ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine: The role of the anesthesiologist in perioperative infection risk-reduction strategies
Myron Yaster MD, Lynn Martin MD MBA, David Polaner MD, and Tessa Mandler MD
Today’s PAAD by Provenzano et al.1 is a must read for EVERY practicing anesthesiologist and pain management specialist. This encyclopedic review by the American Society of Regional Anesthesia and Pain Medicine (ASRA) provides evidence-based recommendations on risk mitigation of infectious complications associated with the practice of regional anesthesia and pain management. “The scope of these current recommendations extends beyond neuraxial blocks and includes various nerve blocks (peripheral and spinal), chronic pain procedures, and minimally invasive surgical techniques used in acute and chronic pain management.”1 Today, we will review several of the recommendations for the role of the anesthesiologist in perioperative risk reduction strategies and limit our discussion to what we as anesthesiologists can do to limit infection. Other topics in these guidelines will be reviewed over the next couple of days. Today’s PAAD offers much more information on environmental cleaning, setting up clean dirty workspace areas, environmental cleaning, and most importantly patient factors that may affect infection than we can cover in this PAAD. Myron Yaster MD
Original article
Provenzano DA, Hanes M, Hunt C, Benzon HT, Grider JS, Cawcutt K, Doshi TL, Hayek S, Hoeltzer B, Johnson RL, Kalagara H, Kopp S, Loftus RW, Macfarlane AJR, Nagpal AS, Neuman SA, Pawa A, Pearson ACS, Pilitsis J, Sivanesan E, Sondekoppam RV, Van Zundert J, Narouze S. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med. 2025 Jan 20:rapm-2024-105651. doi: 10.1136/rapm-2024-105651. Epub ahead of print. PMID: 39837579
The development of an infection related to regional anesthesia is obviously a potentially catastrophic event; we place needles and indwelling catheters every day into the central neuraxis, plexus compartments, and proximate to nerves, where infections can cause meningitis, deep tissue infections and sepsis, and can at their worst result in permanent injury and loss of function. The need for data-based guidelines is addressed by an expert panel in this important paper. Its most obvious limitation is that high quality data do not always exist for the most commonly performed procedures, and those are the ones we do most often in children. Even the very large scale prospective data from the Pediatric Regional Anesthesia Network (PRAN) - over 100,000 audited cases- have serious limitations.2 While infectious complications were rigorously sought and reported, there are considerable difficulties in distinguishing site inflammation from site infection, or colonization from infection. The number of actual proven deep infections resulting from blocks in the database is extremely small. Culturing catheter tips or insertion sites is similarly prone to methodologic problems. These limitations exist in a large number of papers analyzed for the ASRA guidelines, as the authors acknowledge. Nevertheless, this landmark paper is likely the best and most important information regarding infectious complications in regional anesthesia to date, and its recommendations should be considered a standard of care.
It almost goes without saying: hand hygiene is fundamental to prevent hospital acquired infections and is an essential aspect of ALL of our patient interactions.3,4 Interestingly, many erroneously believe that donning sterile gloves obviates the need for hand hygiene. This is simply untrue. Bacterial multiplication still occurs under gloves, and gloves may develop holes or tears. Although soap and water are the time-tested method of hand washing and is best for reducing the risk of spore forming infections, chlorhexidine is the current undisputed champion and its use is mandatory. Further, The WHO and CDC guidelines emphasize the importance of hand hygiene in healthcare settings. WHO advises removing rings, wrist watches, and bracelets, and prohibiting false nails to prevent SSIs.5 Research associates artificial nails and jewelry with higher levels of Gram-negative bacteria and potential glove puncture risks, leading to national guidelines recommending jewelry removal before wearing sterile gloves.5 However, intact nail polish is not considered a risk, although chipped polish is. Finally, a Cochrane systematic review was able to identify only one study of fingernail polish and no studies of jewelry with respect to infections, suggesting that although there is no strong evidence against these items, “their prohibition is reasonable and a generally accepted practice.”1 We wonder based on the stated lack of evidence if this recommendation/guideline is overkill. Please send your thoughts and comments on this issue in particular to Myron for our Friday reader response. Finally, how long should you wash your hands? For non-surgical scrub at least 15 seconds, an a minimum of 2 minutes for surgical scrub.6
Surgical cap, mask, gloves and gowns
In reality, there is little evidence to support the mandatory use of surgical caps, masks, and sterile gowns except when implanted device procedures (tunneled catheters, spinal cord stimulators) are used. Indeed, one of us (TM)7 found little consensus amongst members of PRAN on these issues in the setting of a low incidence of superficial infections and even lower rate of deep infections in the PRAN database. We think, however, common sense dictates the routine use of surgical caps, masks and sterile gloves (after handwashing) for all regional anesthetic techniques particularly if performed in an OR.8 The use of sterile gowns is much more controversial. “Gowns are considered barriers that prevent cross-contamination of infectious material between providers and patients. That said, in most cases the only direct contact point with the patient are the sterile, gloved hands of the proceduralist.”1
