gms | German Medical Science



Complying with these measures allows the use of anaesthesia breathing systems for a period of up to 7 days based on the latest state of knowledge, provided that the system continues to meet functional requirements such as air tightness IB and if stated by the manufacturer in the instructions for use. Can I bring my own food and drink?

GMS Hygiene and Infection Control


The BSF shall be changed after each patient. The anaesthesia breathing system may be used for a period of up to 7 days provided that the functional requirements of the system remain unchanged and the manufacturer states this in the instructions for use.

The breathing system and the manual ventilation bag are changed immediately after the respective anaesthesia if the following situation has occurred or it is suspected to have occurred: Notifiable infectious disease involving the risk of transmission via the breathing system and the manual bag, e.

In case of visible contamination e. Observing of the appropriate hand disinfection is very important. All surfaces of the anaesthesia equipment exposed to hand contact must be disinfected after each case. Wilkes, Cardiff, UK served as an external advisor. Members of the working group: The respective evidence of the recommendations is made clear by means of categorisation in accordance with the directive of the Commission for hospital hygiene and infection prevention state of April , published by the Robert Koch-Institut Berlin.

The categories are as follows:. The recommendations are based on well-designed experimental or epidemiological studies, IB: The recommendations are considered to be effective by experts and by virtue of a consensus resolution by the working group, and they are based on well-founded indications as to their effectiveness. A classification is also possible even if there have not been any studies yet. The recommendations are based partly on indicative clinical or epidemiological studies, partly on comprehensible theoretical explanations or studies.

No recommendation or unresolved issue: Measures supported with insufficient evidence about their efficiency or without consensus on this. Due to frequent patient changes at the anaesthesia workstation, anaesthesia ventilation is characterised by the risk of cross-contamination and subsequent infection.

As the entire complex of prevention measures regarding nosocomial pneumonia is concerned [1] both in the CDC Guidelines [2] and in the recommendations by the commission for hospital hygiene and infection prevention at the Robert-Koch-Institute RKI , the present recommendations are limited to the evaluation of the literature published in the meantime on the application of breathing system filters BSF as an alternative to the change of the anaesthesia breathing system after each patient, and on the hygienic reprocessing of the breathing gas cond uctin g systems of the anaesthesia ventilator.

The requirements for BSF and their potential applications are derived from this objective of filter use. Further prevention measures are only emphasized if they can be considered as a prerequisite for the safe use of BSF without changing the anaesthesia breathing system.

The use of suitable BSF between tracheal tube and anaesthetic system and the adherence to appropriate disinfection measures at all contact points of the anaesthetic equipment represent, if used together, a safe and cost-effective alternative to the use of a new or individually cleaned breathing system and to the reprocessing of the breathing gas conducting parts of the anaesthesia ventilator after each patient IB , and they contribute to the process optimisation.

Operating time according to manufacturer's instructions must be followed IV. The BSF can be used during patient transport and for subsequent ventilation in intensive care. For the duration of use of the BSF for subsequent ventilation without rebreathing, e.

If post operative ventilation takes longer, an appropriate breathing gas humidification must be ensured, e. The breathing system and the manual ventilation bag are changed immediately after the respective anaesthesia if the following situation has occurred or it is suspected to have occurred:.

Respective patients should be operated — if possible — at the end of the operation list; the breathing system and the manual bag are changed after that.

Complying with these measures allows the use of anaesthesia breathing systems for a period of up to 7 days based on the latest state of knowledge, provided that the system continues to meet functional requirements such as air tightness IB and if stated by the manufacturer in the instructions for use.

Moreover, the recommendations for preventing nosocomial pneumonia shall apply in full [2]. Otherwise, if a BSF is used it is unnecessary to sanitize the interior of the device breathing circle system ; exception: Pathogens can be released directly from the patient to the environment or transmitted via the staff. After use on the patient, all breathing gas conducting parts of the anaesthetic system can therefore be contaminated with pathogens, with the greatest levels of contamination being detectable close to the patient [10] , [11] , [12] , [13].

