or oxygen delivery to avoid hypovolemia and postoperative oxygen debt.76,85,87-90
More information about GDFT can be found in the AANA Enhanced Recovery After Surgery, Considerations for Pathway Development and Implementation
Perioperative Antibiotic Administration
Optimizing perioperative antimicrobial dosing, timing, and selection of the appropriate antibiotic agent typically fall under the anesthesia professional’s responsibilities.91 Most guidelines recommend administering prophylactic antibiotics within 60 minutes prior to surgical incision and 120 minutes prior to incision for antibiotics like vancomycin and fluoroquinolones that have longer infusion times.92-95 Studies suggest administering cephalosporin antibiotics (e.g., cefazolin) ≤ 30 minutes prior to incision, which may be more effective in reducing SSI risk compared to the 60 minutes prior.92,94,95
Blood Loss Prevention
Blood transfusions have been associated with an increased risk of developing SSIs due to their immunosuppressive effects.74,96 It is important for anesthesia providers to take steps to reduce the need for transfusion. However, blood products should never be withheld if clinically indicated, as inadequate tissue oxygenation from undertransfusion can also impair wound healing and increase infection risk.74,96
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Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 7: Pandemic Preparedness
Introduction
The COVID-19 pandemic fundamentally transformed our understanding of global health preparedness, revealing critical vulnerabilities and the importance of implementing proactive response strategies. During the COVID-19 pandemic, Certified Registered Nurse Anesthetists (CRNAs), also known as nurse anesthesiologists and nurse anesthetists, demonstrated adaptability and innovation by maximizing their skills and expertise beyond the operating room, providing life-saving interventions in emergency departments, intensive care units, and other critical care areas.1
Drawing from the lessons of COVID-19 and other infectious diseases, these preparedness considerations offer a strategic approach to addressing future infectious disease pandemics, especially focusing on the areas that CRNAs can impact. By integrating advanced clinical skills, infection control measures, team leadership, and interdisciplinary collaboration, CRNAs are uniquely positioned to enhance facility policies, procedures, and emergency management planning for emerging healthcare threats.
Purpose
The following considerations identify areas for policy and procedure development and implementation to enhance preparedness for an emergent pandemic, integrate essential clinical skills, effectively utilize CRNA leadership capabilities, improve infection control measures, and promote resilience of healthcare providers.
CRNAs As Infection Control and Pandemic Preparedness Leaders
As advanced practice registered nurses (APRNs) with advanced nursing competencies, CRNAs have a strong foundation in advanced physiology/pathophysiology, pharmacology, and advanced physical assessment. Additionally, CRNAs have expertise in critical care nursing. This experience, along with their training and expertise in anesthesiology, focus on patient safety and utilization of leadership skills positions CRNAs to help in many different areas related to pandemic preparedness and in times of crisis, including but not limited to:
• Advanced airway management including intubation as well as the initiation and assessment of pharmacological interventions for patients in respiratory distress
• Advanced ventilator management including the conversion of operating room ventilators to ICU ventilators and oversight of patients needing ventilatory management
• Advanced hemodynamic monitoring including titration of vasoactive medications and vascular volume resuscitation
• Placement of invasive lines and monitors including central lines, peripherally inserted central catheters (PICC), and arterial lines
• Rapid advanced physical assessment to allow for triage of multiple patients’ respiratory and hemodynamic status
• Leading a team of rapid responders to provide lifesaving interventions
• Consultation on the management of critically ill patients who are receiving paralytic medications, are in alternative positions such as prone, or who require deep levels of sedation outside that normally managed in the ICU
Preparedness Considerations2-38
The following elements should be assessed, reviewed, and identified in light of any emerging infectious disease to maintain the safety of patients and healthcare providers. Appropriate policies and procedures should be established within a facility, with flexibility to adjust processes based on new evidence and recommendations.
