In: Dental treatment

25 Sep 2009


According to an Associated Press article written by Nick Trougakos, an Oklahoma City nurse anesthetist was accused of reusing needles and syringes for up to 25 patients per day while injecting intravenous pain medications. Obviously, reusing any needle, tubing, intravenous (IV) bag, syringe, or other injectable device in another patient can spread disease that can lead to HIV, hepatitis, cancer, and death. Among the Oklahoma City nurse’s 1220 patients who were subsequently contacted, 52 tested positive for hepatitis С as of August 2002. Consequently, the American Association of Nurse Anesthetists (AANA) sent 33,000 letters to hospital administrators, nurse anesthetists, and students warning them that reusing needles and syringes that are used to administer drugs into IV tubing is hazardous, as is injecting directly percutaneously with those same contaminated needles and syringes. After consultation with infection control experts, the AANA had concerns that there may be widespread misunderstanding by health care practitioners of the dangers of reusing contaminated needles and syringes.

According to the article, the Oklahoma case was not an isolated incident. In 2001, 19 patients of a Brooklyn, NY, clinic contracted hepatitis С when an anesthesiologist reused needles and a vial of medication. Dr Elliot Greene, who serves on the American Society of Anesthesiologist’s task force for infection control, indicated that studies performed in the 1990s documented that health care professionals sometimes reused needles and syringes when injecting drugs into intravenous tubing. Dr Greene was quoted as saying, “There are a lot of people who started practice before this was an issue. They got into certain practice patterns that are now considered bad technique.” levitra 20 mg

How does this relate to your dental practice? There are several possibilities for cross-contamination of intravenous devices and drugs that must be reviewed. Each dental practitioner has the professional responsibility to reevaluate every aspect of his or her IV practice to ensure the absolute safety of this aspect of dental care. All IV needles, catheters, tubing, stopcocks, injection ports, and fluid bags are initially sterile, but the instant that they are connected to the patient’s bloodstream, all of these items, even the most remote IV bag, must be considered contaminated. One might rationalize that as long as the fluid continuously flows forward, the IV bag and most of the tubing may remain sterile throughout a short procedure. However, common sense dictates that none of these items should be reused for another patient if there is even a remote possibility of cross-contamination among patients. Because it is impossible to prove that reused tubing and bags cannot possibly be contaminated by inconspicuous backflow of blood, the only certain method to prevent cross-contamination and the possibility of being accused of infecting a patient—or worse, of infecting hundreds of patients—is to use all-new sterile IV items for each patient.
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Another hazard is the possible contamination of a multiple dose vial while drawing an additional dose with the same needle and syringe that were originally inserted into a patient’s intravenous tubing or stopcock to give the first dose. For instance, you withdraw 50 mg of meperidine from a 30-mL multidose vial and inject it into the IV. Later in the procedure, you decide to withdraw another 50 mg using the same needle and syringe. That immediately contaminates the remaining meperidine and potentially spreads an infectious disease to future patients receiving the remaining 28 doses. From that single mistake, 28 patients could be harmed, and undoubtedly 28 malpractice cases would be filed if a link or even a possible link could be established among the unfortunate, unsuspecting victims. Of course these infections can be acquired elsewhere, but if either an infected patient or his or her lawyer has reason to suspect that the dentist might be the culprit, and if the testimony of the dental assistants demonstrated that the dentist’s IV practices were in fact outdated, the dentist might be judged guilty even if he or she was actually innocent.
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It has been common practice among oral surgeons who inject incremental doses of methohexital or pro-pofol to use a nondisposable metal 3-way valve that is attached to a syringe, to a tube leading to the reservoir bag/bottle of drug and to an extension tube attached to the IV catheter or butterfly. When the syringe is pulled back, the valve permits the syringe to fill by withdrawing drug from the reservoir. When the syringe plunger is pushed, the valve permits the drug to be pushed into the vein through the extension tubing. Changing only the extension tubing between cases decreases the margin of safety that a new, all-sterile setup offers to prevent cross-contamination and infection. It is my opinion, and undoubtedly that of the Centers for Disease Control and Prevention (CDC) if they were asked to comment, that unless the metal valve is sterilized between each case and the reservoir of drug and all associated tubing are thrown away at the end of each case, the system invites.

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.