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10 Sato S, Sakuragi T, Dan K. Human skin ora as a potential source of epidural abscess. Anesthesiology 1996; 85: 127682. 11 Sumner M, Lynch P, Black T. Hair as a resevoir for Staphylococci. Journal of Clinical Pathology 1965; 18: 135. 12 Dineen P, Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet 1973; 2: 11579. 13 Black W, Bannerman C, Black D. Carriage of potentially pathogenic bacteria in the hair. British Journal of Surgery 1974; 61: 7358. 14 Barbeito M, Mathews C, Taylor L. Microbiological laboratory hazard of bearded men. Applied Microbiology 1967; 15: 899906. 15 Cozanitis D, Makela P, Grant J. Microorganisms in the hair of staff and patients in an intensive care unit. Anaesthesist 1977; 26: 57880. 16 Hamilton D, Kobylik B. Infection risk in the bearded patient. Infection Control and Hospital Epidemiology 1988; 9: 55.

17 Ngan Kee W, Jones M, Thomas P, Worth R. Extradural abscess complicating extradural anaesthesia for caesarean section. British Journal of Anaesthesia 1992; 69: 64752. 18 Kindler C, Seeberger M, Siegmund M, Schneider M. Extradural abscess complicating lumbar extradural anaesthesia and analgesia in an obstetric patient. Acta Anesthesiologica Scandinavica 1996; 40: 85861. 19 Yuste E, Canet J, Garcia M, Gil M, Vidal F. An epidural abscess due to resistant Staphylococcus aureus following epidural catheterisation. Anaesthesia 1997; 52: 15068. 20 Cascio M, Heath G. Meningitis following a combined spinal epidural technique in a labouring parturient. Canadian Journal of Anaesthesia 1996; 43: 399402. 21 Bouhemad B, Dounas M, Mercier F, Benhamou D. Bacterial meningitis following combined spinalepidural analgesia for labour. Anaesthesia 1998; 53: 2925.

F O RU M

Entonox equipment as a potential source of cross-infection

R. J. Chilvers1* and M. Weisz2
1 Specialist Registrar in Anaesthetics and 2 Consultant Anaesthetist, Department of Anaesthesia, Peterborough District Hospital, Thorpe Road, Peterborough PE3 9DA, UK Summary

A survey of the hospitals with obstetric units within the Anglia and Oxford Region was performed to assess current practices regarding the cleaning of, and use of lters with, Entonox apparatus. The survey revealed that there was no consensus regarding the cleaning of the equipment and, in contrast to anaesthetic machines in which microbiological lters are recommended and in widespread use, only 10% of the hospitals surveyed were using such lters with the Entonox apparatus in their units. Cleaning procedures were changed in 75% of hospitals when dealing with known `high-risk' patients, the remaining hospitals treating all patients as `high-risk' or denied caring for such patients. All patients should be protected from potential cross-infection, and the recommendation that a microbiological lter should be placed between patients and the breathing system should be extended to Entonox equipment.
Keywords Equipment; breathing systems, breathing lters. Complications; cross-infection. ...................................................................................... Correspondence to: R. J. Chilvers Accepted: 17 July 1999
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In 1994 a worrying report arose from Australia regarding possible patient-to-patient transmission of hepatitis C virus in a hospital [1]. The source of this transmission was thought to be a contaminated anaesthetic breathing system. Following this report and a review of the available literature, the Association of Anaesthetists of Great Britain and Ireland recommended that appropriate microbiological lters should be placed between the patient and the breathing system [2]. Their use is now widespread in the UK [3]. However, Entonox equipment, which is widely used in UK maternity units, Accident and Emergency departments and by paramedic ambulance crews, is not covered by this policy. The aim of this study was to survey the current practices regarding the cleaning of, and use of lters with, Entonox apparatus in the Anglia and Oxford Region.
Methods

Procedures for dealing with known `high-risk' patients were then queried, in particular whether any additional measures were taken. High-risk was dened as those patients known to be infected or having signicant risk factors for human immunodeciency virus (HIV), hepatitis B or hepatitis C. Further questions were then asked relating to tuition in cleaning the apparatus and how often apparatus was checked for malfunction. Any additional comments were noted.
Results

All hospitals with obstetric units in the Anglia and Oxford Region were identied and contacted. A standardised questionnaire (copies available from the author) was used which enquired about practices relating to the routine care of Entonox apparatus with emphasis on cleaning methods and the use of lters. The most senior midwife available was interviewed. The questionnaire covered basic information regarding the grade of the midwife, whether Entonox was used in that unit and who administered it. The use of masks and/ or mouthpieces was ascertained and whether lters were used. Enquiries were then made about cleaning procedures with particular regard to how each part of the apparatus was cleaned (mask, valves and tubing) and how often this was undertaken.

Twenty hospitals with obstetric units in the Anglia and Oxford Region were identied. The response rate was 100%. All hospitals surveyed used Entonox on the delivery suites; in all cases it was self-administered by the mother under the supervision of the attending midwife. Seventeen hospitals used pipeline Entonox; cylinders were available in all units and all hospitals had mouthpieces and masks to use with the apparatus, although one hospital reported that masks were never used. Cleaning of Entonox equipment In all hospitals the midwife and/or the healthcare assistant cleaned the equipment. All hospitals reported that masks were cleaned between patients and various methods were used (Fig. 1). Nearly half the masks were cleaned with soap and water. Mouthpieces were also cleaned or disposed of between patients in all hospitals (Fig. 1). Eight hospitals had single-use, disposable mouthpieces, four hospitals soaked them in sterilizing solution and six hospitals sent the mouthpieces to their central sterile supplies

Figure 1 Methods of cleaning masks and

mouthpieces used with Entonox equipment in the hospitals surveyed.