The risk of viral transmission is considered to be comparatively low [1] , [2]. In the era of insufficient processing of breathing gas conducting parts of the anaesthetic system, particularly of the tracheal tubes and of the anaesthesia breathing system, infections or outbreaks due to contaminated systems were reported sporadically [12] , [18] , [19] , [20] , [21].

This contamination can be minimised with BSF. Pathogen-rich or potentially pathogen-containing bodily fluids such as saliva, blood, sputum etc. This may be enhanced by patient positioning, increased secretion production and blood release due to illness as well as errors and trauma during intubation.

Furthermore, CO 2 -absorption in the rebreathing anaesthesia ventilation system leads to the release of humidity, which condenses over the course of the operation.

Approximately 15—20 ml water per hour accumulate in an unheated breathing system [24] ; which, depending on the fresh gas flow, may remain in the system where it gathers primarily in the lower bends of the breathing systems.

During anaesthesia, pathogen-containing saliva, tracheal secretion and, eventually, blood may gather thus posing a risk of aspiration. During mechanical ventilation both inspiration and expiration gases pass through the junction between tracheal tube and anaesthesia breathing system. Consequently this is the suitable interface at which the application of BSF can effectively block the transport of microbial and particulate contamination within the breathing gas conducting components of the breathing system in each direction of flow.

BSF are designed to prevent the passage of air borne and liquid borne pathogens in both directions, without increasing the air flow resistance and dead space to non physiological levels, and to contribute to the breathing gas humidification. BSF are designed for the retention of aerosols from the ventilation gases. The filter medium is constructed as a three-dimensional depth filter. Clinically relevant characteristics of BSF are dead space and gas flow resistance, which are defined in accordance with ISO [7].

Additional heat and moisture exchanging components may be integrated in the filter housing to improve breathing gas humidification; this combination is called a Heat and Moisture Exchanging Filter HME-F. Breathing systems are nowadays used for up to 7 days on the same anaesthesia ventilator [25]. Modern CO 2 -absorbers can be used until the soda lime is completely exhausted. It is therefore not unlikely that large amounts of liquid will gather in the breathing system, where exhaled bacteria may even proliferate; viruses do not have this capability.

In order to evaluate the suitability of BSF therefore both air-borne and liquid-borne transport processes must be considered. Aerosols are a suspension of liquid or solid particles in a gas. Their typically polydisperse distribution may extend over a wide range of sizes. Liquid particles are usually spherical; their diameter is determ ine d by the surface tension of the liquid and the partial vapour pressure in the environment.

Due to evaporation or condensation of the fluid, the size of liquid particles is variable; a droplet may also contain different numbers of microorganisms.

Solid particles can take very different irregular shapes. Filtration of aerosols is based on the interaction of different mechanisms [26] if the diameter of the particle is sufficiently large, the particle may be retained close to the surface of the filter medium already direct interception.

Due to their mass, smaller particles cannot always follow the changes of direction in the carrier gas surrounding the filter fibres.

During their passage through the filter medium they are adsorbed deeper inside the filter medium inertial impaction. Even smaller particles, e. This increases their virtual diameter, which in turn brings them into contact with the filter medium, where they are adsorbed as well diffusion filtration. These mechanisms characterise the so-called mechanical filters. In suitable filter materials the filtration performance can be additionally increased by applying electrical charge, which attracts and binds particles with opposite charge electret filters.

The spatial effect of these charges allows, at a similar air-borne retention performance, a more open structure of these filter media in comparison with mechanical filters. School and university students: Upon presentation of a student ID, school and university students under 27 years of age receive a discount on KD panoramic cruises and scheduled services, in accordance with the current timetable. On Tuesdays and Thursdays, two cyclists may travel for the price of one on all scheduled services on the Rhine one-way journey, excludes surcharges.

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