OCCUPATIONAL HEALTH

BY DR.ANKITA MADAN

• Treat all patients as possible infection risks utilizing

universal precautions to minimize risk of transmission.• Reduce risk of developing latex allergy by avoiding latex

products and washing hands after contact with latex.• Intraoperative suction should be used to reduce exposure

to diathermy and laser smoke inhalation.• Changes in a colleague's behaviour may suggest

substance abuse and dependence.• Hepatitis B vaccine is recommended for all anesthesia

personnel because of the increased risk for occupational transmission of this blood-borne pathogen.

KEY POINTS

• Sleep deprivation and fatigue are common among anesthesiologists. Sleep deprivation can have deleterious effects on cognition, performance, mood, and health.

SOURCES OF OPERATING ROOM CONTAMINATION

ANESTH ETIC TECHNIQUES•Failure to turn off gas flow control valves at the end of an anesthetia•Turning gas flow on before placing mask on patient •Poorly fitting masks, especially with mask induction of anesthesia •Flushing of the circuit •Filling of anesthesia vaporizers •Uncuffed or leaking tracheal tubes (e.g., pediatric) or poorly fitting laryngeal mask airways •Pediatric circuits (e.g., Jackson-Rees version of the Mapleson D system) •Sidestream sampling carbon dioxide and anesthetic gas analyzersANESTHESIA MACHINE DELIVERY SYSTEM AND SCAVENGING SYSTEM•Open/closed system •Occlusion/malfunction of hospital disposal system •Maladjustment of hospital disposal system vacuum •LeaksHigh-pressure hoses or connectorsNitrous oxide tank mountingO ringsCO2 absorbent canistersLow-pressure circuitOTHER SOURCES•Cryosurgery units •Cardiopulmonary bypass circuits

INFECTIONS

• Occupational exposure to a range of pathogens represents a serious risk to anaesthetists. The risk of transmission of blood-borne pathogens, such as human immunodeficiency virus (HIV) and hepatitis B and C, are well known, but occupational exposure also includes airborne pathogens such as tuberculosis

• a failure to follow recommended procedures for the safe handling and disposal of contaminated ‘sharps’ .

• a failure to wear appropriate protective clothing and eyewear.

•  self-inoculation from a needle during the insertion and suturing of intravascular catheters, the injection of intradermal anaesthesia or resheathing of used needles.

EXPOSURES TO PATHOGENS BY :-

PRECAUTION :- As the infection status of most patients is unknown, the adoption of universal precautions for all patients is recommended.

HIV :-• The risk of acquiring HIV after an occupational

exposure to HIV-infected blood is low.• risk for HIV transmission after percutaneous

exposure to HIV-infected blood in health care settings is 0.3%. 

• After a mucocutaneous exposure, the risk is 0.03% and if intact skin is exposed to HIV-infected blood there is no risk of HIV transmission.

• POST EXPOSURE :-

The site of exposure should be washed immediately with soap and water and the occupational health department informed.

 Post-exposure prophylaxis has been shown to be maximally effective if taken within an hour after an exposure, but benefit may remain if commenced up to 2 weeks after exposure.

HEPATITIS B & C

• Hepatitis B is highly infectious and the risk of transmission after occupational exposure is higher than for HIV.

• The incidence of seroconversion from a high infectivity carrier (e antigen positive) to a non-immune health care worker is up to 40% after exposure by percutaneous inoculation, depending on the magnitude of contact with the blood.

• Hepatitis C is also a blood-borne pathogen. The risk of transmission after a hepatitis C contaminated occupational exposure has been estimated at 2%.Chronic hepatitis develops in 85% of hepatitis C infections with 20% progressing to cirrhosis and 3% to hepatocellular carcinoma. A chronic carrier state may also develop. No vaccine exists but some institutions offer immune serum globulin as post-exposure prophylaxis.

• PREVENTION : An effective vaccine exists to prevent the transmission of hepatitis B

and all anaesthetists should ensure that they are up to date with their immunization schedule.

Anaesthetists in whom no antibodies are present and who suspect exposure to hepatitis B should be immunized passively with hepatitis B immunoglobulin and receive a series of three injections of hepatitis B vaccine. Prior vaccination with seroconversion eliminates the need for immunoglobulin.

TUBERCULOSIS

• Tuberculosis spreads by small (1–5 μm) droplets released when an infected person speaks, coughs or sneezes.

• TRANSMISSION IN ANAESTHETIOLOGISTS BRONCHOSCOPY LARYNGOSCOPY TRACHEAL INTUBATION SUCTIONING OF AIRWAY MECHANICAL VENTILATION• Probability of transmission is also related to the concentration

of infectious droplets and duration of exposure. • STRATEGIES TO PREVENT Education to raise awareness.  The use of appropriate protective clothing and personal

respirators. Limiting the number of personnel in contact with the patient

and where possible delaying surgery until a patient is non-infectious.

Anaesthetists who have experienced a high risk exposure should undergo a tuberculin test and if indicated undertake 6–12 months of chemoprophylaxis.

INFECTIOUS AGENT PREVENTIVE MEASURESHepatitis A Vaccine in some cases; contact precautionsHepatitis B Vaccine; hepatitis B immune globulin, standard

precautionsHepatitis C Standard precautionsHerpes simplex Standard precautions; contact precautions if disseminated

diseaseHuman immunodeficiency virus

Standard precautions; postexposure prophylactic antiretrovirals

Influenza, Vaccine; prophylactic antiretrovirals; droplet precautions

Measles Vaccine; airborne precautionsRubella Vaccine; droplet precautionsSevere acute respiratory syndrome

Standard precautions; airborne precautions

Tuberculosis Airborne precautions; isoniazid ± ethambutol for purified protein derivative conversion

Varicella-zoster Vaccine; varicella-zoster immune globulin; airborne and contact precautions; standard precautions if localized disease

Prevention of Occupationally Acquired Infections

• These are to be used for the care of all patients regardless of their

diagnosis or presumed infection status.Standard precautions should be used in conjunction with other forms of transmission-based precautions for the care of specific patients.Hand washing (hand hygiene)After touching blood, body fluids, or contaminated items and environmental surfaces even if gloves are worn.

• GlovesWear gloves when it is reasonably anticipated that there will be contact with blood or infectious material, mucous membranes, nonintact skin, or contaminated intact skin.Change gloves between tasks on the same patient when the hands will move from a contaminated body-site to a clean one.Remove gloves after use, before touching noncontaminated items and environmental surfaces.

• Mask, eye protection, face shieldUse during procedures likely to generate splashes of blood or body fluids that may contaminate face or mucous membranes.

• GownUse during procedures likely to generate splashes of blood or body fluids that may contaminate clothing or arms.

STANDARD PRECAUTIONS

• Respiratory hygiene/cough etiquetteEducate health care personnel and implement methods to contain respiratory secretions in patients and visitors especially during seasonal outbreaks of viral respiratory tract infections.

• Patient-care equipment and instruments/devicesUse PPE when handling soiled devices to prevent contamination of skin, mucous membranes, or clothing.

• Environmental controlContaminated environmental surfaces should routinely be cleaned and/or disinfected.

• LinenSoiled linen should be handled in a manner that prevents contamination of personnel, other patients, and environmental surfaces.

• Occupational health and blood-borne pathogensUse care to prevent injuries when using or disposing of needles and sharp devices.Contaminated needles should not be recapped or manipulated by using both hands. If recapping is necessary for the procedure being performed, a one-handed scoop technique or mechanical device for holding the needle sheath should be used.Contaminated needles should not be removed from disposable syringes by hand.Do not break or bend contaminated needles before disposal.After use, disposable syringes and needles and other sharp devices should be placed in appropriate puncture-resistant containers located as close as practical to the area in which the items were used.Mouthpieces, resuscitation bags, or other ventilation devices should be available for use as an alternative to mouth-to-mouth ventilation.

