I Need a Total Knee, but…

  • Chamberlin, Keith, MD, MBA, FASA
| Dec 04, 2017

Yes, I need a total knee.  But, if you heard all the Surgical Site Infection (SSI) talks at the ASA in Boston recently, you might well understand why I still NEED a total knee yet do not HAVE a total knee. Yes, I know the chance of infection is low, but frankly not low enough for my knee.  I listened to the SSI lectures as a patient and as a physician-anesthesiologist.  The patient part of me was appalled. 

Have you ever seen a total knee get infected?  Of course, you have. Do we have a role in preventing these infections? Of course we do! And did I believe that before going to six hours of SSI lectures at the ASA? Of course not! Do I believe it now? You bet I do! Is it an annoying disruption to our workflow to do all the things we need to do to help with SSIs? Yes. Heck YES.

SSIs have our attention every day in every OR in this country and is a major improvement initiative of every state and national regulatory agency. Infection rates are posted publicly to assist patients in making wise choices. Most likely, your hospital's infection control department has data on SSIs for every surgeon and procedure. It is projected that by the year 2030 the total number of primary total knee arthroplasty (TKA) procedures in the United States will reach 3.48 million per year, a 673% increase over the number of procedures in 2005. And the cost of TKA revisions for SSIs is projected to exceed $1.62 billion by 2020.  (That is only two years away…) (Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27:61–5)

So the scrutiny of the OR environment will only get more intense. AORN is concerned about OR attire. So is the American College of Surgeons, and the ASA. I went to lectures about surgical attire, masks, shoes and shoe covers, and evidence-based practices. Do you know what truly matters?  Hand washing, antibiotics, site preparation, and the OR environment. And hand washing. We all have the same goal: Prevention of SSIs and recommendations that are evidenced based. But for any issue, the longer the list of related items, the less importance attributed to each item.  (This is the same problem long checklists have…) The fact is that our SSI list is long and contains items that are not evidence supported. (Cloth hats are better at stopping hair and scalp fomites than bouffant caps, J. Am College of Surgeons Vol. 225, No. 5, November 2017.)

What role do anesthesiologists play in this? Hand washing. Cleaning your workstation. Did I mention hand washing? One thing you can do easily is to have a simple tray next to the patient where you can deposit your used laryngoscope and dirty gloves after airway manipulation, before turning back to the anesthesia machine to give a breath or turn on a vaporizer. Check yourself the next time you intubate and see where your hands go immediately after that, gloved or not? See how easy it is to transfer pathogens? Where are your hand sanitizers? Are they  empty? How often do you use them?

The slide that pushed me over the edge was in a talk by Randy Loftus, MD, who showed us soon to be published data where: 1) he took cultures from various places in the OR and 2) identified precisely which strain of bacteria was present at these sites. He then followed those specific bacterial strains for the day. He had one example where bacteria from the OR nursing desk showed up on the anesthesia tubing stopcock for the TO-FOLLOW PATIENT! Yes, the 7:30 AM nursing station bacteria found its way to your noon patient's stopcock. And it was MRSA.  Wash your hands.

And it was not just a few bacteria. Over 50,000 CFUs (colony forming units) were waiting to be injected into your unsuspecting patient. I had to look at the recorded version of the lecture because I thought I had heard it wrong when I left the live session. I had it right. Wash your hands. Clean your anesthesia machine, the vaporizers, the computer and the Pyxis. All the places you touch all the time.

Does a contaminated stopcock make a difference? Oh yes. And how long does it take an open stopcock to become contaminated? 4 minutes. Loftus examined the prior association of stopcock contamination with 30-day postoperative infection and mortality. Look at this table; odds ratio of 58!

increase motality Anes Analgesia  2012 Jun;114(6):1236-48.

So now what? What do I do about my knee and the anesthesiologists wherever I go for surgery?  Do I insist they “scrub the hub” of the stopcock with readily available stopcock disinfecting devices before each injection of the many medications I will need? Do I insist they wash their hands at least five times per hour? Do I insist they place disinfecting devices on the syringes tips they are using? Do I insist they disinfect their workstation, the Pyxis, the anesthesia machine prior to my coming into the room? YOU BET I DO!

Then what happens? When you complete an evaluation of a CME lecture, there is a list of barriers to implementing the ideas in the lecture you are asked to pick one. Here’s one that is not there: the barrier is that no one wants to be “that guy.” When this blog is published, I become one side of “that guy.” You know, the anesthesiologist who goes on and on about SSIs and our role in prevention. I never wanted to be “that guy.” But do you want to be the one who ignores our role in SSI prevention and knowingly injects bacteria into patients? Or the anesthesiologist who sees his patient return to the OR two weeks later for a hardware removal for infection?

How hard is it to “scrub the hub” every time you inject? Frankly, it can be difficult (and sometimes dangerous) depending on how many drugs you are injecting at one time. For example, we use induction agents, muscle relaxants, and narcotics in quick succession. But if you scrub the hub at the start of the case, cap the stopcock with a sterile device, wash your hands before putting on gloves, inject using a syringe whose tip is either brand new or covered with a disinfecting device, keep the dirty airway items and gloves off the anesthesia work area, I feel like you cared and helped me avoid an SSI.

So, I have started scrubbing the hub, washing my hands a lot, and cleaning my workstation and anesthesia machine and the Pyxis before my patients enter the OR (even if the anesthesia techs already did this once...). I dispose of my airway stuff before I turn back to my workstation. Did I prevent an SSI?  I know I helped prevent one. And guess what – the surgeons notice. And they appreciate the effort. Anytime you can get a surgeon to notice what you do and recognize the value of what you do, consider that a win.

Now you have to pick which "that guy or gal" you want to be. The anesthesiologist who worries about SSIs or the one who doesn't. Please worry because you may be my anesthesiologist for my total knee someday. Now go wash your hands…

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  1. Larry Saidman | Dec 04, 2017

    Hi Keith,  Terrific note and information.  Although now retired from practice, I may well need surgery of some sort in the future and will certainly look for the anesthesiologist adhering to your recommendations.  Unfortunately, I must also admit that I was not as conscientious as you would have liked while practicing for more than 50 years.  

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