Available Resources
• Access available research and guidance from organizations such as:
o American Association of Nurse Anesthesiology (AANA)
o Society for Healthcare Epidemiology of America (SHEA)
o Association for Professionals in Infection Control and Epidemiology (APIC)
o Association of periOperative Registered Nurses (AORN)
o U.S. Centers for Disease Control and Prevention (CDC)
o U.S. Food and Drug Administration (FDA)
o U.S. Health and Human Services (HHS)
o U.S. Occupational Safety and Health Administration (OSHA)
o U.S. National Institute of Allergy and Infectious Diseases (NIAID)
o U.S. Administration for Strategic Preparedness and Response (ASPR)
o World Health Organization (WHO)
Infection Transmission
• Identify mode(s) of transmission (e.g., droplet, airborne, contact, bloodborne)
• Determine effective prevention methods
• Determine incubation period
• Establish infectious period
• Assess asymptomatic spread potential
• Identify vulnerable populations and risk factors for severe disease
• Assess the pathogen's ability to survive on surfaces and in different environmental conditions
• Assess the sensitivity and specificity of available diagnostic tests
Anesthesia Clinical Preparedness and Operating Room Infection Control
• Develop crisis/pandemic clinical policies and procedures
• Redesign workflows to minimize contamination risks
• Adapt anesthetic techniques for pandemic scenarios
• Develop strategies for managing aerosol-generating procedures
• Implement intubation and airway management protocols for high-risk procedures
• Develop sedation and mechanical ventilation strategies
• Implement enhanced cleaning and disinfection protocols for anesthesia equipment
• Audit clinical outcomes at different phases of the pandemic to refine strategies
Personal Protective Equipment (PPE)
• Select and use appropriate PPE for anesthesia procedures
• Practice donning and doffing techniques
• Implement hand hygiene protocols
• Enforce respiratory and cough etiquette
Surge Capacity Planning
• Develop anesthesia department policies regarding re-deployment of staff to ICU settings
• Cross-train anesthesia staff for critical care roles
• Develop protocols for rapid ICU conversion of operating rooms
• Implement strategies for managing equipment and medication shortages
Isolation and Quarantine
• Designate ORs that can be converted into negative pressure rooms or areas for isolation in collaboration with engineering department
• Establish criteria for isolation of infected individuals during transport and care
• Determine duration of isolation/quarantine
• Manage exposed individuals according to established policies
• Implement remote monitoring technologies
• Establish remote connection with interdisciplinary healthcare clinicians
• Enable remote ability for patient communication with caregivers/family
Surveillance, Screening, and Reporting
• Implement systems for early detection of potential pandemic-level threats
• Establish triggers for activating pandemic response plans
• Define case definition criteria in collaboration with infection control expert panels
• Determine testing methods and availability
• Implement contact tracing protocols
• Develop technology and systems for collecting and analyzing epidemiological data
• Establish reporting mechanisms to local, national, and international health authorities
• Implement staff health monitoring and vaccination programs
Supply Chain Management
• Establish supply chain strategies, management practices, and financing policies
• Ensure adequate supplies of PPE, disinfectants, and medical equipment are available for use during emergencies
• Develop strategies for addressing the potential need to alter infection control policies and procedures during critical supply shortages
Interdisciplinary Collaboration
• Strengthen partnerships among specialties (e.g., infectious disease, epidemiology, nursing, anesthesiology, critical care, emergency medicine, pharmacy)
• Participate in facility-wide pandemic response teams
• Engage in public health initiatives and planning
• Collaborate with federal, state, and county-level entities, industry, emergency response, and public health sectors for policy development and response implementation
Education and Training
• Create a written pandemic plan with clearly defined roles and responsibilities