• TRANSMISSION-BASED PRECAUTIONSThese should be used along with standard precautions for patients known or suspected to be infected or colonized with highly transmissible pathogens requiring additional precautions.AIRBORNE PRECAUTIONSThese should be used for patients known or suspected to be infected with micro-organisms transmitted by airborne droplet nuclei (particles 5 µm or smaller in size) that can be dispersed over large distances by air currents.Patient placementThe patient should be placed in a single-patient room with (1) documented negative air pressure relative to surrounding areas, (2) 6 to 12 air changes per hour, (3) discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital.The door to the room should be kept closed and the patient should remain in the room.

• Respiratory protectionA fit-tested NIOSH-approved N95 or higher level respirator should be worn when entering the room of a patient with known or suspected infectious pulmonary or laryngeal tuberculosis .Susceptible personnel should not enter the room of patients known or suspected to have measles, varicella or disseminated zoster if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles or varicella, they should wear respiratory protection. Persons known to be immune to measles or varicella need not wear respiratory protection.

These should be used for patients known or suspected to be infected with microorganisms transmitted by large-particle droplets (particles larger than 5 µm) that can be generated during coughing, sneezing, talking, or by performing certain procedures.

•Patient placementThe patient should be placed in a single-patient room.

• Respiratory protectionPersonnel should wear a mask when entering the patient's room.

• Patient transportPatients should be transported from the isolation room only for medically necessary purposes. When transport is necessary, a surgical mask should be placed on the patient and they should be instructed to follow respiratory hygiene/cough etiquette.No mask is required for the person transporting the patient.

DROPLET PRECAUTIONS

•These should be used for patients known or suspected to be infected or colonized with epidemiologically important micro-organisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items.

•Patient placementThe patient should be placed in a single-patient room.

Gloves and hand washingIn addition to wearing gloves as outlined under standard precautions, gloves should be worn when entering the patient's room.Gloves should be changed after contacting infective material or environmental surfaces that may contain high concentrations of micro-organisms.Gloves should be removed before leaving the patient's environment and hands should be washed immediately with an antimicrobial agent or a waterless antiseptic agent.After removal of gloves and hand washing, care should be taken so that contaminated environmental surfaces should not be touched to avoid transfer of microorganisms to other patients.

CONTACT PRECAUTIONS

• Patient transportThe patient should be transported from the room for only medically necessary purposes.If it is necessary to transport the patient, infected or colonized areas of the patient's body should be covered to prevent transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment.Remove contaminated PPE prior to transporting patients and don clean PPE to handle the patient at the transport destination.

• Patient-care equipmentUse disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or dedicate nondisposable equipment to a single patient to avoid transmission of micro-organisms to another patient. If use of common equipment is unavoidable, then items should be adequately cleaned or disinfected before use on another patient.

PPE : personal protective equipment such as gloves, gown, eye-shield, or face mask; NIOSH-National Institute for Occupational Safety

and Health;

Musculoskeletal morbidity

• Lacerations and glass splinters when opening drug ampoules are a common occurrence.

• Repetitive strain injury, previously associated with the holding of facemasks for prolonged periods, is increasingly rare after the introduction of the laryngeal mask airway.

•  The first metacarpo-phalyngeal joint is the commonest joint to be affected by osteoarthritis in any dextrous manual employment.

• Hand ventilation, opening ampoules, drawing up and injecting drugs are all actions that predispose to the development of this condition.

LATEX ALLERGY

• Latex in surgical and examination gloves has become a common source of allergic reactions among operating room personnel.

• The latex found in medical products is actually a composite of many substances including proteins, polyisoprenes, lipids and phospholipids combined with preservatives, accelerators, antioxidants, vulcanizing compounds, and lubricating agents (such as cornstarch or talc).

