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Clinical Case for Discussion: An anesthesia colleague of yours dilutes a 50-microgram ampoule of sufentanil with 9 cc of normal saline, so the final syringe concentration is 5 micrograms per cc. He then injects 10 micrograms of sufentanil from this syringe into the clean IV line of three different patients during his OR day. Is this practice OK? What do you do?
Discussion: Your colleague claims this practice is without risk because he injects into an IV port that is six feet proximal to the IV catheter. He’s done this for twenty years, since his residency training. He’s “never had a complication” and sees no reason to change.
He needs to change, and here’s the most recent evidence why: In January 2008, investigators from the Center for Disease Control (CDC) responded to a request from the Southern Nevada Health District to help investigate three persons with acute hepatitis C virus (HCV) infection (MMWR Morb Mortal Wkly Rep. 2008 May 16;57(19):513-7). All three persons had undergone procedures at a Las Vegas endoscopy clinic. CDC went on to identify a total of six cases of HCV infection among patients who had undergone procedures at the clinic in the 35–90 days prior to onset of symptoms. These patients had no other risks for HCV infection.
On investigation of the clinic, CDC observed practices that had the potential to transmit HCV. The May 2008 issue of Anesthesiology News reported that “certified registered nurse anesthetists (CRNAs) at the center had been improperly administering anesthesia to patients undergoing routine endoscopic procedures.” The California Department of Public Health mailed a letter to all California physicians, dated March 27, 2008. Per this letter, the infected Nevada patients were most likely exposed in the following manner: “1) A clean syringe and needle were used to draw a sedative medication from a new single-use vial. 2) The sedative was administered to a hepatitis C infected patient, and backflow of blood from the patient into the syringe presumably contaminated the syringe with hepatitis C virus. 3) The needle was replaced on the syringe with a new, sterile needle, but the syringe was reused to draw additional sedative from the same vial for the same patient, presumably contaminating the vial with blood containing hepatitis C virus. 4) A clean needle and syringe were used for subsequent patients, but the contaminated vial was reused, exposing subsequent patients to hepatitis C virus.”
Because these practices had prevailed at this clinic for years, nearly 40,000 Nevada patients had to be notified by letter that they should visit their primary care provider to be tested for hepatitis C, hepatitis B, and HIV.
The same March 27, 2008 letter from the California Department of Health included a list of Safe Injection Practices, drawn from the CDC website (Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, Standard Precautions (www.cdc.gov/ncidod/dhqp/gl_isolation.html). These Safe Injection recommendations include the following: “1) Use aseptic technique to avoid contamination of sterile injection equipment. 2) Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. 3) Use fluid infusion and administration sets for one patient only and dispose appropriately after use. 4) Use single-dose vials for parenteral medications whenever possible. 5) Do not administer medications from single-dose vials or ampoules to multiple patients or combine leftover contents for later use. 6) If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile.”
Viral infections have been reported secondary to unsafe anesthesia practitioners. A cluster of four patients with hepatitis C virus (HCV) infection was identified in a single surgery clinic (Germain JM et al, Patient-to-patient transmission of hepatitis C virus through the use of multi-dose vials during general anesthesia. Infect Control Hosp Epidemiol. 2005 Sep;26(9):789-92). Molecular characterization revealed close homology between viruses, and this cluster was deemed to be due to intra-operative unsafe injection practices by anesthesia personnel using multi-dose vials.
From this point forward, your friend’s method of administering sufentanil must be stopped. You show him the above references, and urge him to change his practice for the safety of his patients. Other verboten procedures include: 1) Using an infusion pump to administer portions of a 60 cc syringe of propofol or remifentanyl to more than one patient, even though you change the tubing; 2) Drawing 250 micrograms of fentanyl into one syringe, and then giving 100 micrograms to one patient, and 150 micrograms to the next patient from the same syringe; 3) Using a single 20 cc vial of labetalol to give repeated and multiple doses to more than one patient, if either the needle or the syringe used to draw any dose from that vial was reused.
We’ve urged our freestanding surgery centers to cease stocking large ampoules of drugs such as 5 cc Decadron, 5 or 10 mg midazolam, 5 cc Robinul, or 20 cc labetalol. Reuse of larger ampoules gives practitioners the opportunity to spread viral infection to more than one patient if aseptic technique is ignored. The larger vials may save the institutions money, but the saving of pennies is trivial compared to isolating each patient from the patient(s) that preceded them.
May all your present and future intravenous injection techniques comply with CDC guidelines!
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: