- Email: [email protected]
Mycobacterium szulgai; malnutrition and wounds; biological indicators; sterilizing with infrared radiation
NOVEMBER 2002, VOL 7 6 . NO 5 1\11)i.\(
t
I O U Ilk\(
I I ( f
Myco bacterium sz uIga i; malnutrition and wounds; biological indicators; sterilizing with infrared radiation Mywbacterium szulgai keratitis caused by contaminated ice water Clinical Infectious Diseases, April 15,2002 After two patients who underwent laser-assisted in situ keratomileusis (LASIK) in the same facility developed keratitis caused by Mycobacterium szulgai, a retrospective control study was conducted.' All patients who underwent the procedure from November 2000 through March 2001 were evaluated for evidence of infection. The procedures and techniques used by the surgeons were reviewed, and environmental samples were obtained from all potential water sources. Findings. Of the 52 patients who underwent 92 LASIK procedures during the study period, seven patients were found to have infection caused by Mycobacterium szulgai. Five culture-positive cases and two probable cases were identified among the 18 patients on whom physician A performed 30 procedures. No cases were identified among the 34 patients on whom physician B performed 62 procedures. No breeches of surgical technique were identified, and the only apparent technical difference between the physicians' technique was in the preparation of the sterile saline lavage solution. Physician A used a sterile syringe fitted with an ocular lavage tip that was chilled on the surface of a tub full of ice obtained from an ice machine. Environmental cultures from the ice machine drain
revealed Mycobacterium szulgai genetically identical to the isolates recovered from the five culturepositive patients. Clinical implications. The likely route of exposure was contamination of the lavage tip by melted ice water from the surface of the syringe or melted ice water falling onto the surgical field as the assistant passed the chilled syringe to the surgeon. At present, the risk of using chilled saline for this procedure appears to outweigh the potential benefits. Perioperative nurses should review these findings with surgeons who perform LASIK and remember them when participating in procedures in which ice is used.
Malnutrition and its effect on wound healing Orthopedics, April 2002 This study determined the incidence of preoperative malnutrition, the correlation between abnormal nutrition and delayed wound healing, and the validity of the Rainey McDonald nutritional index in patients admitted for hip and knee replacement arthroplasty.' The nutritional status of 40 consecutive patients who underwent joint replacement performed by the same surgeon was assessed by serological markers 12 to 24 hours before surgery. Serum albumin of less than 3.5 g per dL, serum transferrin of 200 mg per dL, and total lymphocyte count of less than 1,500 cells per mm' were considered indicators of malnutrition. Likewise, a negative 893 AORN JOURNAL
value on the Rainey McDonald nufritional index was considered an indicator of malnutrition. Findings. The incidence of preoperative malnutrition was 40%. Sixteen patients had at least one abnormal serological marker, 10% serum albumin, 30% serum transferrin, and 17.5% total lymphocyte count. The Rainey McDonald nutritional index revealed a negative value in 10% of patients. All patients had healthy surgical scars after suture removal 14 to 15 days after surgery. The researchers believe that the negative effect of malnutrition on wound healing was overcome by surgeondependent factors, including use of antibiotic prophylaxis, surgical technique, the OR environment, and skin and wound care. Clinical implications. Despite the high incidence of malnutrition, no delayed wound healing was noted. Perioperative nurses, however, must understand that malnutrition has been documented as a cogent risk factor for delayed wound healing and implement measures to ensure that nutritional assessment and counseling is conducted in the early preoperative period. Similarly, they must ensure that antibiotic prophylaxis is administered in a timely manner, that all staff members adhere to surgical sterility principles, and that the environment is maintained in a sanitary manner. Perioperative nurses also must facilitate thorough patient teaching and etfective postoperative wound care.