• Conduct simulation-based training for pandemic scenarios
• Provide continuous updates on emerging infectious diseases
Mental Health and Wellbeing
• Establish support systems for anesthesia and clinical staff
• Implement strategies for managing stress and burnout during prolonged crises
• Promote resilience and adaptability strategies
• Promote the AANA Helpline, 800-654-5167, for drug or alcohol concerns
Ethical Considerations
• Develop decision-making frameworks for resource allocation
• Balance individual patient care with public health priorities
Communication and Leadership
• Disseminate updated protocols and guidelines effectively
• Develop strategies for clear communication with healthcare providers, patients and families
• Cultivate CRNA and other healthcare provider leadership skills for crisis management
References
1. National Academies of Sciences, Engineering, and Medicine. 2020. Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020). Washington, DC: The National Academies Press. doi:10.17226/25890
2. Fauci AS, Folkers GK. Pandemic Preparedness and Response: Lessons From COVID19. J Infect Dis. Aug 16 2023;228(4):422-425. doi:10.1093/infdis/jiad095
3. Agampodi S, Mogeni OD, Chandler R, Pansuriya M, Kim JH, Excler JL. Global pandemic preparedness: learning from the COVID-19 vaccine development and distribution. Expert Rev Vaccines. Jan-Dec 2024;23(1):761-772. doi:10.1080/14760584.2024.2395546
4. Sell TK, Watson CR, Mullen L, Shearer MP, Toner ES. Pandemic Exercises: Lessons for a New Era in Pandemic Preparedness. Health Secur. Oct 24 2024;doi:10.1089/hs.2023.0184
5. Ezenwaji CO, Alum EU, Ugwu OP. The role of digital health in pandemic preparedness and response: securing global health? Glob Health Action. Dec 31 2024;17(1):2419694. doi:10.1080/16549716.2024.2419694
6. Kuppalli K. Ebola: Ten years later-Lessons learned and future pandemic preparedness. PLOS Glob Public Health. 2024;4(9):e0003662. doi:10.1371/journal.pgph.0003662
7. Ukoaka BM, Okesanya OJ, Daniel FM, et al. Updated WHO list of emerging pathogens for a potential future pandemic: Implications for public health and global preparedness. Infez Med. 2024;32(4):463-477. doi:10.53854/liim-3204-5
8. McSweeney T, Chang MH, Patel P, Nori P. Antimicrobial Stewardship and Pandemic Preparedness: Harnessing Lessons Learned to Advance Our Mission. Infect Dis Clin North Am. Dec 2023;37(4):669-681. doi:10.1016/j.idc.2023.07.001
9. Hafez S, Ismail SA, Zibwowa Z, et al. Community interventions for pandemic preparedness: A scoping review of pandemic preparedness lessons from HIV, COVID19, and other public health emergencies of international concern. PLOS Glob Public Health. 2024;4(5):e0002758. doi:10.1371/journal.pgph.0002758
10. Hey MT, Carroll M, Steel LB, et al. Surgical capacity is disaster preparedness: A scoping review of how surgery and anesthesiology departments responded to COVID-19. Am J Disaster Med. Spring 2024;19(2):119-130. doi:10.5055/ajdm.0466
11. Mer M, Aryal D, Nielsen ND, et al. Critical Care Pandemic Preparation: Considerations and Lessons Learned from COVID-19. Crit Care Clin. Oct 2022;38(4):761-774. doi:10.1016/j.ccc.2022.07.002
12. Wyssusek K, Lee J, Hames K, et al. Departmental Preparedness for Pandemic Readiness in Anesthesia: A Practical Departmental Readiness Checklist. Bali J of Anesth. 2021;5(3):149-157. doi:10.4103/bjoa.bjoa_14_21
13. Wyssusek K, Eames G, Peters N, Lee J. Anaesthesia preparedness for COVID-19 pandemic readiness: a medication preservation strategy. Br J Anaesth. Sep 2020;125(3):e332-e334. doi:10.1016/j.bja.2020.05.027
14. Liu A, Waldman RN, Deal B, et al. Preparing for the next pandemic: Reflections and recommendations from Florida. PLoS One. 2024;19(12):e0314570. doi:10.1371/journal.pone.0314570
15. Beilstein CM, Lehmann LE, Braun M, Urman RD, Luedi MM, Stüber F. Leadership in a time of crisis: Lessons learned from a pandemic. Best Pract Res Clin Anaesthesiol. Oct 2021;35(3):405-414. doi:10.1016/j.bpa.2020.11.011
16. Arabi YM, Azoulay E, Al-Dorzi HM, et al. How the COVID-19 pandemic will change the future of critical care. Intensive Care Med. Mar 2021;47(3):282-291. doi:10.1007/s00134021-06352-y
17. Thomson WR, Puthucheary ZA, Wan YI. Critical care and pandemic preparedness and response. Br J Anaesth. 2023;131(5):847-860. doi:10.1016/j.bja.2023.07.026