Patient skin antisepsis
“Chlorhexidine gluconate, particularly when combined with alcohol, has been established as a highly effective antiseptic for skin preparation prior to surgical procedures. Its efficacy is backed by RCTs and meta-analyses that demonstrate its role in significantly reducing the incidence of SSIs, offering a more effective alternative to povidone iodine, especially in the context of clean surgery. An RCT and multiple meta-analyses have shown that the use of chlorhexidine-alcohol significantly reduces the rate of SSIs and results in cost savings compared with povidone iodine.”1 “For interventional pain procedures, the US Food and Drug Administration (FDA) has not approved the use of chlorhexidine for neuraxial procedures due to a lack of clinical safety trials regarding possible neurotoxicity. However, the use of chlorhexidine for spinal anesthesia has not been shown to increase neurological complications.9 Guidance in the UK recommends use of 0.5% rather than 2% chlorhexidine for neuraxial blocks.10 The use of chlorhexidine prior to epidural catheterization has been shown to be superior to povidone iodine in reducing catheter colonization rates.11 Although there are no studies directly comparing infection rates with the use of chlorhexidine gluconate versus povidone iodine for interventional pain procedures, based on extrapolation of data from other surgical subspecialties, chlorhexidine-based products may offer improvement in infection control rates.” When using chlorhexidine-alcohol one should allow time for it to dry before performing your procedure. Finally, povidone iodine when compared with chlorhexidine, both formulated with alcohol, was non-inferior in preventing SSIs after cardiac or abdominal surgery.12 Therefore I (MY) as well as many neurosurgeons think Duraprep, an iodine alcohol prep solution may be used for epidural and spinal procedures and conform with the package insert.
Multidose vials and infectious risk
Infectious outbreaks can occur with both single-dose and multidose medication vials. The rubber septum on medication vials should be disinfected with alcohol prior to piercing. Indeed, I (MY) have repeatedly witnessed the misconception that the rubber septum beneath the plastic cap of a drug dose vial is sterile. It isn’t, and requires a thorough alcohol scrub. Finally, single-dose vials should not be used for multiple patients and “WHO advises using multidose vials only if there is no alternative.”1 There simply are too many opportunities to falter on standard precautions, aseptic technique or proper storage.
The significance of the patient factor is significant in our patient population, which is vastly different than the “large child” (aka adults) who are primarily studied in the research shaping the new ASRA guidelines. As the authors aptly concluded, “the issues addressed are constantly evolving, therefore, consistent updating will be required.”1 We may need leverage our pediatric databases to tailor the guidelines for the pediatric patient.
Do you routinely wear sterile cover gowns when you perform a block? Do you routinely perform hand-hygiene BEFORE donning sterile gloves? Do you ALWAYS wear sterile gloves when you perform nerve blocks? Do you remove jewelry before donning gloves? Send your thoughts and comments to Myron who will post in a Friday Reader Response.
References
1. Provenzano DA, Hanes M, Hunt C, et al. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Regional anesthesia and pain medicine 2025 (In eng). DOI: 10.1136/rapm-2024-105651.
2. Walker BJ, Long JB, Sathyamoorthy M, et al. Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network. Anesthesiology 2018;129(4):721-732. (In eng). DOI: 10.1097/aln.0000000000002372.
3. Glowicz JB, Landon E, Sickbert-Bennett EE, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update. Infection control and hospital epidemiology 2023;44(3):355-376. (In eng). DOI: 10.1017/ice.2022.304.
4. Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesthesia and analgesia 2011;112(1):98-105. (In eng). DOI: 10.1213/ANE.0b013e3181e7ce18.
5. Pittet D, Allegranzi B, Boyce J. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infection control and hospital epidemiology 2009;30(7):611-22. (In eng). DOI: 10.1086/600379.
6. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6(10):641-52. (In eng). DOI: 10.1016/s1473-3099(06)70600-4.
7. Mandler TN, Gagliardi AG, Parikh HB, Austin TM, Yaster M, Polaner DM. Sterile techniques during regional anesthesia placement among pediatric anesthesiologists. Paediatric anaesthesia 2023;33(4):326-327. (In eng). DOI: 10.1111/pan.14611.
8. Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010;112(3):530-45. (In eng). DOI: 10.1097/ALN.0b013e3181c4c7d8.
9. Sviggum HP, Jacob AK, Arendt KW, Mauermann ML, Horlocker TT, Hebl JR. Neurologic complications after chlorhexidine antisepsis for spinal anesthesia. Regional anesthesia and pain medicine 2012;37(2):139-44. (In eng). DOI: 10.1097/AAP.0b013e318244179a.
10. Obstetric Anaesthetists A, Campbell JP, Plaat F, et al. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014;69(11):1279-86. (In eng). DOI: 10.1111/anae.12844.
11. Kinirons B, Mimoz O, Lafendi L, Naas T, Meunier J, Nordmann P. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anesthesiology 2001;94(2):239-44. (In eng). DOI: 10.1097/00000542-200102000-00012.
12. Widmer AF, Atkinson A, Kuster SP, et al. Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial. Jama 2024;332(7):541-549. (In eng). DOI: 10.1001/jama.2024.8531.