NOVEMBER 2002, VOL 76. NO 5
Using a seven-day incubation period for biological indicators Infection Control and Hospital Epidemiology, July 2002 This study evaluated fluorescent readout results of two different types of biological indicators in both 132" C (269.6" F) gravity displacement and 132" C (269.6" F) vacuum-assisted steam sterilization cycles using full and fractional cycles.' Growth data were compared to seven-day incubation cycles. This study also evaluated a new automated rapid fluorescent reader. During the study, biological indicators were placed in a specific sterilizer using a standardized protocol for both types of indicators. A positive control was run each day. After cycle completion, the indicators were removed, cooled, and inserted into the automated reader. After this reading, indicators were transferred to an aerobic incubator. Growth results were recorded at 24 hours for the first type of indicator, at 48 hours for the second type of indicator, and at seven days for both. Any indicators showing negative fluorescent results but positive growth were subcultured. The new reader was not used for the seven-day incubation period. Findings, The indicators were negative by both rapid fluorescent testing and growth at seven days when gravity or vacuum-assisted steam sterilization was used for full-cycle parameters in accordance with the manufacturer's guidelines. Even when the vacuum-assisted cycle was set for zero
minutes, none of the spores from the indicators tested survived after 24 hours of incubation. When the gravity displacement cycle was reduced from 240 seconds to 90 and 95 seconds, three false negative results were obtained from the reader at one hour, and growth was detected at 24 hours. Clinical implications, This study demonstrates that rapid fluorescent readout results with these two types of indicators appear to reliably predict 24-hour growth, 48-hour growth, and seven-day growth. The researchers concluded that the automated rapid fluorescent readouts are reliable and effective monitoring methods. Clinicians and managers, however, must evaluate the latest published evidence care%lly when making decisions about which biological indicators to use. This study suggests that the new reader may be helpful in streamlining the process and reducing the risk of human error associated with determining the adequacy of sterilization for gravity displacement and vacuum-assisted cycles,
Using infrared radiation for instrument sterilization Infection Control and Hospital Epidemiology, July 2002 A prototype was constructed to assess the potential of infrared radiation to destroy bacterial spores on unwrapped, nonheatsensitive, nonlumened instrum e n t ~Viable .~ spores of Bacillus subtilis were deposited and allowed to dry on an instrument load containing 28 unwrapped
NOTES 1. G P Holmes et al, "A cluster of cases of A4ycobucteriirm szulgui keratitis that occurred after laser-assisted in situ keratomileusis," Clinical Infectious Diseases 34 (April 15, 2002) 1039-1046.
instruments. For simulated use, each load contained instruments laden with Bacil1u.s sirhtilis tossed randomly into the sterilization tray. The test cycle exposed the instruments to infrared radiation for I0 minutes. After the cycle, the instruments were immersed in tryptic soy broth and incubated for 120 hours at 37" C (98.6" F). Survivor spores were counted. Test tubes laden with Bacilhs subtilis were placed in the instrument loads, and the infrared radiation lethality was evaluated at 30second intervals from two minutes to four and one-half minutes. Findings. All the instruments exposed to infrared radiation under simulated use conditions were culture negative. Air temperature in the chamber reached a maximum of 180" C (356" F), and 10-6 sterility assurance level was reached after eight minutes and 40 seconds of exposure. The results of this simulation indicate that infrared radiation is indeed capable of destroying Bacillus subtilis spores in what appears to be the worse case conditions for contamination. Clinical implications. Infrared radiation promises to be a viable alternative technology for steriiization of selected nonheat-sensitive instruments in a relatively short period of time. Perioperative clinicians should be prepared to give this method of sterilization serious consideration when it becomes available. GEORGE ALLEN RN, PHD, CNOR, CIC NURSING RESEARCH COMMIITEE
2. J Rai, S S Gill, B R J Satish Kumar, "The influence of preoperative nutritional status in wound healing after replacement arthroplasty," 0rtl~upea'~c.s 25 (April 2002) 417-42 1. 3. M J Alfa et al, "Evaluation of rapid readout 894
AORN JOURNAL
NOVEMBER 2002, VOL 76, NO 5
biological indicators for 132” C gravity and 132” C vacuum-assisted steam sterilization cycles using a new automated fluorescent reader,” Infection Control and Hospital Epideemiologv 23 (July 2002) 388-392.
4. V H Mata-Portugiiez, L S Perez. E Acosta-Gio, “Sterilization of heat-resistant instruments with infrared radiation,” Infection Control and Hmpital Epidemiology 23 (July 2002) 393-396.
The above informotion Is intended for general use only. The clinical imptications are specific to the abstracted artice only. Those infending to put these researchers’ findings into practice in their clinical setting are strongly encouraged to review fhe original article to deter-
mine its applicabili~to their practice seBng. If you have research related questions you would like answered, p/ease send them fo Depament of Research, AORN, 2 1 70 S Parker Rd, Suite 300, Denvec CO 8023 1-571 1 or [email protected].
AORN Announces Research and Grant Program Revision Effective immediately, AORN announces a revision to its research grant program. The changes in the program will support more timely funding of proposals that are submitted in response to requests for proposals (RFPs) related to AORN’s research priorities. The revised research grant program will consist
of two tiers of funding. The first addresses RFPs related to AORN’s strategic initiatives and research priorities. The second level of funding provides support to AORN members who are completing degree requirements. Visit http://www.aom.org/research /grantprgm.htm for more information.
Misleading Weight-Loss Product Promotion Widespread The use of false claims, misleading testimonials, and deceptive before-and-after photographs in advertising for weight-loss products is widespread and has increased during the past decade, according to a Sept 17, 2002, news release from the Federal Trade Commission (FTC). Approximately 40% of advertisements studied, including those appearing in mainstream, national publications, made at least one claim that is almost certainly false, and 55% made a1 least one claim that is very likely false. Nearly 50% of the advertisements claim that product users can lose weight without dieting or exercising. The FTC report was prepared with assistance from the Partnership for Healthy Weight Management, a coalition of representatives from the science, academic, and health care professions, as well as government and commercial entities. The report examines 300 weight-loss product promotions that appeared in all major types of media between February 200 1 and May 200 1. A comparison of advertisements from 2001 to those that ran
in 1992 showed two major trends: a shift from advertisements for “low-calorie meal replacements” to pills and other products that claim to work without diet and exercise and an increase in the number of specific misleading promises about product performance. According to health and nutrition experts, many heavily advertised weight-loss products and programs either are unproven or unsafe, and they frustrate efforts to promote healthy weight loss by promising unrealistic results. Since 1990, the FTC has filed 93 cases challenging false and misleading weight-loss claims invotving over-the-counter medications, dietary supplements, commercial weightloss centers, weight-loss devices, and exercise equipment. FTC Releases Report on Weight-Loss Advertising (news release: Washington, DC: Federal Trade Commission, Sept 1 7, 2002) h i t p : / W .ftc.gov/opa/2002/09~eIghtloss rpt.htm (accessed 26 Sept 2002).
895 AORN JOURNAL
t
I O U Ilk\(
I I ( f
Myco bacterium sz uIga i; malnutrition and wounds; biological indicators; sterilizing with infrared radiation Mywbacterium szulgai keratitis caused by contaminated ice water Clinical Infectious Diseases, April 15,2002 After two patients who underwent laser-assisted in situ keratomileusis (LASIK) in the same facility developed keratitis caused by Mycobacterium szulgai, a retrospective control study was conducted.' All patients who underwent the procedure from November 2000 through March 2001 were evaluated for evidence of infection. The procedures and techniques used by the surgeons were reviewed, and environmental samples were obtained from all potential water sources. Findings. Of the 52 patients who underwent 92 LASIK procedures during the study period, seven patients were found to have infection caused by Mycobacterium szulgai. Five culture-positive cases and two probable cases were identified among the 18 patients on whom physician A performed 30 procedures. No cases were identified among the 34 patients on whom physician B performed 62 procedures. No breeches of surgical technique were identified, and the only apparent technical difference between the physicians' technique was in the preparation of the sterile saline lavage solution. Physician A used a sterile syringe fitted with an ocular lavage tip that was chilled on the surface of a tub full of ice obtained from an ice machine. Environmental cultures from the ice machine drain
revealed Mycobacterium szulgai genetically identical to the isolates recovered from the five culturepositive patients. Clinical implications. The likely route of exposure was contamination of the lavage tip by melted ice water from the surface of the syringe or melted ice water falling onto the surgical field as the assistant passed the chilled syringe to the surgeon. At present, the risk of using chilled saline for this procedure appears to outweigh the potential benefits. Perioperative nurses should review these findings with surgeons who perform LASIK and remember them when participating in procedures in which ice is used.