18. U.S. Government Accountability Office. Public Health Preparedness: Building and Maintaining Infrastructure Beyond The COVID-19 Pandemic. GAO-24-105891. Accessed Apr 8, 2025, https://www.gao.gov/products/gao-24-105891
19. Johns Hopkins Bloomberg School of Public Health. The Characteristics of Pandemic Pathogens. Accessed Jan 5, 2025, https://centerforhealthsecurity.org/sites/default/files/2022-12/180510-pandemicpathogens-report.pdf
20. World Heath Organization. Preparedness and Resilience for Emerging Threats Module 1: Planning for respiratory pathogen pandemics. Updated Mar 21, 2024. Accessed Apr 8, 2025, https://www.who.int/publications/i/item/9789240084674
21. Schmidt AP, Módolo NSP, de Amorim CG, et al. Two years of the COVID-19 pandemic: an anesthesiology perspective. Braz J Anesthesiol. Mar-Apr 2022;72(2):165-168. doi:10.1016/j.bjane.2022.02.004
23. Loveday H, Wilson J. Pandemic preparedness and the role of infection prevention and control - how do we learn? J Infect Prev. Mar 2021;22(2):55-57. doi:10.1177/17571774211001040
24. Hsu VP, Haessler S, Banach DB, et al. SHEA position statement on pandemic preparedness for policymakers: introduction and overview. Infect Control Hosp Epidemiol. Jul 2024;45(7):801-803. doi:10.1017/ice.2024.66
25. Shenoy ES, Banach DB, Batshon LJ, et al. SHEA position statement on pandemic preparedness for policymakers: the role of healthcare epidemiologists in communicating during infectious diseases outbreaks. Infect Control Hosp Epidemiol. 2024;45(7):808812. doi:10.1017/ice.2024.63
26. Weber DJ, Malani AN, Shenoy ES, et al. SHEA position statement on pandemic preparedness for policymakers: mitigating supply shortages. Infect Control Hosp Epidemiol. Jul 2024;45(7):813-817. doi:10.1017/ice.2024.67
27. Okeagu CN, Reed DS, Sun L, et al. Principles of supply chain management in the time of crisis. Best Pract Res Clin Anaesthesiol. Oct 2021;35(3):369-376. doi:10.1016/j.bpa.2020.11.007
28. Strengers P, O'Brien SF, Politis C, Mayr W, Seifried E, Spencer BR. White paper on pandemic preparedness in the blood supply. Vox Sang. Jan 2023;118(1):8-15. doi:10.1111/vox.13378
29. Wright AM, Snowdon A, Saunders M, Trampas D. The necessity of healthcare supply chain resilience for crisis preparedness. Healthc Manage Forum. Mar 2024;37(2):95100. doi:10.1177/08404704231207386
30. U.S. Department of Health and Human Services. Preparedness for Influenza and Other Pathogens with Epidemic and Pandemic Potential. Accessed Apr 8, 2025,
31. Administration for Strategic Preparedness and Response. ASPR Strategic Plan for 2022-2026. Accessed Jan 5, 2025, https://aspr.hhs.gov/StratPlan/Pages/default.aspx
32. Administration for Strategic Preparedness and Response. EMS Infectious Disease Playbook. Accessed Jan 5, 2025, https://www.ems.gov/assets/ASPR-EMS-InfectiousDisease-Playbook-June-2017.pdf
33. Centers for Disease Control and Prevention. Healthcare System Preparedness and Response. Updated Apr 11, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/pandemic-flu/hcp/healthcare-preparedness-response/index.html
34. National Institute of Allergy and Infectious Diseases (NIAID). Pandemic Preparedness Plan. Dec 2021. Accessed Jan 5, 2025, https://www.niaid.nih.gov/sites/default/files/pandemic-preparedness-plan.pdf
35. The White House. National COVID-19 Preparedness Plan. March 2022. Accessed Apr 8, 2025, https://bidenwhitehouse.archives.gov/wp-content/uploads/2022/03/NAT-COVID19-PREPAREDNESS-PLAN.pdf
36. Food and Drug Administration. FDA COVID-19 Pandemic Recovery and Preparedness Plan (PREPP) Initiative. Accessed Jan 5, 2025, https://www.fda.gov/aboutfda/reports/fda-covid-19-pandemic-recovery-and-preparedness-plan-prepp-initiative
37. Occupational Safety and Health Administration. Protecting Workers during a Pandemic Accessed Jan 5, 2025, https://www.osha.gov/sites/default/files/publications/OSHAFS3747.pdf
38. Occupational Safety and Health Administration. Emergency Preparedness and Response. Accessed Jan 5, 2025, https://www.osha.gov/emergency-preparedness
Infection Prevention and Control Guidelines for Anesthesia Care
Chapter 8: Infection Prevention and Control Glossary
