Risk and safety concerns in anesthesiology practice: The present perspective.

Newer developments and advancements in anesthesiology, surgical, and medical fields have widened the functional scope of anesthesiologist thus increasing his professional responsibilities and obligations. While at workplace, anesthesiologist is exposed to a wide array of potential hazards that can be detrimental to his overall health. Numerous risks and safety concerns have been mentioned in the literature, but the magnitude of challenges in anesthesiology practice are far greater than those cited and anticipated. Many times these challenging situations are unavoidable and the attending anesthesiologist has to deal with them on an individual basis. These hazards not only affect the general health but can be extremely threatening in various other ways that can increase the potential risks of morbidity and mortality. This article is an attempt to bring a general awareness among anesthesia fraternity about the various health hazards associated with anesthesia practice. Also, a genuine attempt has been made to enumerate the various preventive methods and precautions that should be adopted to make practice of anesthesiology safe and smooth.

INTRODUCTION

The progressive advancements in anesthetic and surgical techniques as well as with the advent of modern equipment and newer drugs, the duties, responsibilities and expectations from anesthesiologist have also increased tremendously in the last few years. However, the health of anesthesiologist is affected to a great extent by ever increasing professional and social burden both at workplace and in the personal life.[1] Anesthesiologists are expected to provide safe and smooth anesthesia services not only in the operation theaters and intensive care units, but also at various remote locations, pre-interventional consultations, pain clinics, magnetic resonance imaging (MRI) suite, and radiotherapy centers. Anesthesiologist is also an essential part of trauma and natural disaster management team. In these locations, anesthesiologists are exposed to a number of health hazards and even a simple needle prick from an unknown source can evoke intense anxiety and fear among many anesthesiologists.[23] This article revolves around these health hazards that can be extremely harmful to professional and personal health of the attending anesthesiologist.

Therefore, occupational health and safety acquires prime importance while delivering professional duties. The definition of occupational health, as given by WHO in 1995, is of significant dimension when such issues are of concern. The definition aims at “the promotion and maintenance of highest degree of physical, mental and social well being of workers in all the occupation; prevention amongst workers of departures from health caused by their working conditions; protection of workers in their employment from risks resulting from factors adverse to health; placing and maintenance of the worker in an occupational environment adapted to the physiological and psychological capabilities; summarize the adaptation of work to man and of each man to his job.” The basic principle of this definition is Plan-Do-Check-Act (PDCA).

Hazards can be broadly classified into following categories:

Types of hazards

Biological hazards

Mechanical hazards

Chemical hazards

Physical hazards

Personal Hazards

Biological hazards

Ever lurking dangers of infectious diseases

In day to day practice anesthesiologists are exposed to numerous pathogens that include bacteria, viruses, etc. The incidence of such hazards varies from hospital to hospital and from country to country and results in clinically asymptomatic carrier state to overt fatal infection.[4] The risk is quite high in developing nations like India where many airborne and blood borne diseases are prevalent not only in endemic form but do acquire epidemic proportions also quite frequently. Besides the current epidemics such as swine flu and dengue as well as the prevalence of airborne pathogens like tuberculosis is equally threatening. Airborne infections are commonly contracted at congestive places either by direct droplet infection or may be inhaling infected droplet nuclei while blood borne infections are contracted during securing of intravenous lines, central venous catheters, and exposures to number of body fluids from the patient. The blood borne infections are most commonly contracted during invasive procedures such as securing of intravenous lines, central venous catheters, and exposures to number of body fluids from the patient. The needle stick injury, injury during suturing of central venous catheter, injury during local infiltration and regional anesthesia, accidental falls of sharp objects on the legs and feet, exposure to infected CSF, oro-pharyngeal secretions, infected wounds, administration of anesthesia in infected burns and wounds are all possible mechanisms by which an anesthesiologist can contract these infections.[5]

Preventive measures and precautions

Precautions should be exercised for prevention of infection transmission between patient and anesthesiologist and vice versa and hand hygiene is the simplest measure one can adopt in the operation theatre. The operation theatre functioning should be strictly based on the institutional policies framed by the infection control committee. The sterilization of all operation theatre equipment and anesthetic apparatus should be carried out on a regular basis as per the recommendations of the universal protocols and guidelines. There should be strict measures to dispose of the onetime usable equipment as it can be a potential source of infection from patient to patient and to anesthesiologist and this include the bacterial filter also. The anesthetic association of Great Britain and Ireland (AAGBI) recommends the changing of anesthetic circuits on a daily basis in line with universal protocols. The anesthetic procedures, particularly the invasive procedures should ensure complete sterilization and adoption of barrier precautions especially during performance of such procedures in high risk patients.