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department (CSSD). The remaining two units washed the mouthpieces with soap and water. Use of lters Only two hospitals surveyed used lters on the breathing systems. In both cases the lters were placed between the mask or mouthpiece and the demand valve. The lters were changed after every patient and were disposable (one) or sent for sterilisation (one). These two hospitals recently had new Entonox equipment tted in the units. A third hospital had lters introduced for a short time and subsequently withdrawn; the reason for this was unknown. One-way expiratory valve, demand valve and corrugated tubing In the majority of hospitals (18/20) the expiratory valve was not cleaned between patients, in two hospitals the external surface was wiped clean (with soap and water or alcohol spray). One hospital sent the demand valve for autoclaving once a week. The corrugated tubing was not cleaned or replaced after use at any hospital. Cleaning of Entonox equipment following use with known `high-risk' patients When questioned regarding the use and cleaning of Entonox apparatus following use with a known `high-risk' patient, three hospitals reported that no additional measures were taken and all patients were treated as `high-risk'. In other hospitals, 8/20 sent all the equipment to CSSD (masks, mouthpieces, valves and tubing); one reported that everything was cleaned `a bit more thoroughly', another reported that the mask and valve were cleaned with soap and water, two hospitals reported that all the equipment would be discarded and a further two hospitals were uncertain

but would contact their local infection control team. Two hospitals reported that they never had `high-risk' patients (Fig. 2). Tuition in cleaning apparatus All the midwives questioned reported that they had learnt about the cleaning of used Entonox apparatus `on the job' and no-one reported formal tuition in disinfection methods for Entonox apparatus.
Discussion

There is no general consensus regarding the cleaning of Entonox equipment in labour wards in the Anglia and Oxford Region. These ndings support those of another recent study, which collected data from over 100 maternity units [4]. Our survey shows that masks and mouthpieces were cleaned using a variety of methods but little attention was paid to the expiratory valve, tubing and demand valve. Hence we would agree with Bajekal and colleagues [4] that these measures are unlikely to prevent viral transmission. In contrast to anaesthetic machines, in which lters are recommended and in widespread use [2, 3], only two hospitals were using microbiological lters on Entonox apparatus and in both cases this equipment had been installed recently. The manufacturers had clearly perceived a need for lters. Although the extent to which the transmission of infective organisms via anaesthetic breathing systems occurs is unknown, the fact that use of lters to prevent contamination of anaesthetic breathing systems by expired gases is now recommended should suggest the acceptance of this practice for Entonox equipment. Entonox apparatus differs from conventional anaesthetic systems in that there is a

Figure 2 Additional methods used when

cleaning Entonox equipment with known `high-risk' patients.

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non-return expiratory valve close to the patient. Although gas ow is only one way through the expiratory valve, this valve is only 15 cm from the patient's mouth and thus deposition of potentially infected debris on the valve must be commonplace. The rubber tubing and the demand valve are more remote from the patient but surely any contamination must be considered to affect the entire equipment. The sterile precautions adopted should be the same as those for anaesthetic breathing systems, i.e. the use of a microbiological lter between the mask or mouthpiece and the expiratory valve. All patients should be protected from potential cross-infection. In our study, `high-risk' patients were treated differently from non `high-risk' patients in 15/20 hospitals surveyed. We found this observation worrying, as implicit in this behaviour is the assumption that normal procedures are not sufcient for protection against blood-borne and other viruses. Even for the known `high-risk' cases the procedures were probably only adequate in half the hospitals surveyed (i.e. all Entonox equipment discarded, all equipment sent to CSSD, or the use of microbiological lters). Interestingly, of the three hospitals that treated all patients as high-risk, only one was using lters routinely. As the infected individual is not always easily identied it follows that all patients should be treated as potentially infected and universal precautions adopted for all. The study by Bajekal and co-workers [4] did not specically address which proportion of the hospitals they surveyed used

different levels of decontamination depending on patient risk assessment. We recommend the immediate extension of the current recommendation that a microbiological lter should be tted between the patient and the breathing system to include Entonox apparatus.
Acknowledgments

We would like to thank the hospitals that participated in this survey.

References 1 Chant K, Kociuba K, Munro R, et al. Investigation of possible patient to patient transmission of Hepatitis C in a hospital. New South Wales Public Health Bulletin 1994; 5: 4751. 2 The Association of Anaesthetists of Great Britain and Ireland. A report received by the council of the Association of Anaesthetists on blood borne viruses and anaesthesia, January 1996. 3 Atkinson MC, Girgis Y, Broome IJ. Extent and practicalities of lter use in anaesthetic breathing circuits and attitudes towards their use: a postal survey of UK hospitals. Anaesthesia 1999; 54: 3741. 4 Bajekal RR, Turner R, Yentis SM. Anti-infective measures and Entonox equipment: a survey. Anaesthesia 2000; 55: 1534.

F O RU M

Training in obstetric general anaesthesia: a vanishing art?

R. V. Johnson,1* G. R. Lyons,2 R. C. Wilson2 and A. P. C. Robinson2
1 Specialist Registrar in Anaesthesia, Department of Anaesthesia, Royal Halifax Inrmary, Free School Lane, Halifax HX1 2YP, UK 2 Consultant Anaesthetists, Department of Anaesthesia, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, UK Summary

General anaesthesia in obstetric practice has largely been replaced by the use of regional techniques. We have studied this phenomenon and the subsequent impact on training in this technique both retrospectively and with a prospective audit. There has been a decline in the use of general anaesthesia for Caesarean section such that trainee anaesthetists are getting less practical exposure to this important procedure. Audit revealed a decit with consultant involvement in training and heightened awareness has resulted in improved supervision. Possible implications for future consultant working practices are discussed.
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