Malnutrition and its effect on wound healing Orthopedics, April 2002 This study determined the incidence of preoperative malnutrition, the correlation between abnormal nutrition and delayed wound healing, and the validity of the Rainey McDonald nutritional index in patients admitted for hip and knee replacement arthroplasty.' The nutritional status of 40 consecutive patients who underwent joint replacement performed by the same surgeon was assessed by serological markers 12 to 24 hours before surgery. Serum albumin of less than 3.5 g per dL, serum transferrin of 200 mg per dL, and total lymphocyte count of less than 1,500 cells per mm' were considered indicators of malnutrition. Likewise, a negative 893 AORN JOURNAL
value on the Rainey McDonald nufritional index was considered an indicator of malnutrition. Findings. The incidence of preoperative malnutrition was 40%. Sixteen patients had at least one abnormal serological marker, 10% serum albumin, 30% serum transferrin, and 17.5% total lymphocyte count. The Rainey McDonald nutritional index revealed a negative value in 10% of patients. All patients had healthy surgical scars after suture removal 14 to 15 days after surgery. The researchers believe that the negative effect of malnutrition on wound healing was overcome by surgeondependent factors, including use of antibiotic prophylaxis, surgical technique, the OR environment, and skin and wound care. Clinical implications. Despite the high incidence of malnutrition, no delayed wound healing was noted. Perioperative nurses, however, must understand that malnutrition has been documented as a cogent risk factor for delayed wound healing and implement measures to ensure that nutritional assessment and counseling is conducted in the early preoperative period. Similarly, they must ensure that antibiotic prophylaxis is administered in a timely manner, that all staff members adhere to surgical sterility principles, and that the environment is maintained in a sanitary manner. Perioperative nurses also must facilitate thorough patient teaching and etfective postoperative wound care.
NOVEMBER 2002, VOL 76. NO 5
Using a seven-day incubation period for biological indicators Infection Control and Hospital Epidemiology, July 2002 This study evaluated fluorescent readout results of two different types of biological indicators in both 132" C (269.6" F) gravity displacement and 132" C (269.6" F) vacuum-assisted steam sterilization cycles using full and fractional cycles.' Growth data were compared to seven-day incubation cycles. This study also evaluated a new automated rapid fluorescent reader. During the study, biological indicators were placed in a specific sterilizer using a standardized protocol for both types of indicators. A positive control was run each day. After cycle completion, the indicators were removed, cooled, and inserted into the automated reader. After this reading, indicators were transferred to an aerobic incubator. Growth results were recorded at 24 hours for the first type of indicator, at 48 hours for the second type of indicator, and at seven days for both. Any indicators showing negative fluorescent results but positive growth were subcultured. The new reader was not used for the seven-day incubation period. Findings, The indicators were negative by both rapid fluorescent testing and growth at seven days when gravity or vacuum-assisted steam sterilization was used for full-cycle parameters in accordance with the manufacturer's guidelines. Even when the vacuum-assisted cycle was set for zero
minutes, none of the spores from the indicators tested survived after 24 hours of incubation. When the gravity displacement cycle was reduced from 240 seconds to 90 and 95 seconds, three false negative results were obtained from the reader at one hour, and growth was detected at 24 hours. Clinical implications, This study demonstrates that rapid fluorescent readout results with these two types of indicators appear to reliably predict 24-hour growth, 48-hour growth, and seven-day growth. The researchers concluded that the automated rapid fluorescent readouts are reliable and effective monitoring methods. Clinicians and managers, however, must evaluate the latest published evidence care%lly when making decisions about which biological indicators to use. This study suggests that the new reader may be helpful in streamlining the process and reducing the risk of human error associated with determining the adequacy of sterilization for gravity displacement and vacuum-assisted cycles,
Using infrared radiation for instrument sterilization Infection Control and Hospital Epidemiology, July 2002 A prototype was constructed to assess the potential of infrared radiation to destroy bacterial spores on unwrapped, nonheatsensitive, nonlumened instrum e n t ~Viable .~ spores of Bacillus subtilis were deposited and allowed to dry on an instrument load containing 28 unwrapped
NOTES 1. G P Holmes et al, "A cluster of cases of A4ycobucteriirm szulgui keratitis that occurred after laser-assisted in situ keratomileusis," Clinical Infectious Diseases 34 (April 15, 2002) 1039-1046.