Tuberculosis

The incidence and prevalence is much higher in developing nations like India as compared to the west and as such anesthesiologists in these countries are invariably exposed to surgical patients suffering from a clinically carrier state to severe symptomatic TB.[6] The risks of contracting infection with mycobacteriumincreases during performance of various procedures in operation theatre such as laryngoscopy, intubation, bronchoscopy, Ryle's tube insertion, oro-pharyngeal suctioning, tracheal suctioning, use of open circuits (Bains and Jackson Rees) for mechanical ventilation, etc.[7]

These risks can be minimized by using protective clothing, wearing of masks and gloves during suctioning and other oral procedures.[8] A possible or suspected exposure should be confirmed by a tuberculin test and if it is positive thus one should take drug therapy for TB as indicated.

Swine flu

Many patients of swine flu got admitted in emergency surgical wards and the intensive care units at the peak of the epidemic period. Besides a high probability of contracting infection from the potential source patient, anesthesiologist had to manage the compromised pulmonary function, hyper-reactive airway; systemic hypotension and multi-organ dysfunction in these patients.[9]

Though only emergency surgeries are recommended in such patients still precautions have to be taken during such interventions especially in ICU during procedures such as suctioning, dressings, intubation, etc. The role of protective clothing and specially designed face masks (N95) is of immense significance in providing adequate protection. Closed loop circuits should be used to avoid contamination and infection of other operation theater personals. In case of exposure, a 5-day course of oseltamivir is sufficient besides vaccination for swine flu virus.

Acquired Immunodeficiency syndrome virus

The prevalence of HIV in surgical patients and consequent risks to anesthesiologists have continuously increased though it still remains much lower than other viral infections. The exact incidence is difficult to ascertain for abraded and intact skin but studies have observed an incidence of 0.03% to 0.3% after percutaneous exposure to HIV infected blood and mucocutaneous exposure, respectively.[10] The common sources of infection being venous catheterization, neuraxial anesthesia, punctures during intramuscular injections and withdrawal of blood sample, during laryngoscopy, intubation and extubation as well as during oral and tracheal suctioning.[15]

The centers for disease control and prevention has laid down certain guidelines and should be followed in all form of anesthesiology practice to prevent any incidence of HIV infection. The recommended postexposure prophylaxis insists on immediate washing of the exposed site with plain water and soap. Antiviral drugs should be administered within an hour and include tenofovir, emtricitabine, zidovudine, lamivudine, and lopinavir andretonavir. The rapid HIV antibody test should be carried out if exposure is <2 h and test should be repeated at 6 and 12 weeks and thereafter at 6 months as source patients can be in the window period.

Infectious hepatitis

The incidence of hepatitis B carrier state is estimated at 1 in 500 persons in general population that is a potential risk factor as majority of these patients will asymptomatic.[11] The risk of the seroconversion rate increases manifold in infection with hepatitis B virus if the source patient is in the highly infective period, that is, Hepatitis E antigen positive state. The 0.03 mL of infectious blood is sufficient to cause hepatitis B infection and the incidence is more with hollow needles than with solid needles especially in nonimmunized health care workers.[1213] The complications and consequences after contracting HCV include chronic hepatitis in more than 80% of exposed personals and among them 20% of the patients can develop hepatic cirrhosis after 10–15 years and 3–5% can develop fatal hepatocellular carcinoma.[14]

Anesthesiologists should ensure a complete immunization with Hepatitis B vaccine with booster at regular intervals of 5 years. In nonimmunized healthcare workers and also in whom no antibodies can be demonstrated should be treated with hepatitis B-immunoglobulin along with three injections of hepatitis B vaccine. However, in case of hepatitis C infection, no vaccine available till date and nor the postexposure prophylaxis is of much significance.[15] Simple measures such as wearing of protective clothing, gloves, masks, avoiding reinsertion of needle into its cap, dressing of all abrasions and cuts, disposing of the contaminated material in meticulous manner, sterilization of anesthesia equipment and apparatus are sufficient enough to prevent infection to a large extent.[16]