Airborne Precautions: measures designed to prevent the transmission of infectious agents that remain suspended in the air over long distances. These precautions involve stringent measures like N95 respirators or Powered Air-Purifying Respirators (PAPRs), and specialized Airborne Infection Isolation Rooms (AIIRs), and are part of the broader Transmission-Based Precautions, tailored to airborne pathogens.1-4
Administration: The direct application of a sterile product or preparation to a single patient by injecting, infusing, or otherwise providing a sterile product or preparation in its final form.5
Antiseptic: an agent applied to living tissue, such as skin or mucous membranes, to inhibit the growth of or destroy microorganisms, reducing the risk of infection.2,6-8
Antiseptic Handrubbing: The process of applying an alcohol-based antiseptic agent to hands until dry, effectively reducing or eliminating microorganisms. It is preferred over handwashing in clinical settings when hands are not visibly soiled due to its efficiency and skin-friendliness.9-12
Antiseptic Handwashing: Washing hands with water and soap or detergent containing an antiseptic agent for at least 20 seconds is indicated for visibly soiled hands or specific situations. This method removes dirt, organic material, and microorganisms.9-12
Asepsis: the condition of being free from contamination by disease-causing microorganisms, such as bacteria, viruses, fungi, and parasites.8,9,13
Bloodborne Pathogens: pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).14
Beyond-use date (BUD): The date, or hour and the date, after which a CSP must not be used, stored, or transported. The date is determined from the date and time the preparation is compounded.5
Compounded sterile preparation (CSP): A preparation intended to be sterile that is created by combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug product or bulk drug substance.5
Compounding: The process of combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug product or bulk drug substance to create a sterile preparation.5
Compounding record: Documents the compounding of each CSP.5
Contact Precaution: measures taken to prevent the transmission of infectious agents spread through direct or indirect contact with the patient or the patient’s immediate environment. These precautions include wearing gloves and gowns, ensuring proper hand hygiene, and using dedicated or disinfected equipment for patient care.1-4,9
Contamination: the presence of unwanted microorganisms or other harmful substances on surfaces, objects, or living tissue, which may increase the risk of infection or disease transmission. Contamination can occur through direct contact, or indirectly through contact with contaminated surfaces or objects.8,14
Creutzfeldt-Jakob disease (CJD): a rare, fatal neurodegenerative disorder caused by abnormal prion proteins. It is characterized by rapid cognitive decline and belongs to a group of diseases known as transmissible spongiform encephalopathies (TSEs).15-17
Critical Device: medical equipment that directly contacts sterile areas of the body, such as the bloodstream or tissue, requiring sterilization to prevent infection transmission if contaminated.2,18,19
Decontamination: the process of removing, inactivating, or destroying pathogens and contaminants to reduce the risk of infection or harm, often through cleaning, disinfection, or sterilization.8,20
Disinfectant: a chemical agent used on inanimate objects to destroy pathogenic microorganisms, but not necessarily all microbial forms (e.g., bacterial endospores). Refer to disinfectant label to determine whether the agent is a "limited-," "general-" or "hospital-" grade disinfectant.6,8
Disinfection: the destruction of pathogenic and other kinds of microorganisms by physical or chemical means. Destroys most recognized pathogenic microorganisms, but not necessarily all microbial forms, such as bacterial spores.6,8
Droplet Precaution: measures taken to prevent the transmission of infectious agents spread through close respiratory or mucus membrane contact with patients. Considered to be the intermediate level of transmission-based precautions.1-4
Droplets: small moisture particles typically generated when a person coughs, sneezes, talks, or breathes, or when water is converted to a fine mist. These particles may include infectious pathogens, which tend to quickly settle out from the air so that any risk of disease transmission is generally limited to persons in close proximity to the droplet source.1-4
