It can be difficult to discern the exact nature of events from the initial news stories however it appears that physicians and nurses in an outpatient endoscopy clinic located in Las Vegas Nevada improperly drew doses of sedatives for patients from a single multi dose vial possibly exposing 40,000 patients to a risk of hepatitis C or aids. Apparently they did not use a fresh syringe and needle for each entry into the vial so that transmission between patients via the vial contents was possible. I cannot believe this has happened – it seems so contrary to every teaching on disease transmission and current safe practice. Do not even consider reusing the same syringes or needles between patients. Any item that is used on more than one patient should be designed for such use and properly disinfected between uses.
However the above is not a unique event. On several occasions in the recent past anesthesiologists have been identified with transmitting Hepatitis C through the misguided practice of syringe/needle reuse and multi dose vials. In 2002 there was a hepatitis C outbreak in Norman Oklahoma related to needle and syringe reuse. About 71 people were infected there. In 2007, an anesthesiologist from Dix Hills New York was associated with a cluster of Hepatitis C infections related to his practice. As a result 11,000 of his former patients were contacted about infection risk. Also in 2007 another anesthesiologist, was sued for Hepatitis C transmission from faulty infection control practice while giving anesthesia for colonoscopy. This last anesthesiologist practiced at about 10 different physician offices and about 4,500 of his former patients were placed at risk because of his failure to use reasonable infection control.
The ASA newsletter (66:2002) provides a summary of the ASA infection control guidelines: 1) Syringes and needles are sterile, single-patient-use items. 2) After entry into or connection with a patient’s intravenous infusion, the syringe and needle should be considered contaminated and used only for that patient. 3) Medication from a syringe must not be administered to multiple patients even if the needle on the syringe is changed. 4) All infusion fluids, administration sets (intravenous tubing and connections) and pressure transducer setups are single-patient-use items. Absence of blood contamination cannot be guaranteed by visual inspection. 5) Sterile needles and syringes should always be used to aspirate the contents of an ampule or vial. 6) Each time a multidose vial is entered, aseptic techniques should be used, including cleansing the rubber stopper with alcohol and using a sterile needle and syringe. If visible contamination of a multidose vial has occurred or if sterility is questionable, the vial should be discarded. 7) Immediately after use, or at least at the end of each patient’s anesthetic, all used syringes and needles should be discarded in an appropriate puncture-resistant sharps container. Unused syringes, needles and related items should be stored in a clean area to avoid contamination by contaminated syringes and equipment. 8) Health care workers with breaks in the skin or exudative or weeping lesions should refrain from direct patient contact and from handling patient care equipment unless the open area can be protected. Strict attention to hand washing, hand antisepsis, aseptic technique and use of gloves and other barrier precautions is important to avoid transmission of pathogenic microorganisms to patients and health care workers.
There apparently persists the misguided concept that injecting high on the iv tubing is safe. This is wrong! The ASA Newsletter article cited above notes the following: In 1990, Trepanier et al. investigated the risk of cross-infection related to the multiple use of disposable syringes for anesthesia in the operating room. The rate of blood contamination in the intravenous (I.V.) tubing was 3.3 percent at the injection site closest to the I.V. catheter and 0.3 percent at the furthest site. The presence of a one-way check-valve did not affect the contamination rate. Trepanier and his group also found that changing the needle alone on a used syringe was useless for preventing contamination of blood into the syringe.
Considering the difficulty in maintaining sterility and preventing contamination of multi dose containers several states are considering a ban on their use for most medications. Once a syringe is connected to a patient’s IV it is by definition contaminated and should never be used on another patient. If a multidose vial has been entered by a syringe and needle that has been in contact with a patient that vial is also contaminated and should be discarded once the care of that patient is over. It would be prudent not to use multidose vials between patients but to discard the remaining drug at the end of each case. A Google news search on any of the key words mentioned will bring up the innumerable newspaper sources for this material.
Reference: Trepanier CA et al: Risk of cross-infection related to the multiple use of disposable syringes. Can J Anaesth 1990;37:156-159
David S. Smith, M.D., Ph.D.
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