Mechanical hazards

These are not common hazards in routine anesthesia practice but nevertheless can be potential source of injury and harm to the anesthesiologist at the workplace. These can range from simple collisions with equipment and objects in a confined and congested space of operation theater, slips and falls in the operation theater, falls on the pointed objects and broken pieces of glass, falls due to entanglement with various cables of the monitoring gadgets, etc. The sustained injury mechanisms can vary in the form of crushing, cutting, fracture, abrasions, shearing, and puncture.

The simple measures to reduce injury from such hazards include covering of all wires and cables of monitoring gadgets and workstation in one sheet that should come from one side only, measures to keep the OT area less congested as far as possible, cutting of drug ampoules with cutting knife and use of snap off ampoules, use of dustbins and cleaning of blood or fluid from floor as quickly as possible.

Physical hazards

These hazards can be from various sources such as noise pollution of various alarms and monitoring gadgets, sounds of cautery and harmonic, vibrations of various equipment and suction apparatus, bright lights, electrical hazards from various electrical and electronic appliances and temperature changes in the operation theater.

Radiation and nuclear hazards

Both the ionizing and nonionizing radiation has been implicated as the potential hazard to the anesthesiologists at their workplace.[17] The anesthesiologist is exposed to radiation six times more than other personals during the neurointerventional angiographic procedures and the increasing use of C-arm in the orthopedic procedures exposes the anesthesiologists to beyond the recommended dose limit of radiation of 15 mSv/yr and the cumulative effects of radiation affect entire body or cause localized damage to a certain area of the body such as cataract.[18-21] Anesthesiologist as a part of disaster management team has to face nuclear hazards occasionally such as the deadly Chernobyl and the latest is the Fukushima nuclear hazard.[22] These different sources of radiations may be threatening to the human body as a whole or may cause localized damage to a certain area of the body, depending upon the extent and dosage of the irradiation.

The use of protective lead jackets and thyroid covering collars should be compulsory for all the personals; badges and radiation dose measuring meter should be analyzed on monthly basis to calculate cumulative exposure to radiation; keeping a distance from the patient as the patient is potential source of scatter radiation.[192023]

Laser hazards

The most harmful effect from the laser use occurs to eyes from either the direct exposure or reflection through various surfaces and leads to damage to various ophthalmological tissues such as cornea, retina macula, optic nerve and lens. These hazards can simply be avoided by the use of special glasses meant to protect from the lasers as well as notifying on the door of the operation theatre by a danger sign during the ongoing procedure so as to limit the unnecessary entry of individuals and accidental laser injuries to them.

Radiology suite

Pediatric, non-cooperative and patients on mechanical ventilation require the services of anesthesiologists during radiologic diagnostic interventions either in the form of procedural sedation or general anesthesia.[24] A major concern with cardiac patients involves the malfunctioning of aneurysm clips, pacemakers prosthetic heart valves,[2526] which can be potentially lethal in such patients.

Anesthesiologist with these implanted devices should refrain from entering such areas and should be vigilant when they take such patients for the requisite interventions. The vibrations and the acoustic noise can be equally harmful resulting in severe vertigo, nausea, and vomiting and should be prevented with the use of special ear plugs.

The modern technology has provided various monitoring gadgets to help the anesthesiologist during the surgical procedure, but at the same time exposes him to various potential hazards of such electrical equipment. Though, there are no established reports but it is generally postulated that exposure to the electromagnetic fields of such monitoring gadgets can result in the possible carcinomatous changes in the brain, breast, and hematopoietic system. These concerns definitely require large meta-analytical studies in future.

Orthopedic and soft tissue injuries

Abrasions, lacerations, and cut injuries from glass are common during the snapping of drug ampoules. One of the most common neglected aspect during administration of general and neuraxial anesthesia is the positioning of anesthesiologist. Though the exact incidence is not known but such wrong positioning during airway securing and administration of neuraxial anesthesia is harmful for the back muscles and can potentially lead to disc problems in certain high risk individuals. The introduction of laryngeal mask airway (LMA) has virtually eliminated the risk of first metacarpo-phalyngeal joint injury due to prolonged holding of the face mask during short duration anesthesia for day care procedures.