Hand hygiene: a general term that refers to any action of hand cleansing to remove microorganisms from hands. Effective hand hygiene is crucial in preventing healthcareassociated infections and improving patient safety. 2,9,10
Healthcare-associated infection (HAI): an infection that patients acquire while receiving medical care in healthcare settings. These infections develop during or after a patient's stay in a healthcare facility and are not present or incubating at the time of admission.2,21,22
High-level disinfection: an advanced disinfection method that disinfects bacteria, fungi, and viruses but not necessarily high numbers of bacterial spores. It is used primarily for semi-critical medical devices that come into contact with mucous membranes or non-intact skin.2,7,19
Immunocompromised patients: individuals whose immune systems are weakened or deficient due to congenital or acquired immunologic disorders, making them more susceptible to
infections. This include individuals with conditions like HIV/AIDS, cancer, organ transplants, or immunosuppressive treatments, making them more susceptible to infections.23
Immunity: the state of protection against a specific disease, characterized by the presence of antibodies in the blood that recognize and defend against specific antigens or pathogens.24,25
Immunization: the process by which a person develops immunity or protection against a specific disease, typically through vaccination. This process is not always effective at preventing disease.24,26
Infection: the invasion and multiplication of microorganisms (e.g., bacteria, viruses, fungi, or parasites) in a host, evading immune defenses and potentially causing harm. It often triggers an immune response (e.g., fever, inflammation, nausea, aches).2
Intermediate-Level Disinfection: a disinfection method destroys all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. Typically used for disinfection of non-critical devices.2,8,19,27
Low-Level Disinfection: a process that inactivates most vegetative bacteria, some fungi, and some viruses, but is not effective against more resistant microorganisms such as bacterial spores or certain viruses. It is used for disinfecting non-critical devices and environmental surfaces that come into contact with intact skin.2,8,19,27
Multidrug-Resistant Organisms (MDROs): bacteria that have developed resistance to multiple classes of antimicrobial agents, complicating treatment and increasing healthcare risks.2,28,29
Non-Critical Device: medical equipment or environmental surfaces that carry the lowest risk of disease transmission. They typically come into contact only with intact skin or do not directly contact patients.2,18,19
Personal Protective Equipment (PPE): a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE includes, but is not limited to, gloves, masks, respirators, goggles, face shields, and gowns.2,8,20,30
Repackaging: The act of removing a sterile product or preparation from its original primary container and placing it into another primary container, usually of smaller size without further manipulation.5
Respiratory Hygiene/Cough Etiquette: a set of infection prevention measures designed to minimize the transmission of respiratory pathogens via contact, droplet, or airborne transmission in healthcare settings.2,3,31,32
Semi-Critical Device: medical devices or instruments that come into contact with mucous membranes and do not ordinarily penetrate body surfaces.2,18,19
Spaulding Classification: strategy for reprocessing contaminated medical devices. The system classifies a medical device as critical, semicritical, or noncritical on the basis of risk to patient safety from contamination on a device. The system also established three levels of
germicidal activity (sterilization, high-level disinfection, and low-level disinfection) for strategies with the three classes of medical devices (critical, semicritical, and noncritical).2,8,19,27
Standard Precautions: a set of infection prevention practices applied universally to all patients, regardless of their infection status, to reduce the risk of transmission of microorganisms. Key components include hand hygiene, use of PPE, respiratory hygiene/cough etiquette, safe injection practices, proper handling of sharps, cleaning and disinfection of equipment and surfaces, and waste management.2,3
