Sterility Protocols During Regional Anaesthesia: An AORA Initiative

Abstract

The frequency of infection following peripheral nerve block (PNB) is not very clear. The major reason for the paucity of literature is under-reporting of infectious complications. Though rare, the infectious complications associated with peripheral nerve blocks can be devastating and occasionally fatal [1]. A case of necrotising fasciitis following an axillary approach to brachial plexus blockade for carpal tunnel release has been reported where the PNB was directly attributed to the infection. With the increase in the number of peripheral nerve block procedures being performed (both single injection and continuous techniques), it is expected that the infectious complication rate may also increase. There is no uniform consensus amongst anaesthesiologists across the globe regarding the appropriate sterile technique that should be practised during administration of regional anaesthesia. In a UK and Ireland based survey of obstetric anaesthesiologists, only half of the responders wore a face mask for both neuraxial (spinal and epidural) techniques. One-third of those who did not wear a mask believed that the mask actually increased the risk of infection [2]. It can be easily assumed that a similar attitude is present while performing peripheral nerve blocks. The aseptic chain starts right from hand washing and ends after the block needle has been taken out from the patient's body (in a single injection technique) or till the perineural catheter is completely removed (in a continuous technique). Any breach in this chain may increase the chances of introducing infection. Removal of JewelleryIn 2006, the American Society of Regional Anesthesia (ASRA) guidelines recommended removal of jewellery as a part of aseptic technique though there is a scarcity of evidence (Grade B) [3]. The compliance amongst anaesthesiologists is variable. In a 2002 survey of obstetric anaesthesiologists, 86% agreed that removal of their wrist watch was essential prior to epidural blockade, but only 50% agreed that removal of finger rings was necessary [4]. According to Hartley et al in 1999, wearing a wrist watch prevents proper hand washing, resulting in higher bacterial growth and thus, should be removed before any aseptic procedure [5]. A 2005 review on hand hygiene showed that though the skin under jewellery (rings, bracelets and wrist watches) showed a higher microbial load, the evidence was insufficient to say that hand washing was ineffective in ring wearers [6]. In 2013, ASRA proposed a pre-block checklist and conducted a survey to gather feedback. In an internet survey of regional anaesthesia fellowship directors and graduates, only over half of them either strongly agreed or agreed that removal of jewellery before a regional nerve block was appropriate. The rest of them either strongly disagreed, disagreed or stayed neutral [7].Recommendation-Though the evidence is not compelling, it is a good practice to remove all the jewellery before performing either a single injection or continuous peripheral nerve block to ensure the technique ...