As far as possible, use of definite methods of airway securing with LMA in cases anesthesia is required for short duration. Positioning should be comfortable while administering general anesthesia, neuraxial blockade, or during laryngoscopy and intubation.

Chemical hazards

Noxious pollutants from diathermy and laser use

The wearing of ordinary surgical face masks are not protective enough and exposes anesthesiologists to inhalation of toxic fumes, vapors, and gasses during the use of diathermy and laser. The size of pores in the surgical face mask cannot prevent inhalation of particles lesser than 0.5 μm in diameter whereas the size of the toxic fumes, vapors, and gasses during the use of diathermy and laser is usually lesser than 0.31 μm. Though no human studies have been published till date but data from various animal studies have established that inhalation of such fumes can be carcinogenic and damaging to eyes and skin and can potentially cause renal, hepatic and central nervous system toxicity.[27]

These problems can be overcome by the use of plenum, hepafilters, scavenging systems, wearing of protective eye glasses and use of various suction equipments.

Anesthetic gasses

Nitrous oxide and various halogenated anesthetics such as halothane, isoflurane, and enflurane have been implicated in various harmful biological effects after absorption through alveolar-capillary membrane. The exposure of anesthetist to inhalational anesthetics is higher as compared to other operation theater personals and may even cross the limits of environmental tolerance.[28] Once these lipid-soluble agents are metabolized into body, the more harmful effects are exerted by their metabolites that can potentially cause hepatic, renal, and pulmonary toxicity and decreased psychomotor efficiency on chronic exposure. Though, issues have been raised from time to time about the teratogenic effects of anesthetic gasses and the resultant congenital abnormalities in the newborn as well as a higher rate of spontaneous abortion among female anesthesiologists but nothing conclusive has been established as yet.[29] However, various studies carried out so far have failed to establish a definite link and relation between these claims.

Various health agencies have provided a regulation for technical limit of N2O in operation theatre to a limit equal to 50 ppm but till date there are no limits set for halogenated anesthetics. Control of substances hazardous to health (COSHH) has established regulations about the permissible levels of these anesthetics in 1999.

Fire and explosion hazards

Fires and explosions in operation theatres can cause severe form of burn injury and inhalational trauma to the pulmonary tissue. The oxygen enriched atmosphere of operation theatre along with presence of inflammable substances and ignition sources such as diathermy and lasers are potential factors that can cause fire or explosion in the operation theatre.[30]

The present day safety requirements mandates the availability of fire extinguishers at specified allotted places in the operation theatre that can decrease the said risks to a great extent. Good house keeping, maintenance, and discipline help prevent such mishaps.

Allergic risks

Latex allergy is one of the common allergies observed in the surgical suite often with the use of latex containing surgical gloves. It can occur as contact dermatitis or delayed type IV reaction or can result in serious anaphylactic shock. One can elicit past history of allergy to certain compounds especially to certain food items. The repeated exposure to allergens can make one prone to develop some serious form of allergy.

Special gloves are available that have minimal latex content. Washing of the hand immediately after the use of gloves can prevent though cannot eliminate the incidence of allergy

Personal hazards

Drug abuse and addiction

Substance abuse and dependence has acquired an important dimension in the present day anesthesiology practice. Multiple risk factors, individual susceptibility, long monotonous working hours, fatigable work shifts, personal problems in the family and marital discord, easy availability of the sedative and potent psychoactive drugs predispose the anesthesiologist to substance abuse that can prove harmful not only to himself but can be devastating for the patient as well.[131-33] The high propensity of anesthesia risk and the resultant catastrophic consequences along with increasing consumer awareness and litigation can put huge mental pressure on anesthesiologist that further predisposes him to acquire the path of substance abuse. Data from various developed nations like US and UK indicate that general incidence of alcohol or drug abuse is estimated at 1 in 15 doctors.[134] Among these cases gender predominance was seen with 81% of the male developing substance abuse while hierarchy split ratio included 43% trainees, 36% consultants, 11.5% locums, and 10% nonconsultant career grades. The drug dependent anesthesiologist can be harmful not only to himself but his habits can prove equally fatal to the patient as well. There are however no provision in our system which freely allows an a anesthesiologist to confess his drug addiction and substance abuse habit to a responsible and concerned authority so that an appropriate and timely action can be instituted to prevent undesirable consequences. Rather more helpful will be establishing universal protocols and guidelines that allow easy confession, rehabilitation and safe practice of anesthesiology.

