Circulation 84,122 • Volume 23, No. 2 • Summer 2008   Issue PDF

Mock Debate Held on Syringe Reuse Dangers

The APSF Committee on Technology held a mock debate on syringe reuse on May 6, 2008, in Chicago, IL. The vision of the committee was to develop material which could be used to discourage the unsafe clinical practice of reusing infusion syringes during anesthetic care. This effort was a direct corollary of the final paragraph in the Spring 2008 issue of the APSF Newsletter Q&A column, which stated that it is insufficient to condemn syringe reuse practices without acknowledging the factors that lead to these behaviors.

Addressing the symptoms without trying to cure the underlying “disease” would be but a short-term solution. Thus, we must investigate, understand, and eliminate the factors that predispose one to the practice of unsafe medicine. As clinicians, we face severe production pressure and take “shortcuts” in the process of safe preparation of medication; we may give in to the financial importance that others, or we ourselves, place on speed and efficiency; or we may sincerely believe that we are preventing waste, thereby reducing the cost of medicine. An understanding of this complex environment may help to eliminate the root cause of such behaviors, which could then facilitate safer practices. At this session, members of the COT reviewed several of the summary points from the CDC presentation on syringe reuse and multiple publicized episodes of viral transmission related to syringe reuse. It was noted that as many as 27% of clinicians could be reusing propofol infusion syringes (while changing the microbore tubing) based on 220 respondents to an APSF Poll. Subsequent to this discussion, 2 teams were randomly organized to conduct an impromptu mock debate on the proposition, “Syringe reuse should be our recommended practice, when using a syringe pump with extended length microbore tubing.”

The proponents of this mock proposition argued that there are no data to show that this practice is unsafe; therefore, in the absence of such data it is an acceptable practice. Currently this practice is acceptable and common on medical missions where resources are severely limited. The practice is economically sound and results in less waste; it is also convenient and saves time. Connections are limited, therefore lessening the risk of misconnections and associated hazards. The group argued that it could be considered “financial malpractice” to not reuse infusion syringes in this manner. Furthermore, it is environmentally sound, using fewer resources, with less plastic and storage needed. The group pointed out the lack of intellectual arguments or scientific evidence for the reflux of potentially infectious material up the exchangeable tubing, and into the reusable syringe. Conversely, the group opposing this practice argued that going against single-use labeling required safety data to prove that the practice is safe and acceptable. The lack of evidence is neither compelling nor sufficient to alter a potentially safer practice. The burden of proof must be on proving that this practice is safe. For example, concerns were raised that reflux into a syringe could occur during syringe decompression for refilling, or, during the pressurized injection of another, and potentially contaminated, syringe of bolus drug distally in the IV line. Concerns exist that the plunger of the infusion syringe is in fact contaminated, and may contaminate the internal wall of the syringe, once injected. Alternative practices, such as using prefilled syringes could address convenience issues. On rebuttal, this group further believed that economic, storage, and environmental concerns could be addressed by using “just in time” delivery methods and implementing recycling for disposables. The “learned hand rule” was recommended to justify economics; what is the likelihood of an adverse event multiplied by the cost of such an event?

On rebuttal, the affirmative first group argued that we don’t throw away anesthesia machines between cases, and breathing circuit components are always reused. Broad cross contamination issues persist with potentially greater risks from dirty gloves, lack of hand washing, pulse oximeter probes, ECG leads, and blood pressure cuffs that may transmit infectious material between patients.

The COT found this to be a useful and exciting exercise to objectively examine the basis for beliefs and resultant behaviors, particularly when participants were “given permission” to take the unconventional position.