Bennett SN, McNeil MM, Bland LA, et al. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med 1995; 333:147-153.
Strict compliance with aseptic techniques is essential when using the anesthetic propofol to avoid outbreaks of postoperative infections, the authors state. No other single intravenous agent has been associated with as much contamination or such widespread outbreaks as propofol, they say, citing unpublished data from the U.S. Food and Drug Administration in Rockville, MD.
An investigation at seven hospitals was conducted by the Atlanta-based Centers for Disease Control and Prevention. The study found the failure of anesthesia personnel to follow proper aseptic techniques when using the anesthetic propofol, led to outbreaks of postoperative infections affecting 49 patients. Two died.
Anesthesia personnel implicated in the outbreaks had committed at least one lapse in aseptic technique, including:
* preparing multiple syringes of propofol at one time for use throughout the day;
* reusing syringes or infusion-pump lines, or both, on different patients;
* using syringes of propofol that had been prepared up to 24 hours beforehand;
* transferring prepared syringes of propofol between operating rooms or facilities;
* sometimes failing to wear gloves during the insertion of intravenous catheters;
* sometimes failing to wear gloves during procedures that involved toughing mucous membranes or preparing or administering propofol.
At one hospital, anesthesia personnel failed to disinfect the rubber stoppers of 50 ml propofol vials before use.
Propofol is exceptionally prone to contamination because it is lipid-based and contains no preservatives or anti-microbial agents to retard bacterial growth, and refrigeration is not recommended by the manufacturer, the authors stated.
To prevent infectious outbreaks, anesthesia personnel should carefully follow manufacturer's directions, including disinfecting the surface of the neck of the ampule or the rubber stopper in a vial before use and preparing propofol just before use, the authors say.
Report infections or acute febrile episodes that may be linked to propofol to state health departments. Information about propofol-related outbreaks is collected by the CDC's Hospital Infections Program (Centers for Disease Control and Prevention, Mail Stop E69, Atlanta, GA 30333. Telephone: 404-639-6413) and the FDA's MedWatch medical-products reporting program (800-FDA-1088).
Escarce JJ, Chen W, Schwartz JS. Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA 1995; 273:1,581-1,585.
With the introduction of minimally invasive surgery for gallstone patients, the clinical threshold for cholecystectomy has dropped, resulting in a rapid rise in the number of procedures, the authors found.
Cholecystectomy rates among elderly Medicare patients were stable until laparoscopic cholecystectomies became available in 1989, then rose by 22% from 1989 to 1993, the authors discovered in a review of data from Medicare hospital discharge files for Pennsylvania.
Lap choly patients were more likely to have uncomplicated gallstone disease and to have undergone elective surgery. Open cholecystectomy patients were sicker, both in their general health and their gallstone-related illnesses.
Since the lap choly involves less postoperative pain and quicker recovery, patients with mild or infrequent symptoms who were reluctant to undergo the open procedure, may have become candidates for that laparoscopic surgery, the authors conjecture.
The study did not determine the extent to which clinical thresholds were lowered. However, in an editorial in the same issue, David F. Ransohoff, MD, and Charles K. McSherry, MD, of the University of North Carolina at Chapel Hill, express concern that the threshold will be lowered too much and some patients may unnecessarily be subjected to risks of complications, such as bile duct injury.
Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet 1995; 345:36-40.
Too many hysterectomies are being performed by the abdominal route, the authors state. Previous pelvic surgery, mild endometriosis, history of pelvic sepsis, uterine fibroids or oophorectomy should no longer be considered contraindications for vaginal hysterectomy.
Of 98 women who had contraindications for vaginal surgery based on those traditional criteria, 77 underwent laparoscopic hysterectomy and 23 underwent vaginal hysterectomy.
Mean operative time was longer with laparoscopic hysterectomy than with vaginal hysterectomy (131 minutes vs. 77 minutes).
The authors concluded that laparoscopic hysterectomy is a waste of time and money for most patients, and that when used, the procedure should be converted to a vaginal procedure as soon as possible. *
* Ambulatory Surgery Centers -- New Perspectives for Physicians. Feb. 29 - March 2, Coronado, CA. Sponsored by the American Society of Outpatient Surgeons (ASOS). For more information, contact ASOS, 401 N. Michigan Ave., Chicago, IL 60611-4267. Telephone: (800) 237-3768. Fax: (312) 321-6869.
* SAMBA 11th Annual Meeting. May 2 - 5, Boston. Sponsored by the Society for Ambulatory Anesthesia (SAMBA). For more information, contact SAMBA, 520 N. Northwest Highway, Park Ridge, IL 60068. Telephone: (708) 825-5586. Fax: (708) 825-1692.
* Post-Anesthesia and Ambulatory Post-Anesthesia Nursing Review and Certification Exam Preparation. March 9, Cleveland, OH; March 16, Atlanta. Anesthesia Drugs: An Indepth Review. March 10, Cleveland; March 17, Atlanta. Sponsored by Clemson University Continuing Education in Nursing Department. For more information, contact Olivia Shanahan, Continuing Education Department, School of Nursing, Clemson University, Box 341711, Clemson, SC 29634-1711. Telephone: (803) 656-3078. Fax: (803) 864-1877. *