Sterilization: validated process used to render a product free of all forms of viable microorganisms. In a sterilization process, the presence of microorganisms on any individual item can be expressed in terms of probability. Although this probability can be reduced to a very low number, it can never be reduced to zero. Used for sterilizing critical devices.2,8,20,33
Transmission-Based Precautions: infection control measures used in healthcare settings for patients with known or suspected infectious diseases that require special handling beyond standard precautions. These precautions are categorized into contact, droplet, and airborne precautions, each tailored to the specific mode of transmission of the pathogen. By implementing these precautions, healthcare providers can effectively interrupt the transmission of infectious agents and protect both patients and staff from acquiring or spreading diseases.1,3,27,34
Tuberculosis Infection (Latent): a condition where Mycobacterium tuberculosis is present in the body, but the person has no symptoms, is not infectious, and typically has a positive tuberculin skin test or blood test. The infection is inactive but has the potential to become active TB disease in the future.35-38
Tuberculosis Infection (Active): a condition where Mycobacterium tuberculosis is actively multiplying in the body, causing symptoms such as cough, fever, night sweats, and weight loss. Infected individuals are typically contagious and have a positive tuberculin skin test or blood test. 35-38
Vaccine: A biological agent that stimulates the immune system to produce immunity against specific pathogens, typically administered through injections, orally, intranasally, or percutaneously, to protect the body from diseases.24,26
References
1. Centers for Disease Control and Prevention. Transmission-Based Precautions Updated May 13, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/infectioncontrol/hcp/basics/transmission-based-precautions.html
2. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. Dec 2007;35(10 Suppl 2):S65-164. doi:10.1016/j.ajic.2007.10.007
3. Virginia Department of Health. Transmission-based precautions. Accessed March 19, 2023. https://www.vdh.virginia.gov/haiar/ip/transmission-based-precautions/
4. Centers for Disease Control and Prevention. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings. Updated Apr 15, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/healthcare-associated-infections/hcp/preventionhealthcare/infection-control-outpatient-oncology.html
5. The United States Pharmacopeial Convention. General Chapter <797>. Accessed Jul 9, 2024, https://www.usp.org/compounding/general-chapter-797
6. McDonnell G, Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev. Jan 1999;12(1):147-79. doi:10.1128/cmr.12.1.147
7. Rutala WA, Boyce JM, Weber DJ. Disinfection, sterilization and antisepsis: An overview. Am J Infect Control. Nov 2023;51(11s):A3-a12. doi:10.1016/j.ajic.2023.01.001
8. Centers for Disease Control and Prevention. Glossary from the Guideline for Disinfection and Sterilization in Healthcare Facilities. Updated Nov 28, 2023. Accessed Apr 8, 2025, https://www.cdc.gov/infection-control/hcp/disinfectionsterilization/glossary.html
9. World Health Organization Guidelines guidelines on hand hygiene in health care. World Health Organization & WHO Patient Safety. Accessed May 17, 2024, https://www.who.int/publications/i/item/9789241597906
10. Hand Hygiene Guidance. Centers for Disease Control and Prevention. Updated 01/30/2020. Accessed March 15, 2023, 2023. https://www.cdc.gov/handhygiene/providers/guideline.html
11. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. Dec 2002;30(8):S1-46. doi:10.1067/mic.2002.130391
12. Centers for Disease Control and Prevention. Clinical Safety: Hand Hygiene for Healthcare Workers. Accessed Apr 8, 2025, https://www.cdc.gov/cleanhands/hcp/clinical-safety/
13. The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An International Perspective. Aseptic versus Clean Technique. Updated Nov 20, 2013. Accessed March 12, 2025, https://www.jointcommission.org//media/tjc/documents/resources/health-services-research/clabsitoolkit/clabsi_toolkit_tool_3-8_aseptic_versus_clean_techniquepdf.pdf
