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St. Luke’s Roosevelt Hospital Center College of Physicians and Surgeons Of Columbia University New York, NY
To the Editor:
We read with interest Dolinski and Gerancher’s description of positioning of patients undergoing regional anesthesia (1). Although we applaud any new approach that potentially increases the success of neuraxial blocks, we were shocked by the photograph that accompanied their letter. That photograph was a particularly egregious example of the lamentable decline in aseptic technique that has unfortunately become acceptable practice. The anesthesiologist performing the block (resident?) is without mask, and the second anesthesiologist holding the patient’s back (attending?) is without gloves.
Although the risk of infection following neuraxial techniques is slight, lack of scrupulous asepsis "invites serious danger from meningitis or epidural abscess" (2). Common sense and universal precautions should be adequate to convince anesthesiologists to wear a mask during the administration of neuraxial anesthesia. However, if more evidence is necessary, we suggest a review of the report of an epidural abscess that was proven to be caused by a phage of Staphylococcus that was cultured from the nose of the anesthesiologist who had inserted the catheter (3).
Anesthesiologists share with all physicians the responsibility to provide safe and compassionate care for their patients. Although the absence of gloves and mask during initiation of neuraxial anesthesia may not necessarily cause the patient to develop an infection, their use surely makes the procedure a safer one. The ethical principle of primum non nocere ("first do no harm") is well established and implores physicians to avoid harming or exposing the risk of harm to their patients. Surely, this must apply to minimizing the risks associated with neuraxial techniques. Anesthesiologists must consider the potential harm caused by our techniques and do everything to reduce potential morbidity. Is there any reasonable justification to forego appropriate sterile precautions when performing neuraxial blocks? We think not!
References
Department of Anesthesiology Wake Forest University School of Medicine Winston-Salem, NC
In Reply—
We thank Drs. Browne, Birnbach, and Tsen for their comments. Our intent was to offer two practical adjuncts to neuraxial block placement. In a British survey of obstetric anesthesiologists’ practice behavior regarding the wearing of face masks during neuraxial block placement, 41.3% routinely wore masks and 50.6% did not (1). Our photo does, indeed, accurately depict how we practice. One of us (SD) wears a mask during epidural placement, and one of us (JG) does not. We both wear sterile gloves and a hat when personally performing the procedure or touching the site of placement and the sterile equipment. If our photograph were more panoramic, one would see that we place these blocks in a holding room where a cloth drape separates our aseptic field from other chronically hospitalized patients, visitors, and hospital personnel walking about.
We agree that epidural abscess and meningitis are devastating problems. However, there are more case reports in the literature describing the occurrence of these complications despite the anesthesiologist wearing a face mask than there are implicating the anesthesiologist when no mask was worn. In fact, in a recent case report of Streptococcus Mitis meningitis following spinal anesthesia by Villevieille et al. (2), not only was a mask worn, but also a sterile gown. The block was placed in the operating room with all personnel dressed sterilely! As Dr. Tsen points out, "...observational and case control studies have implicated (italics added) health care providers, including anesthesiologists, as the source of infections." Case reports frequently implicate the ear, nose, and throat flora of the anesthesiologist, but do not prove the anesthesiologist caused the infection. There is a case report that implicates a neurologist whose throat swab was linked to the meningitis causing organism by polymerase chain reaction fingerprinting and fatty acid profile after lumbar puncture (3). There is one case report that implicates an anesthesiologist whose nasal swab was linked to the organism causing an epidural abscess by phage typing (4). No mention was made of mask use in either of these case reports. The study cited by Dr. Tsen implicated one anesthesiologist having caused four cases of spinal meningitis (two in one day), with each case developing spinal meningitis from a different organism: Streptococcus Sanguis and Streptococcus Mitis (5). The other two cases had yet two different organisms: Streptococcus Salivaris and Streptococcus Cremoris. In the latter two cases, both patients had undergone epidural blood patches for spinal headaches, and it is not stated whether the same anesthesiologist placed those.
It is a fact, that a reduction in these kinds of infections by wearing of a face mask remains to be proven. The use of face masks was originally debated by Wildsmith (6) and Yentis (7) in the British literature, and for those interested, we encourage the review thereof. After the debate, Wildsmith engaged in a laboratory study designed to investigate if the use of a face mask reduced contamination of agar plates placed 30 cm directly in front of anaesthesiologists who spoke at them for several minutes. Face masks did decrease agar plate growth, but there was increased growth on the agar plates once the face mask was worn for 15 min (8). This occurred despite the study being performed in a completely draft-free room—hardly representative of a usual holding room. We would guess that not too many anesthesiologists change their masks for each new procedure; some probably wear the same mask all day long, and some take longer than 15 min to place a neuraxial block. O’Kelly et al. (9) showed similar results of reduced agar plate bacterial growth simply by having mask-less anesthesiologists not speak while sitting in front of the agar plate. Others have even suggested that face masks themselves contribute to the risk of infection by increasing skin scale shedding (10).
Because it boils down to opinion whether face masks make neuraxial block placement safer, we can neither emphatically recommend the use of face masks nor resolutely recommend they not be worn. Instead, we now offer an edited photograph as an erratum next to the original ( Figs. 1, 2). We can, however, recommend that the reader place a hand over the picture found most objectionable.
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