• The protein content is responsible for most of the generalized allergic reactions to latex-containing surgical gloves. These reactions are exacerbated by the presence of powder that enhances the potential of latex particles to aerosolize and to spread to the respiratory system of personnel and to environmental surfaces during the donning or removal of gloves.

REACTION SIGNS/SYMPTOMS

CAUSE MANAGEMENT

Irritant contact dermatitis

Scaling, drying cracking of skin

Direct skin irritation by gloves, powder, soaps

Identify reaction, avoid irritant, possible use of glove liner, use of alternative product

Type IV—delayed hypersensitivity

Itching, blistering, crusting (delayed 6–72 hours)

Chemical additives used in manufacturing (such as accelerators)

Identify offending chemical, possible use of alternative product without chemical additive, possible use of glove liner

Types of Reactions to Latex Gloves

Type I—immediate hypersensitivity

Proteins found in latex

Identify reaction; avoid latex-containing products; use of nonlatex or powder-free, low-protein gloves by co-workers

A. Localized contact urticaria

Itching, hives in area of contact with latex (immediate)

Antihistamines, topical/systemic steroids

B. Generalized reaction

Runny nose, swollen eyes, generalized rash or hives, bronchospasm, anaphylaxis

Anaphylaxis protocol

RADIATION• Anaesthesiologists can be exposed to ionizing radiation from X-rays and

to non-ionizing radiation from lasers. Although the dose after an individual exposure may be extremely small, repeated episodes may lead to cumulative exposure with potentially adverse health effects.

The magnitude of radiation absorbed by individuals is a function of three variables:

• Total radiation exposure intensity and time.• Distance from the source of radiation.• The use of radiation shielding. The lead aprons and thyroid collars commonly worn leave exposed many

vulnerable sites, such as the long bones of the extremities, the cranium, the skin of the face, and the eyes. Because radiation exposure is inversely proportional to the square of the distance from the source, increasing this distance is more universally protective.

The U.S. Regulatory Commission has established an occupational exposure limit of 5,000 mrem/year.

Oncogenesis, teratogenesis, and long-term genetic defects can occur with sufficiently high exposure to radiation. The risks associated with radiation vary considerably, depending on age, gender, and specific organ site exposure.

Magnetic resonance imaging

(MRI)• The hazards associated with MRI include exposure to

an intense magnetic field, acoustic noise and the possible risk of hypoxia if quenching of a superconducting magnet occurs.

• There is no evidence for an accumulative harmful effect of strong magnetic fields, although temporary symptoms of nausea or vertigo from stimulation of the semicircular canals may occur; safe levels of exposure are recommended.

• The effects of these hazards may be minimized by remaining in the control room while the scan is taking place.

DIATHERMY AND LASER

SMOKE INHALATION• Inhalation of smoke and vapour generated by the use of

surgical diathermy and lasers represents a potential hazard to anesthesiologist. Surgical masks do not filter toxic gases nor trap particles <0.5 μm in diameter.  The median diameter of particles produced in smoke plumes is 0.31 μm. 

• Pulmonary lesions have been demonstrated in laboratory animals after inhalation of smoke from tissues treated with a carbon dioxide laser, and the smoke plume generated by diathermy has been found to contain carcinogens such as benzene. Other chemicals (e.g. toluene, styrene, carbon disulphide) have been identified in diathermy smoke and can cause corneal irritation, dermatitis, renal and hepatic toxicity and affect the central nervous system.

• Operator exposure can be reduced effectively by suction devices; their routine use is advisable.

ELECTROMAGNETIC

FIELDS• The use of monitors and electrical equipments

continually exposes the anesthesiologist to electromagnetic fields. 

• Adverse health effects resulting from this exposure are not well defined but there are reports that an increased risk of brain cancer, breast cancer and leukaemia occurs in populations exposed to electromagnetic fields.

• While the potential health hazards and safe upper limits of exposure remain to be determined, anesthesiologist should aim to minimize their exposure.

