Clinical Issues—September 2010

Article Outline

• Abstract
• Safe perioperative use of glutaraldehyde
  • Question
  • Answer
• Safe patient handling and movement in the perioperative setting
  • Question
  • Answer
• Thermal burns during phacoemulsification
  • Question
  • Answer
• Wearing surgical masks while administering a spinal anesthetic
  • Question
  • Answer
• Learner Evaluation. Continuing Education Program
  • Clinical Issues
    • Purpose/Goal
    • Objectives
    • Content
• References
• Copyright

This Month

Safe perioperative use of glutaraldehyde

Key words: high-level disinfection, glutaraldehyde, disinfectant, glutaraldehyde-based products, adverse effects, low-level disinfection, chemical disinfection, liquid sterilant.

Safe patient handling and movement in the perioperative setting

Key words: ergonomics, prepping, patient handling.

Thermal burns during phacoemulsification

Key words: corneal burns, thermal burns, phacoemulsification, cataract surgery.

Wearing surgical masks while administering a spinal anesthetic

Key words: surgical mask, spinal anesthetic, anesthesia care provider, aseptic technique.

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Safe perioperative use of glutaraldehyde 

Question 

We have not used glutaraldehyde products for high-level disinfection for many years but our use of this method has increased during the last several months. Are there special precautions that we should take to protect ourselves from this toxic chemical?

Answer 

There are several precautionary measures that should be used when glutaraldehyde is used as a high-level disinfectant. The measures involve personal protective equipment (PPE), engineering controls, work practice controls, and emergency procedures.¹ In addition, the manufacturer's directions for safe use should always be followed.²

High-level disinfection is a process that kills all microorganisms, with the exception of high numbers of bacterial spores and prions. High-level disinfectants have the ability to inactivate hepatitis B and C viruses, HIV, and Mycobacterium tuberculosis, but do not inactivate the virus-like prion that causes Creutzfeldt-Jakob disease. High-level disinfectants kill vegetative bacteria, tubercle bacilli, some spores and fungi, and lipid and nonlipid viruses on items that are submerged in the appropriate concentration of the disinfectant for the appropriate contact time.³

Glutaraldehyde is a toxic chemical and a sensitizer. The short-term or acute health effects of exposure to glutaraldehyde liquid or vapor may include eye irritation; skin burns; irritation of the nose, throat, and respiratory tract; coughing; wheezing; nausea; headaches; drowsiness; nosebleeds; and dizziness.¹ There also are potential long-term effects because glutaraldehyde is a sensitizer (ie, with repeated exposures, a worker may become sensitive to glutaraldehyde). When a health care worker becomes sensitized, even a small amount of glutaraldehyde may cause a strong reaction. This may present as an asthma attack, with breathing difficulty, wheezing, coughing, and tightness in the chest.¹ Glutaraldehyde vapors can intensify the symptoms of preexisting asthma and inflammatory or fibrotic pulmonary disease.² Glutaraldehyde exposure also may cause health care workers to develop occupational asthma.¹ Health care workers may develop chronic skin reactions that may present as an allergy, chronic eczema, itching, and skin rashes.

Exposure to glutaraldehyde can be limited through use of PPE, work practice controls, and engineering controls. Use of PPE includes wearing gloves that are impervious to glutaraldehyde (ie, 100% nitrile rubber, 100% butyl rubber gloves),¹, ² protective eyewear (ie, splash-proof goggles, safety glasses with side shields, a wrap-around full face shield),¹, ² moisture-repellent or splash-proof skin protection (ie, gowns, jumpsuits, aprons),¹ and masks.³ Work practice controls include storing glutaraldehyde in closed, labeled, air-tight containers; posting signs to remind staff members to replace container lids; not allowing eating, drinking, or smoking where glutaraldehyde is stored; using less toxic products if possible; using an automated, contained process for glutaraldehyde transfer (eg, transfer pumps); and adhering to the hazards communication program⁴ (ie, labeling, having material safety data sheets available, educating employees).¹ Engineering controls include using a large, well-ventilated room (ie, 10 air exchanges per hour) with local exhaust ventilation (ie, a laboratory fume hood, a capture velocity of at least 100 feet per minute).¹

