{
  "abstract": "Hygienic standards and environmental concerns Vivian H. Y. Ip MBChB FRCA Clinical Professor, Department of Anesthesia, Perioperative, and Pain Medicine University of Calgary Calgary Alberta Canada Email: hip@ualberta.ca Conflict of Interests: Dr. Vivian Ip is the Chair of the Environmental Sustainability Section, the Chair of the Regional Anesthesia Section at the Canadian Anesthesiologists’ Society, and the Advisor of the Green Anesthesia Special Interests Group at the American Society of Regional Anesthesia and Pain Medicine. Word count = 1333 References = 22   Introduction Regional anesthesia has been practiced for over a decade, the infection complications have reduced significantly with the evolution of infection control and prevention practices. 1 Institutional protocols as well as vigilant surveillance and audits ensure infection control and prevention practice standards are upheld. Nowadays, the infectious complications of regional anesthesia in acute pain medicine in terms of neuraxial or peripheral nerve blocks are very rare.1 Nonetheless, there is always a dual challenge in healthcare with infection prevention and environmental impact. While infection prevention practice can be resource intensive, especially without consideration on the environmental sustainability and promote responsible use of resource. High-income countries often possess an abundance of resources, which can lead practitioners to overlook the critical need for responsible resource use. These resources are, in fact, costly and finite, as well as the potential to generate a substantial waste and carbon footprint. With the healthcare industry contributing a significant amount of net global carbon dioxide emission, and if healthcare were a country, it would rank the 5th largest emission of carbon dioxide in the world, there should be an evaluation of how this can be improved. Ironically, the environmental impact affects the health of humanity, considerations of responsible use of resource, while balancing patient safety is paramount. This expert opinion discussion aims to outline the strategies in clinical practice to be ‘clean and green’ in regional anesthesia. The scale of the problem: Infection rate in regional anesthesia versus the environmental impact of healthcare A recent review investigated the pooled estimate of overall infectious complications following all central neuraxial block was 9/100000 (95%CI: 5, 13/100000), central neuraxial infections following all central neuraxial block was estimated to be 2/100000 (95% CI: 1,3/100000), and even rarer following spinal anesthesia at 1/100000 (95% CI: 1,2/100000). Even rarer is the infection rate reported in the obstetric population with an overall infection rate of 1/100000 (95% CI: 1,3/100000) and central neuraxial injections at 4/1000000) (95% CI: 0.3, 1/100000) following all central neuraxial blocks.1 For peripheral nerve blocks, the reported rate of infections complications was slightly higher at 1.8%. (95% CI 1.2, 2.5/100) (Selvamani) A 10-year cohort study review of ultrasound-guided nerve block using non-sterile gel, sterile transparent film barrier and disinfect ultrasound transducer in between uses fount no infection rate in 7476 patients.2 Another study found no significant infection in 211 femoral nerve catheters.3 A large retrospective review of 9649 patients reported zero infections in the lumbar plexus catheters.4 Regarding environmental sustainability, healthcare industry contributes 4.6% of the global net carbon emissions.5 Recently, the ‘United Nations Environment Program’ issued a stern statement urging immediate action to curb carbon emissions to prevent catastrophic temperature spikes and mitigate the worst impacts of climate change. To stay on track for limiting global temperature rise to 1.5°C (34.7°F), carbon emissions must decrease by 42% by 2030 and by 57% by 2035.6 Failure to act could lead to a temperature rise of 2.6–3.1°C (36.7–37.6°F). In 2023, annual global temperatures reached a record high of 1.45°C, and if current policies persist, the world is on track for a 2.7°C increase by 2100.6 Sadly, anthropogenic emissions continue to increase globally and a reverse course to maintain, minimise greenhouse gas emissions seems impossible. Hygienic Standards in RA Recently, ASRA Pain Medicine produced an excellent guideline on infection control in both acute and chronic pain practice.7 The article contains several procedural recommendations with the associated level of evidence. The only Grade A evidence is that preoperative antibiotic prophylaxis given 1 hour prior to surgical incision