14. Occupational Safety and Health Administration 1910.1030 - Bloodborne Pathogens (2019).
15. Brown P, Brandel JP, Sato T, et al. Iatrogenic Creutzfeldt-Jakob disease, final assessment. Emerg Infect Dis. Jun 2012;18(6):901-7. doi:10.3201/eid1806.120116
16. Johnston L, Conly J. Creutzfeldt-Jakob disease and infection control. Can J Infect Dis Nov 2001;12(6):332-6. doi:10.1155/2001/786564
17. Rutala WA, Weber DJ. Creutzfeldt-Jakob disease: recommendations for disinfection and sterilization. Clin Infect Dis. May 1 2001;32(9):1348-56. doi:10.1086/319997
18. Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Centers for Disease Control and Prevention. Accessed March 14, 2023. www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
19. Juwarkar CS. Cleaning and sterilisation of anaesthetic equipment. Indian J Anaesth. Sep 2013;57(5):541-50. doi:10.4103/0019-5049.120152
20. Occupational Safety and Health Administration. Compliance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030. Accessed May 18, 2024, https://www.osha.gov/laws-regs/standardinterpretations/2009-02-27
21. Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections - an overview. Infect Drug Resist. 2018;11:2321-2333. doi:10.2147/idr.S177247
22. Association for Professionals in Infection Control and Epidemiology, Inc. What are healthcare-associated infections? Accessed March 12, 2025, https://apic.org/monthly_alerts/what-are-healthcare-associated-infections/
23. Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS Hyg Infect Control. 2022;17:Doc07. doi:10.3205/dgkh000410
24. Centers for Disease Control and Prevention. Vaccine Glossary. Updated Sept 17, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/vaccines/glossary/index.html
25. Centers for Disease Control and Prevention. Immunity Types. Updated July 30, 2024. Accessed Apr 8, 2025, https://www.cdc.gov/vaccines/basics/immunity-types.html
26. World Health Organization. Vaccines and immunization: What is vaccination? Updated April 23, 2024. Accessed March 12, 2025, https://www.who.int/news-room/questionsand-answers/item/vaccines-and-immunization-what-is-vaccination
27. Rutala, WA, Weber, DJ, Healthcare Infection Control Practices Advisory Committee.Guideline for disinfection and sterilization in healthcare facilities. Atlanta, GA: Centers for Disease Control and Prevention; Jun 2024.
28. Varela MF, Stephen J, Lekshmi M, et al. Bacterial Resistance to Antimicrobial Agents. Antibiotics (Basel). May 17 2021;10(5)doi:10.3390/antibiotics10050593
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The Infection Control Guide for Certified Registered Nurse Anesthetists was adopted by the AANA Board of Directors in 1992 and revised in 1993, 1997, November 2012.
In February 2015, the AANA Board of Directors archived the guide and adopted the Infection Prevention and Control Guidelines for Anesthesia Care.
In April 2025, the AANA Board of Directors revised the guide.