Emergency procedures include ensuring availability of an eyewash station and emergency showers. Employees who have experienced eye exposure should flush the affected eye for 30 minutes to remove any chemical.¹, ² Employees who have experienced skin contact should take a shower for 15 to 20 minutes to flush the area to remove any chemical. After any exposure, employees should change clothes.¹, ² Reusable clothing should be laundered, but heavily contaminated clothing that cannot be washed and decontaminated should be discarded.²

Procedures for handling spills include cleaning up the spill immediately by vacuuming or wet methods to clean up pure glutaraldehyde and reduce dust.¹, ² The area should not be swept. The protocol for cleaning large spills (ie, larger than a small drip or splash) includes using appropriate respiratory equipment; appropriate PPE, including rubber boots or shoe protection; cleanup tools; chemicals for deactivation of glutaraldehyde; mops; buckets; sponges, towels, or a squeegee; and a plastic dust pan and scoop.² Contain and neutralize or contain and dispose according to appropriate federal, state, and local regulations, and rinse the area thoroughly.

The Occupational Safety and Health Administration (OSHA) requires that the latest version of the material safety data sheet for glutaraldehyde be maintained on site and be readily accessible to personnel in their work areas. The material safety data sheet provides personnel with valuable information about toxicity, reactivity, required protective equipment and apparel, storage, and disposal of the material,² and may be available in a hard copy or an electronic format.⁴

The National Institute for Occupational Safety and Health recommended exposure limit for glutaraldehyde vapor is 0.2 parts per million (ppm) as measured by air sampling and monitoring techniques.⁵ The threshold limit value (TLV) is predicated on the human irritation threshold.⁶ The TLV is the airborne concentration of a substance that most workers can be exposed to on a daily basis without adverse health effects. Individuals vary in their susceptibility; therefore, a lesser exposure may cause symptoms or aggravate preexisting conditions for some people.² Although OSHA does not have a required permissible exposure limit for glutaraldehyde, OSHA can regulate exposure to glutaraldehyde and has recommended that the American Conference of Governmental Industrial Hygienists limits be followed, which give a ceiling TLV (TLV-C) of 0.05 ppm for occupational exposure to glutaraldehyde vapors.¹, ⁴, ⁷ The TLV-C is the concentration that should not be exceeded at any time. If a TLV-C of 0.05 ppm is exceeded, then the employee should use an appropriate respirator for glutaraldehyde vapor during either routine or emergency work. The OSHA respiratory protection standard 1910.134 and requirements are accessible at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716.⁸

Glutaraldehyde should be used and disposed of according to the manufacturers' written instructions and federal, state, and local regulations.⁹, ¹⁰ State and local regulations may be more stringent than those imposed at the federal level,², ¹¹ and the most stringent regulations should be followed. Personnel should know their obligations under state laws and local ordinances and use appropriate PPE when disposing of high-level disinfectants.³

Facility policy and procedures should be developed that preclude glutaraldehyde solution contact and decrease glutaraldehyde vapor exposure to the lowest possible level below the TLV-C. The safe use of glutaraldehyde is a complex process, and all precautionary measures should be followed to prevent workplace exposure and injury.

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Safe patient handling and movement in the perioperative setting 

Question 

I was asked to hold up both legs of a 275-lb patient while another person performed the surgical skin prep. No one else was available to help with the process. Does AORN have any recommendations regarding holding patients' limbs for prepping and draping?