instruments. For simulated use, each load contained instruments laden with Bacil1u.s sirhtilis tossed randomly into the sterilization tray. The test cycle exposed the instruments to infrared radiation for I0 minutes. After the cycle, the instruments were immersed in tryptic soy broth and incubated for 120 hours at 37" C (98.6" F). Survivor spores were counted. Test tubes laden with Bacilhs subtilis were placed in the instrument loads, and the infrared radiation lethality was evaluated at 30second intervals from two minutes to four and one-half minutes. Findings. All the instruments exposed to infrared radiation under simulated use conditions were culture negative. Air temperature in the chamber reached a maximum of 180" C (356" F), and 10-6 sterility assurance level was reached after eight minutes and 40 seconds of exposure. The results of this simulation indicate that infrared radiation is indeed capable of destroying Bacillus subtilis spores in what appears to be the worse case conditions for contamination. Clinical implications. Infrared radiation promises to be a viable alternative technology for steriiization of selected nonheat-sensitive instruments in a relatively short period of time. Perioperative clinicians should be prepared to give this method of sterilization serious consideration when it becomes available. GEORGE ALLEN RN, PHD, CNOR, CIC NURSING RESEARCH COMMIITEE
2. J Rai, S S Gill, B R J Satish Kumar, "The influence of preoperative nutritional status in wound healing after replacement arthroplasty," 0rtl~upea'~c.s 25 (April 2002) 417-42 1. 3. M J Alfa et al, "Evaluation of rapid readout 894
AORN JOURNAL
NOVEMBER 2002, VOL 76, NO 5
biological indicators for 132” C gravity and 132” C vacuum-assisted steam sterilization cycles using a new automated fluorescent reader,” Infection Control and Hospital Epideemiologv 23 (July 2002) 388-392.
4. V H Mata-Portugiiez, L S Perez. E Acosta-Gio, “Sterilization of heat-resistant instruments with infrared radiation,” Infection Control and Hmpital Epidemiology 23 (July 2002) 393-396.
The above informotion Is intended for general use only. The clinical imptications are specific to the abstracted artice only. Those infending to put these researchers’ findings into practice in their clinical setting are strongly encouraged to review fhe original article to deter-
mine its applicabili~to their practice seBng. If you have research related questions you would like answered, p/ease send them fo Depament of Research, AORN, 2 1 70 S Parker Rd, Suite 300, Denvec CO 8023 1-571 1 or [email protected].
AORN Announces Research and Grant Program Revision Effective immediately, AORN announces a revision to its research grant program. The changes in the program will support more timely funding of proposals that are submitted in response to requests for proposals (RFPs) related to AORN’s research priorities. The revised research grant program will consist
of two tiers of funding. The first addresses RFPs related to AORN’s strategic initiatives and research priorities. The second level of funding provides support to AORN members who are completing degree requirements. Visit http://www.aom.org/research /grantprgm.htm for more information.
Misleading Weight-Loss Product Promotion Widespread The use of false claims, misleading testimonials, and deceptive before-and-after photographs in advertising for weight-loss products is widespread and has increased during the past decade, according to a Sept 17, 2002, news release from the Federal Trade Commission (FTC). Approximately 40% of advertisements studied, including those appearing in mainstream, national publications, made at least one claim that is almost certainly false, and 55% made a1 least one claim that is very likely false. Nearly 50% of the advertisements claim that product users can lose weight without dieting or exercising. The FTC report was prepared with assistance from the Partnership for Healthy Weight Management, a coalition of representatives from the science, academic, and health care professions, as well as government and commercial entities. The report examines 300 weight-loss product promotions that appeared in all major types of media between February 200 1 and May 200 1. A comparison of advertisements from 2001 to those that ran
in 1992 showed two major trends: a shift from advertisements for “low-calorie meal replacements” to pills and other products that claim to work without diet and exercise and an increase in the number of specific misleading promises about product performance. According to health and nutrition experts, many heavily advertised weight-loss products and programs either are unproven or unsafe, and they frustrate efforts to promote healthy weight loss by promising unrealistic results. Since 1990, the FTC has filed 93 cases challenging false and misleading weight-loss claims invotving over-the-counter medications, dietary supplements, commercial weightloss centers, weight-loss devices, and exercise equipment. FTC Releases Report on Weight-Loss Advertising (news release: Washington, DC: Federal Trade Commission, Sept 1 7, 2002) h i t p : / W .ftc.gov/opa/2002/09~eIghtloss rpt.htm (accessed 26 Sept 2002).
895 AORN JOURNAL