WASTE GASES

• During the 1970s and 1980s several studies suggested that a link existed between exposure to anaesthetic agents and hepatic disease, reduced mental performance and reduced manual dexterity.

•  Evidence also suggested a higher rate of spontaneous abortion among female anaesthetists exposed to anaesthetic gases while the incidence of congenital abnormalities in children of both male and female anaesthetists was raised compared with controls.

• In 1999, legal limits for environmental levels were published in the Control of Substances Hazardous to Health Regulations (COSHH) as doubts about potential adverse health effects persisted. Emphasis was placed on the need for control measures including good anaesthetic practice, frequent changes of theatre air and gas scavenging.

• In 1998, the British Medical Association reported that an estimated 1 in 15 doctors will suffer with a form of alcohol or drug dependence at some point in their lives.

•  Alcohol abuse featured more commonly in those above 40 yr; drug abuse alone, most commonly opioids, benzodiazepines, or both, was more prevalent in those below 40 yr.

• Within anaesthesia, specific risk factors when combined with an individual's genetic predisposition may precipitate the development of chemical dependence. Anaesthetists are unique in the fact that they give drugs directly to the patient rather than prescribing them for others to administer. This along with ready access to a wide range of potent psychoactive drugs and a detailed knowledge of pharmacology are factors in the development of drug dependence. 

SUBSTANCE MISUSE

• Anaesthetists usually work alone and may feel they have less control over their professional lives than colleagues in other specialities while the requirement to work anti-social hours may contribute to conflict in an individual's personal life. The nature of anaesthesia means mistakes can have potentially catastrophic consequences and, in an increasingly litigious society, the threat of medicolegal proceedings can be an enormous burden.

• Consideration of non-professional pressures (e.g. financial, marital) must also be given in the understanding of drug abuse and dependence.

• Dependence on highly lipid soluble opioids such as fentanyl develops rapidly and an affected individual requires ever increasing doses of the drug as tolerance develops.

• Difficult relationships with colleagues• Mood swings (e.g. depression, anger, irritability, paranoia, elation)• Unreliable, poor time keeping• Poor administration and record keeping• Disproportionate levels of postoperative pain in patients when compared with apparently

administered drugs• Progressive increase in use of narcotics and other drugs for anaesthetic management• Inconsistencies in recording and unaccountable missing drugs• Preference for working alone• Frequent requests to use the toilet• Difficult to find between cases or when on call• Often appears at the hospital when not on call• Unusual willingness to take on extra work commitments• Carrying syringes and ampoules in clothing• Bloody swabs and syringes in inappropriate places (e.g. offices)• Wearing of long sleeved gowns (to hide track marks and prevent chills seen in early withdrawal)

• Pinpoint pupils when using or dilated pupils when withdrawing (opioids)• Smell of alcohol on breath• Found comatose or dead• Witnessed self-administration

SIGNS AND SYMPTOMS OF CHEMICAL DEPENDENCE SEEN IN THE HOSPITAL

• Withdrawal from family, friends and leisure activities• Neglect and deterioration in appearance

• Mood swings (e.g. depression, anger, irritability, paranoia, elation)

• Fatigue and lethargy• Poor concentration, memory, confusion and impaired judgement• Frequent unexplained illness• Domestic instability

• Legal problems (e.g. driving while under the influence of drink, drugs, or both)

• Financial difficulties, gambling and fraud• Frequent house moves or job changes

• Drugs and alcohol found at home, offices or inappropriate places (e.g. car)

• Smell of alcohol on breath• Weight loss• Symptoms of withdrawal from drugs or alcohol

SIGNS AND SYMPTOMS OF CHEMICAL DEPENDENCE SEEN OUTSIDE THE WORKPLACE

• Education of all personnel should allow early identification and treatment of anaesthetists with a drug or alcohol related problem, so appropriate treatment can be instigated before serious consequences have occurred, either for the individual or their patients.