Answer 

The “AORN guidance statement on safe patient handling and movement in the perioperative setting”¹ addresses lifting and holding of patients' extremities. The guidance statement identifies several high-risk tasks specific to perioperative nurses. Ergonomic tools were developed for the seven high-risk tasks:

Several unique aspects of high-risk patient handling tasks associated with prepping a patient's limb have been identified.¹ Preparing an extremity for surgery generally requires that the extremity be elevated to allow complete circumferential skin preparation. The limb can be suspended by having a person hold the limb or by placing the limb on a holding device. In some instances, the limb may be held manually during the entire skin prep while a second person performs the skin prep. The person performing the skin prep also may hold the limb if the limb is small or if only the distal portion needs to be prepped. To maintain asepsis, the person lifting the extremity must hold the limb extended away from his or her body. The size of the limb, length of prep time, posture necessary to hold the extremity, and the physical ability of the person holding the limb all contribute to whether the caregiver can safely suspend the limb for the duration of the prep.¹

The following questions should be considered when determining how to safely raise and hold a limb:

Ergonomic tool #3 “Lifting and holding legs, arms, and head for prepping in a perioperative setting” available in the guidance statement contains a calculation of the average weight of an adult patient's leg, arm, and head as a portion of whole-body mass (Figure 1). Maximum lift and hold loads were calculated based on 75th percentile shoulder flexion strength and endurance capabilities of US adult women, where the maximum weight for a one-handed lift is 11.1 lb and the maximum weight for a two-handed lift is 22.2 lb. This means that 75% of the US adult female population would be able to hold 11.1 lb with one hand and 22.2 lb with two hands with the arm flexed from the shoulder. The table indicates the limits of one caregiver to lift and hold the body part for zero, one, two, or three minutes with one or two hands. Muscle strength capabilities diminish as a function of time. After one minute, muscle endurance decreases by 48%; after two minutes endurance decreases by 65%, and after three minutes of continuous holding, strength capability is only 29% of initial lifting strength.¹

• 
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• Figure 1.

From Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:680. Reprinted with permission.

Using the table as a guide for deciding how many caregivers are needed to lift the legs of a 275-lb patient shows that a minimum of two caregivers is needed for each limb. For both legs, a minimum of four caregivers is required to minimize the risk of muscle fatigue and the risk for musculoskeletal disorders. Fewer caregivers may be needed for the task, depending on the type of assistive devices used.¹

The guidance statement was developed with the help of ergonomists, industrial hygienists, researchers, and perioperative nurses from the National Institute of Occupational Safety and Health; the James A. Haley Veterans' Hospital in Tampa, Florida; the American Nurses Association; and AORN. The guidance statement was originally published in 2007 as a separate booklet³ and is now incorporated into Perioperative Standards and Recommended Practices.¹

The Safe Patient Handling and Movement Tool Kit is available on the AORN web site at http://www.aorn.org/PracticeResources/ToolKits/SafePatientHandlingMovementToolKit. The tool kit includes an educational PowerPoint® presentation, a pocket reference guide, reminder posters, a bibliography, and a gap analysis tool. The tool kit helps perioperative personnel implement the guidance statement and educates them about how to safely move patients while protecting themselves from injury.

The percentage of adults ages 20 to 74 years who are obese (ie, have a body mass index equal to or greater than 30) has more than doubled, from 15% between 1976 and 1980 to 35% between 2005 and 2006 (age adjusted) according to the Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Examination Survey, and National Health and Nutrition Examination Survey. Age-adjusted rates are computed to eliminate differences in observed rates that result from age differences in population composition.⁵ New equipment is being developed to assist perioperative nurses as our workforce ages and the obesity rate increases.

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Thermal burns during phacoemulsification 

Question 

Staff members at our surgery center were shocked when a patient undergoing cataract surgery sustained a corneal burn. This had never happened to any of our patients before. Is this a common occurrence? What can we do to prevent this problem in the future?