for invasive procedures, as there is strong certainty suggesting preoperative antibiotic prophylaxis reduces risk of surgical site infection. Although these types of invasive procedures tend to refer to chronic pain. For acute pain procedural recommendations, most are of grade B evidence, with the more robust and consistent evidence to prevent infection being hand hygiene, the use of chlorhexidine in alcohol, and the aseptic non-touch techniques (ANTT).7 8 In the ASRA Pain Medicine infection consensus guideline, it states that all procedural staff should perform hand hygiene prior to the first case of the day, before and after glove use, before and after patient contact, and any time hands are visibly soiled. Hand hygiene with skin antisepsis is a key component, and the single most important basic preventative measure that significantly reduce hospital-acquired infections with high certainty.7 9 Another area with great certainty is the use of chlorhexidine in alcohol for preparation of the procedural site. A Cochrane meta-analysis in 2015 showed that preoperative skin preparation with chlorhexidine in alcohol was associated with lower infection rates after clean surgeries.10 Furthermore, the ANTT clinical procedure guideline has been incorporated into many institutional protocols globally. It is a specific type of aseptic technique with a unique theory and practice framework to improve and standardize aseptic technique for all clinical procedures. This technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites and is also endorsed by NICE in the UK.8 11Upon examination of the outbreak investigations with bacterial meningitis amongst patients undergoing spinal procedures where healthcare providers did not wear a face mask, the organism causing the infection was traced back to the respiratory flora of the unmasked provider. This provides strong epidemiological evidence to advocate for all personnel in the immediate area as well as the person performing the neuraxial blocks, when catheter or injection of drug into the spinal canal or subdural space, should wear a surgical face mask to minimise the risk of droplet transmission.12 13 Environmental considerations in regional anesthesia in the context of infection prevention The main concern is overuse of resources in practices that are considered to reduce infection rate but not supported by robust evidence. Without responsible use of resource to minimize waste generation, energy used to process reusable attires and equipment, as well as medication waste, it leaves a significant carbon footprint without meaningful clinical impact. There is also a myth that disposable equipment reduces infection risks compared to reusable supplies. Reusable supplies and equipment do not increase risk of infection when adequate sterilization is the key. A recent systematic review included 9 studies including more than 45,000 cases demonstrated no significant difference in surgical site infection rates between the reusable and disposable groups. At the same time, reusable surgical headwear significantly lowers the carbon footprint than disposable alternatives.14 Studies have shown that there is no difference between reusable or disposable supplies to reduce the risk of surgical site infection in orthopedic and spinal surgery,15 coronary artery surgery,16 intensive care unit.17 However, reusable supplies generate much less carbon emission.18–20 Another strategy to reduce waste and emissions is creative thinking of ‘doing more with less’. One example is using alcohol-based hand rub between patients. This approach is advocated by the hand hygiene liaison group, limits the use of resources, saves water, towels and energy used compared to handwashing.21 22 Fine balance While clinical guidelines are essential to provide valuable guidance on clinical practice, some recommendations lack robust evidence. Yet, once published as a guideline, they may be followed rigidly without assessment or consideration of the level of evidence. Though guidelines are meant to inform rather than replace clinical judgement, this concept might be overlooked. Furthermore, there will be a point where diminishing returns are reached whereby adding more resources and intervention while holding other factors constant will not result in reduction in infection rates. The financial and social cost can then become disproportionally high compared to clinical benefits. It is important to realize that resource is finite and a greater harm and significant negative impact on society, such as more frequent and intense weather events, may be caused by trying to achieve a relatively small gain. Furthermore, better financial and resource allocation to other parts of healthcare may yield greater clinical benefits, for example, allocate funding on climate resiliency. Conclusion Therefore, looking ahead, there needs to be a raise in awareness and education, while drafting policy that balances infection prevention taking account of responsible use of resources without compromising patient safety.References Selvamani BJ, Kalagara H, Volk T, et al. Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk. Reg Anesth Pain Med. 2024. doi:10.1136/rapm-2024-105496.Alakkad H, Naeeni A, Chan VWS, et al. Infection related to ultrasound- guided single- injection peripheral nerve blockade: a decade of experience at Toronto Western hospital. Reg Anesth Pain Med. 2015;40:82–4. 222.Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg. 2001;93:1045–9.Njathi CW, Johnson RL, Laughlin RS, et al. Complications after continuous posterior lumbar plexus blockade for total hip arthroplasty: a retrospective cohort study. Reg Anesth Pain Med. 2017;42:446–50.The Lancet Digital Health. Curbing the carbon footprint of health care. Curbing the carbon footprint of health care (Accessed May 25, 2025)United Nation Environment programme. Emissions gap report 2024. 2024 (Oct) Emissions Gap Report 2024 | UNEP - UN Environment Programme (Accessed Nov 6, 2025)Provenzano DA, et al. ASRA pain medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med. 2025;0:1–50.ANTT Clinical Practice Framework. ANTT Practice Framework (Accessed May 25, 2025)Simmons CG, Hennigan AW, Loyd JM, et al. Patient safety in anesthesia: hand hygiene and perioperative infection control. Current Anesthesiology reports 2022;12:493–500.Torres de Araujo Azi LM, Fonseca NM, Linard LG. SBA 2020: regional anesthesia safety recommendations update. Braz J Anesthesiol. 2020;70:398–418.National Institute for Health and Care Excellence. Healthcare-associated infections: prevention and control in primary and community care. Recommendations | Healthcare-associated infections: prevention and control in primary and community care | Guidance | NICE (Accessed May 25, 2025)Use of Surgical Masks in the Operating Room: A Review of the Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013 Nov 19. APPENDIX 8, Summary of Recommendations by Source. Available from: https://www.ncbi.nlm.nih.gov/books/NBK195770/ Teare L, Cookson B, Stone S. Hand hygiene.Smith C, King W, O’Brien D, et al. Masks, gowns, and caps for interventional spine pain procedures. Pain Medicine 2018;19(6):1293–1294.Gumera A, Mil M, Hains L, et al. Reusable surgical headwear has a rduced carbon footprint and matches disposables regarding surgical site infection: a systematic review and meta-analysis. The J of hospital infection. 2024;152:164–172.Kieser DC, Wyatt MC, Beswick A, et al. Does the type of surgical drape (disposable versus non-disposable) affect the risk of subsequent surgical site infection. J Orthop. 2018;15(2):566–570.Bellchambers J, Harris JM, Cullinan P, et al. A prospective study of wound infection in coronary artery surgery. Eur J Cardiothorac Sug. 1999;15(1):45–50.Albert NM, Slifcak E, Roach JD, Bena JF, Horvath G, Wilson S, Van Den Bossche R, Vargas N, Rhoades V, Hartig KM, Lachiewicz H, Murray T. Infection rates in intensive care units by electrocardiographic lead wire type: disposable vs reusable. Am J Crit Care. 2014 Nov;23(6):460–7; quiz 468. doi: 10.4037/ajcc2014362. PMID: 25362669.Donahue LM, Petit HJ, Thiel CL, Sullivan GA, Gulack BC, Shah AN. A life cycle assessment of reusable and disposable surgical caps. J Surg Res. 2024 Jul;299:112–119. doi: 10.1016/j.jss.2024.04.007. Epub 2024 May 14. PMID: 38749314.Vozzola E, Overcash M, Griffing E. Environmental considerations in the selection of isolation gowns: a life cycle assessment of reusable and disposable alternatives. Am J Inf Cont. 2018;46:881–6. https://doi.org/10.1016/j.ajic.2018.02.002Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg. 2012;114:1055–66.Teare L, Cookson B, Stone S. Use alcohol hand rubs between patients: they reduce the transmission of infection. BMJ. 2001;323:411–2. https://doi.org/10.1136/bmj.323.7310.411 (Accessed May 29, 2025)Boyce JM, Pittet D. guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Infect Control Hosp Epidemiol. 2002;23:S3–40. https://doi.org/10.1086/503164.",
  "authors": [
    {
      "affiliations": [
        "Anesthesia, University of Calgary, Calgary, Canada"
      ],
      "name": "Vivian Ip"
    }
  ],
  "title": "FT16 Hygienic standards and environmental concerns",
  "uid": "196c846c-9b48-5c28-9744-93c71b09cc9d"
}