• Denial is often the first response shown by an affected individual when they are presented with concerns or evidence of dependence.

• Colleagues may also choose to believe implausible excuses offered by an individual rather than see a friend and colleague labelled as a ‘drug addict’.

• However, all anaesthetists have a duty of care to patients and colleagues alike. Accessible protocols allowing confidential reporting of suspected or actual drug abuse, alcohol abuse, or both must be followed.

•  In anaesthetists treated for a previous fentanyl addiction, the risk of relapse in the first 18 months after a return to work was about 20%.Factors identified as contributory to the risk of relapse include addiction to an opioid, coexisting psychiatric illness, a family history of substance misuse and a history of previous relapse.

STRESS

• Stress is an inevitable factor in professional and personal life and can lead to negative health effects, both mental and physical.

• Moderate levels of stress are an important driving factor in optimizing performance, but prolonged and excessive levels of stress, coupled with inadequate coping mechanisms, can lead to decreased job satisfaction, impairment of decision making and even suicide. 

• Individual personality type is a significant factor in the development of stress. Doctors tend towards a ‘type A’ personality associated with insecurity of status, anxiety and time urgency and these individuals may be more susceptible to stress.

• Chronic exposure to stress will lead to exhaustion, characterized by physical and emotional symptoms, mental dysfunction and, ultimately, ‘burnout’.

• Stress has also been identified as a precipitating factor in the development of alcohol and drug misuse.

• The management of stress hinges on the recognition of its nature and causes, and an understanding of how individuals respond. Modifications to lifestyle can then be made before clinical skills become impaired.

SOURCES OF STRESS AMONGST ANAESTHETISTS

• Lack of control of the work environment• Strained professional relationships• Work overload• Unpredictability of work• Administrative responsibilities• Teaching responsibilities• Continuing medical education and professional development• Peer review• Potential litigation• Sleep deprivation and disruption of circadian rhythms• Conflict between the demands of work and home• Personal or family illness• Marital disharmony• Financial concerns

FATIGUE

• Human physiology dictates circadian patterns of alertness and performance and includes a vital need for sleep. Sleep loss and disruption of circadian rhythm can lead to reduced attention and vigilance, poor memory, impaired decision making, prolonged reaction time and disrupted communications.

•  Workload pressures, insufficient numbers of personnel and increasing complexity of procedures compound the problem for doctors. Many studies have shown that fatigue reduces medical task performance. 

• Fatigue-related incidents may occur as a result of the individual experiencing ‘microsleeps’. These brief, uncontrolled and spontaneous episodes of physiological sleep may last seconds or minutes and the individual may not be aware of them. 

• Other factors exaggerating the detrimental effects of fatigue include hypovolaemia, hypoglycaemia, alcohol and drug use, poor general health and concomitant use of some prescription medications.

STRATEGIES TO MAINTAIN

ALERTNESS• Minimize sleep debt by maximizing sleep before on call• Nap wherever possible for 45 min or >2 h• Overcome sleep inertia by increasing light levels, stretching, walking

briskly and taking refreshment

• Alert colleagues if microsleeps/nodding off occurs and ask for relief

• Whenever relief is available, take a break• Caffeinated drinks• If working next day, nap rather than working through• Nap before driving home• Post call, sleep rather than party to pay off sleep debt. Go to bed

earlier than normal

• Chronic fatigue may also affect an individual's physical health. Peptic ulcer disease, which is more common in shift workers, and gastrointestinal dysfunction presenting as vague, non-specific abdominal symptoms have led some to believe in the existence of a ‘shift-work maladaptation syndrome’.

• Strategies to reduce fatigue-related incidents include relief planning, regular and rehearsed equipment checking routines, improved workplace design (including drug ampoule and syringe labelling protocols) and regulation of working hours. 

• The implementation of the ‘New Deal’ and European Working Time Directive has reduced the number of continuous hours worked by trainees with many moving to a shift pattern of working. 

THANK YOU