Answer 

Thermal injuries that result from phacoemulsification cataract surgery are a serious complication. The rate of thermal injuries is unknown. In a survey of five western states, Bradley and Olson¹ calculated the wound burn rate to be 0.98% in 1,000 procedures. The Pennsylvania Patient Safety Authority reported 20 corneal burns during cataract surgery from December 2004 through July 2009.² A search of the US Food and Drug Administration's MAUDE (Manufacturer and User Experience) database using the phrase “phaco and burn” yielded a reported 1,450 thermal injury events from May 1992 to April 2010.² The postulated cause of the thermal injuries was overheating of the phacoemulsifier probe tip.² Phacoemulsification-related thermal burns are also associated with emerging techniques, including smaller incisions, clear corneal incisions, and the use of viscoelastic materials.³

During cataract surgery, phacoemulsification removes the opaque lens of the eye by ultrasound energy and aspiration via a small incision.⁴ Heat is generated at the phacoemulsification tip by the conversion of electrical energy to mechanical energy. This causes vibration, which creates heat. The probe tip oscillates rapidly, so heat is also created by friction between the phacoemulsification tip and the sleeve that fits over this tip for irrigation. Laboratory test data and clinical observation have demonstrated that the tip can overheat in as little as one to three seconds, causing a “phacoburn.”³

Both irrigation and aspiration prevent overheating. Balanced salt solution irrigation is used to cool the oscillating tip and remove the aspirant. Causes of insufficient irrigation or aspiration may occur when the

Perioperative nurses and surgeons can implement strategies to help reduce the risk of a thermal injury during phacoemulsification. Strategies for perioperative nurses include, but are not limited to,

The strategies for surgeons include, but are not limited to,

■gaining experience with the specific phacoemulsification unit used at the facility;

■becoming familiar with the machine's aspiration characteristics;

■seeking information about the manufacturer's recommendations;

■ensuring an adequate incision to avoid restriction of the irrigation/aspiration sleeve;

■verifying adequate irrigation flow before insertion of the phacoemulsification tip;³

■avoiding overtorquing of the wound; and

■avoiding excessive ultrasound power by

■applying power while shaving the lens and not when moving the phacoemulsification tip away from the lens and

■reducing the amount of phacoemulsification power, when possible, to reduce heat production.²

Possible consequences of a corneal or thermal burn are wound closure difficulty, wound leakage, corneal stroma or endothelium damage, fistula formation, and postoperative astigmatism.³ Maintaining the saline solution irrigation flow is key to preventing phacoemulsification-induced thermal injuries.³

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Wearing surgical masks while administering a spinal anesthetic 

Question 

We are looking at measures to decrease the risk of health care-associated infections in our facility. Should the anesthesia care provider wear a mask in the preoperative area when he or she is administering a spinal or epidural anesthetic?

Answer 

Masks should be worn by practitioners who are placing a catheter or injecting material into the spinal or epidural space in all settings (eg, preoperative holding, labor and delivery, pain management treatment rooms, OR).¹ Potential infectious complications of spinal or epidural anesthesia or analgesia include meningitis, paralysis, and death.², ³

After an investigation into eight cases of postmyelography meningitis in 2005, the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) reviewed the evidence and recommended that masks be worn during spinal or epidural procedures (Table 1).¹ “The HICPAC is a federal advisory committee consisting of 14 external infection control experts who provide advice and guidance to the CDC and the Secretary of the Department of Health and Human Services regarding the practice of health care infection control and strategies for surveillance and prevention and control of health care-associated infections in US health care facilities.”⁴

TABLE 1. Clinical Case Characteristics and Anesthesiologists' Test Findings for Five Patients Who Developed Bacterial Meningitis After Receiving Intrapartum Spinal Anesthesia—Ohio and New York, 2008-2009¹

PCR = polymerase chain reaction; rDNA = recombinant DNA; S salivarius = Streptococcus salivarius.

⁎Period from anesthesia injection to onset of meningitis signs.

†Ohio patients' isolates were indistinguishable by pulsed-field gel electrophoresis.

‡Cerebrospinal fluid obtained during autopsy.

§Specimen obtained after anesthesiologist B had received antimicrobial prophylaxis.

1Bacterial meningitis after intrapartum spinal anesthesia—New York and Ohio, 2008-2009. MMWR Morb Mortal Wkly Rep. 2010;59(03):65-69. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a1.htm. Accessed May 28, 2010.

