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Anesthesiologist passed hepatitis C to patients — Are yours safe?
Take steps now to minimize risk in your surgery program
Anesthesia providers, especially those who practice in freestanding facilities and offices, are buzzing about a cluster of three hepatitis C infections found in patients who received intravenous anesthesia from the same anesthesiologist based in New York City in August 2006. The anesthesiologist worked at about 10 outpatient practices.
Although the investigation by the New York City Department of Health and Mental Hygiene is not complete, the available evidence suggests that the infections occurred during the administration of anesthesia medications during outpatient surgical procedures. There is no indication that the procedures themselves caused the infections.
The New York State Department of Health has not established that the anesthesiologist has done anything wrong, according to Claudia Hutton, a department spokeswoman quoted in a story from The Associated Press.1 The doctor has had a medical license since 1977 and doesn't have a history of infections, Hutton said.
This anesthesiologist has stopped working during the investigation, the city health department said in a statement.
Investigators have not determined whether there were any other times when hepatitis transmission occurred during administration of anesthesia by this physician. Therefore, the city health department is contacting about 4,500 patients who received IV anesthesia from this anesthesiologist for an outpatient procedure between Dec. 1, 2003, and May 1, 2007, when the anesthesiologist practiced in New York City. The agency is recommending that they be tested. The city health department also is recommending HIV testing at the same time, but no HIV infections have been linked to this incident.
In March 2007, the city health department was notified about the first case in a patient who had received IV anesthesia for a surgical procedure in August 2006. Prior to the procedure, the patient tested negative for hepatitis C. It is unlikely that this patient contracted the illness another way. Since then, blood testing of other patients who received anesthesia from this same doctor in August 2006 has thus far confirmed two additional cases of hepatitis C as part of this cluster. Initial laboratory testing of the hepatitis C viruses from both of these patients revealed that they closely match each other and the original patient's virus, which suggests that all three came from the same source.
Were universal precautions followed?
Anesthesiologists are puzzled by reports of the transmission.
Richard A. Beers, MD, professor of anesthesiology at State University of New York (SUNY) Upstate Medical University in Syracuse, says, "I cannot speculate on how transmission might occur during intravenous anesthesia, but a flagrant breach of universal precautions would have had to occur when IVs were started, intravenous drugs were injected, or airway devices were inserted." If universal precautions are followed, "then the chances of viral transmission from the clinician to the patient are zero," says Beers, who adds that good hand-washing practices still are important.
Girish P. Joshi, MD, MB, FFARCSI, professor of anesthesiology and pain management at the University of Texas Southwestern Medical Center at Dallas and president of the Society for Ambulatory Anesthesia (SAMBA), knows of a couple of anesthesiologists who have hepatitis C. In such cases, managers must confirm that universal precautions are being followed, Joshi says. "Just be sure, with no 'ifs, ands, or buts' about it," he says.
The two infected anesthesiologists Joshi knows "double-glove and take extra precautions," he says. For example, they wear a mask, although hepatitis C isn't spread through air particles. The mask prevents any of their sputum from reaching the patient, he explains. Anesthesiologists with hepatitis C who have cuts should take precautions, such as covering them with bandages, Joshi says.
The most likely culprit in the recent cluster of hepatitis cases is glass ampoules of medications, says Donald M. Mathews, MD, associate chairman for academic affairs in the Department of Anesthesiology at St. Vincent's Hospital Manhattan in New York City, and assistant professor of anesthesiology at New York Medical College in Valhalla.
"Often while cracking open an ampoule, an anesthesiologist's skin can be lacerated," Mathews says. "It is possible that some of the anesthesiologist's blood could end up in the ampoule."
It is also possible that there were self-accidental needlesticks following which the anesthesiologist continued to use the needle and/or syringe during patient care, he says. "It is also possible that the anesthesiologist had some kind of open wound that caused his blood to contaminate the needles/ syringes he used," Mathews says.
Others claim that the transmission may not have come from the anesthesiologist.
"Hepatitis C transmission is through blood and serum; therefore, it is unlikely that an anesthesiologist is the vector for transmission if he/she is carrying hepatitis," says Rebecca S. Twersky, MD, MPH, medical director of the Ambulatory Surgery Unit at Long Island College Hospital and professor of anesthesiology at State University of New York Downstate, both in Brooklyn.
So what is the more likely way this can happen? "Contamination of anesthesia equipment of a patient that carried hepatitis that can serve as the vector for all the patients exposed to that patient," she says. This contamination can be through syringes, multidose vials, IV bags, or needles, Twersky says. "It only takes one patient that is positive for hepatitis." The infectivity of hepatitis is so much greater than for HIV or other diseases, she says. "All you need is probably one virus particle," she adds.
Follow these tips
To ensure that hepatitis C is not spread during anesthesia administration, consider using single-dose vials, stopcocks, and no needles, Twersky advises.
"When patients' blood can microscopically get into a needle, and that needle is then inserted into a multidose vial, e.g. fentanyl, propofol, midazolam, muscle relaxants — many drugs that we use are multidose vials — the vial becomes contaminated," Twersky says. The anesthesiologist then may use a clean needle on the next patient and withdraw medication that already may have been contaminated, she says. "By using single-dose vials, that could be eliminated," Twersky says.
Mathews agrees that the use of multidose vials is of concern. "If a multidose vial is penetrated with a needle that has already been used for patient care, it has the possibility of harboring the virus that could be then transmitted to every one who subsequently receives medicine from the vial," he says.
Stopcocks allow no backflow into the needles, Twersky points out. "By changing needles for every patient, every syringe, that can further minimize" the risk, she says.
Some people may believe that a needle or syringe can be reused if the drug is administered far "upstream" from the patient, Mathews says. "This is an undefendable practice, in my opinion," he says. "If the anesthesiologist involved believed this, he may have been reusing needles and syringes during subsequent patient care."
Discard needles/syringes after contact
Any needle or syringe that comes in contact with a patient or the patient's IV line should be discarded after the care, Mathews says. "Multidose vials should never be penetrated with a needle that has already come in contact with a patient or their intravenous line," he says. Needles and syringes that are involved with anesthesiologist's self-needlesticks should be discarded, Mathews says. Additionally, glass ampoules should be opened in a way to prevent skin laceration, he says.
In an out-of-hospital facility, costs sometimes drive the economies, Twersky says. When people think they are saving money by reusing syringes or using multidose vials, they are not," she says. "The cost of patient safety and quality, by losing a protective barrier to cross-contamination, is much greater."
Although the New York cases occurred in the ambulatory surgery setting, this incident "could happen anywhere," Joshi points out. "It's not just the domain of ambulatory surgery."