Rehabilitation and resumption of professional duties require a lot of co-operation from the colleagues. The factors leading to the present situation should be identified and an effort should be made with the help of psychologist to eliminate whatever are the possible causative factors.[35]

Stress and burnout

The fast pace of life and competitive atmosphere of modern times has given birth to stress in almost every spheres of life and anesthesiology could not remain exceptionally insulated from the mental and physical harmful effects of stress. Stress is necessary evil as “optimal stress” levels are essential for enhanced performance whereas more than optimal stress can lead to poor decision making, decreased performance levels, and discordial atmosphere at workplace and at home [Figure 1]. The survey studies in Europe have observed that one third of the anesthesiologists felt stressed at most of the times while 5% felt stressed almost all the times.[3637] Contributory factors to developing such a higher levels of stress included overwork, nature of duties especially night shifts, disturbances of natural sleep cycle, additional administrative responsibilities besides heavy clinical schedule, family problems, financial problems, litigation problems, etc. Stress “burnout” is the end result of taking too much stress for a long time leading to mental and physical exhaustion and ultimately resulting in mental and physical breakdown and a tendency to commit suicide. Inexperienced trainee anesthesiologists are even more exposed to stress at work and run a greater risk of burnout. They sometimes experience very demanding situations and may feel lonely and inadequate at work. Such a situation can make anesthesia unattractive and may explain why some young doctors have been reluctant to choose it as a career.[38-41]

Figure 1

Relationship between stress levels and performance, happiness and health

Exhaustion and fatigue

Stress can lead to fatigue which can be mental, physical or emotional. It can significantly impair one's ability in performing professional duties and can lead to poor sleep that results in lack of alertness and vigilance during performance of clinical skills.[42-44] Difficult airway management, resuscitation procedures and interpretation of ECG are all affected as shown by a study especially among the emergency physicians working in the night shifts.[45] This fact acquires important dimension in practicing anesthesiologists as majority of them travel at night for emergency cases. Fatigue can lead to impaired decision making, prolonged reaction time and can result in ‘power naps’ which can cause accidents while driving.[46] Metabolic consequences though rare but are associated with fatigue and include hypoglycaemia, hypovolemia, ill health, gastritis, coronary artery disease, and high propensity for drug abuse.

Stress busting techniques and strategies

Numerous measures can be adopted in order to decrease and eliminate stress from the professional and personal lives.[47] To enhance the motivational levels in health personals, these stress busting strategies go a long way for the daily routine work.[48] Attitudinal and behavioral modification in response to stressful situations.

Planning and developing newer strategies to cope up with anticipated stress.

Maintaining a good discipline in daily schedules.

Communicating and discussing all the niggling issues with either spouse or colleagues or friends.

Realization of inner self potential.

Indulging in hobbies and relaxing during idle time.

Inculcating a sense of optimism.

Maintaining a good sleep pattern, regular exercise and good nutrition.

Suicides

Again the data available from the developing nations is scarce where the expected rate of suicide is considered to be higher than the developed nations that show a higher rate of mortality among anesthesiologists as compared to general physicians. However, as compared to general population the mortality rate was half with a standardized mortality ratio of 0.48. Various surveys and statistical evidence have established a much higher rate of premature retirement, ill health, suicides, and mortality in male anesthesiologists compared to female anesthesiologists and also to other medical specialties with an estimated risk of suicide at 1.45 (95% CI 1.07–1.97, P=0.002) with an estimated incidence of 250 per 100000 anesthesiologists.[4950] This suicidal ratio is significantly higher as compared to physicians of other specialties and approximately 15 times higher than the normal population and depression and drug abuse has been the major contributors to these mortalities.

CONCLUSION

Prioritization of safety situations can be dealt if possible as mandatory, desirable, or others. It requires a lot of attitudinal and behavioral modification and bridging of gaps in current preventive and precautionary measures, support from hospital authorities and an active role of governmental or regulating agencies to fill these gaps with appropriate global evidences is desirable.