In 2008, the New York State Department of Health received reports of three cases of bacterial meningitis at a hospital after patients received a combined spinal-epidural anesthesia from the same anesthesiologist. The three patients presented with a combination of headache, back and neck pain, nausea and vomiting, confusion, disorientation, seizure, and rigors. During an investigation of the involved health care facility, the New York State Department of Health

The cerebrospinal fluid specimen from one of the three patients showed Streptococcus salivarius when the polymerase chain reaction method was performed. The cluster of S salivarius was associated with one anesthesiologist.²

In 2009, the CDC, Ohio Department of Health, and the local city health department conducted an investigation when two healthy intrapartum patients presented with fever, nausea, severe headache, lethargy, confusion, and unresponsiveness on the same day after receiving spinal injections from the same anesthesiologist. One patient recovered, and the other died. The blood and cerebrospinal fluid cultures of both patients were positive for S salivarius. As in the New York investigation, medication vials were cultured, the hospital infection preventionists and medical director were interviewed, and the hospital's intrapartum spinal anesthesia procedures were reviewed. The oropharynx, buccal mucosa, and tongue swab cultures of the anesthesiologist did not result in any growth; however, the polymerase chain reaction method identified S salivarius from the anesthesiologist's cultures.²

Streptococcus salivarius is a bacterium that is part of the normal flora of the mouth.²Streptococcus salivarius and other viridans streptococci are the most common sources of meningitis after spinal procedures.², ⁵, ⁶, ⁷Streptococcus salivarius may be transmitted by droplet transmission or contamination of the sterile equipment.⁶, ⁷

Potential sources of bacterial introduction during spinal and epidural procedures include

A surgical mask is effective in preventing the spray from the mouth while the wearer is talking.², ⁵ Not wearing a mask while administering spinal anesthesia can be considered a break in aseptic technique, potentially allowing the transmission of S salivarius.² A properly worn, clean surgical mask provides protection against droplet transmission of S salivarius.⁵, ⁷ The CDC HICPAC and the American Society of Regional Anesthesia and Pain Medicine recommend that masks be worn when a health care provider is placing a catheter or injecting material into the spinal or epidural space.², ³ Meningeal membrane puncture is a potential portal of entry for infectious agents.⁷ Surgical masks should be worn whenever the spinal or epidural space is entered.¹ Additional preventative measures for spinal and epidural procedures include hand hygiene, removal of jewelry, adherence to strict aseptic techniques, and refraining from excessive talking.², ³, ⁶

The author of this column has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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Learner Evaluation. Continuing Education Program 

Clinical Issues 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.

Purpose/Goal 

To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

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References 

Safe perioperative use of glutaraldehyde
1. Hospital eTool. Healthcare-wide hazards module—glutaraldehyde (Occupational Safety and Health Administration). http://www.osha.gov/SLTC/etools/hospital/hazards/glutaraldehyde/glut.htmlAccessed May 28, 2010
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2. Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST58:2005—Chemical Sterilization and High-Level Disinfection in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2005;
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3. Recommended practices for high-level disinfection. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 389–404
   • View In Article
4. Comparison of Hazard Communication Requirements OSHA Hazard Communication Standard 29 CFR 1910.1200 (HCS) Globally Harmonized System (GHS) (Occupational Safety and Health Administration). Washington, DC: US Government Printing Office; 2007;http://www.osha.gov/dsg/hazcom/ghoshacomparison.htmlAccessed May 28, 2010
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5. Glutaraldehyde. NIOSH Publication Number 1994-113, 3rd Supplement 2003-154 In:  Schlecht PC,  O'Connor PF editor. NIOSH Manual of Analytical Methods (NMAM®). 4th ed.. Atlanta, GA: The National Institute for Occupational Safety and Health; 1994;http://www.cdc.gov/niosh/docs/2003-154/pdfs/2532.pdfAccessed May 28, 2010
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6. Glutaraldehyde. NIOSH Publication Number 2005-149 NIOSH Pocket Guide to Chemical Hazards. Atlanta, GA: The National Institute for Occupational Safety and Health; 1994;http://www.cdc.gov/niosh/npg/npgd0301.htmlAccessed May 28, 2010
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7. Glutaraldehyde. In: TLVs and BELs: Threshold Limit Values for Chemical Substances and Physical Agents: Biological Exposure Indices. Cincinnati, OH: ACGIH; 2009;p. 1–10
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8. Occupational Safety and Health Administration. Occupational Safety and Health Administration Standard 1910.134. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716Accessed May 28, 2010
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9. Hazardous waste disposal. Guidelines for Protecting the Safety and Health of Health Care Workers (National Institute for Occupational Safety and Health). http://www.cdc.gov/niosh/docs/88-119/pdfs/88-119.pdfAccessed May 28, 2010
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10. Title 40: protection of environment. Code of Federal Regulations. College Park, MD: The National Archives and Records Administration; 2009;http://www.access.gpo.gov/cgi-bin/cfrassemble.cgi?title=200940Accessed May 28, 2010
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11. Public health notification from FDA, CDC, EPA and OSHA. Avoiding hazards with using cleaners and disinfectants on electronic medical equipment (US Food and Drug Administration). http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/UCM062052Accessed May 28, 2010
    • View In Article

Safe patient handling and movement in the perioperative setting
1. Guidance statement for safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 673–696
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2. Owen BD. Preventing injuries using an ergonomic approach. AORN J. 2000;72(6):1031–1036
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   • Abstract
   • Full Text
   • Full-Text PDF (1271 KB)
   • CrossRef
3. Petersen C. Safe Patient Handling and Movement in the Perioperative Setting. Denver, CO: AORN, Inc; 2007;
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4. Wicker P. Manual handling in the perioperative environment. Br J Perioper Nurs. 2000;10(5):255–259
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5. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics; 2010;http://www.cdc.gov/nchs/data/hus/hus09.pdfAccessed May 28, 2010
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Thermal burns during phacoemulsification
1. Bradley MJ, Olson RJ. A survey about phacoemulsification incision thermal contraction incidence and causal relationships. Am J Ophthalmol. 2006;141(1):222–224
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   • Abstract
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2. Pennsylvania Patient Safety Authority. Preventing corneal burns during phacoemulsification. Pa Patient Saf Advis. 2010;7(1):23–25
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3. Sippel KC, Pineda R. Phacoemulsification and thermal wound injury. Semin Ophthalmol. 2002;17(3-4):102–109
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4. Vaughn D, Asbury T, Riordan-Eva P. General Ophthalmology. In: 15th ed. Stamford, CT: Appleton & Lange; 1999;p. 407
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Wearing surgical masks while administering a spinal anesthetic
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Infection Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 (National Guidelines Clearinghouse). http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=10985&nbr=5765Accessed May 28, 2010
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2. Bacterial meningitis after intrapartum spinal anesthesia—New York and Ohio, 2008-2009. MMWR Morb Mortal Wkly Rep. 2010;59(03):65–69http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a1.htmAccessed May 28, 2010
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3. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med. 2006;31(4):311–323
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4. Healthcare Infection Control Practices Committee (HICPAC). Centers for Disease Control and Prevention. http://www.cdc.gov/hicpacAccessed May 28, 2010
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5. Baer ET. Post-dural puncture bacterial meningitis. Anesthesiology. 2006;105(2):381–393
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6. Sandkovsky U, Mihu MR, Adeyeye A, De Forest PM, Nosanchuk JD. Iatrogenic meningitis in an obstetric patient after combined spinal-epidural analgesia: case report and review of the literature. South Med J. 2009;102(3):287–290
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7. Rubin L, Sprecher H, Kabaha A, Weber G, Teitler N, Rishpon S. Meningitis following spinal anesthesia: 6 cases in 5 years. Infect Control Hosp Epidemiol. 2007;28(10):1187–1190
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