Episode #59 Vaccines, Body Piercings and Humidity Levels

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. I hope you are ready because we are going to cover quite a few topics today. We will start with the recommendation for Covid-19 Vaccination for Health Care Professionals and then we will discuss 2 important patient safety related concerns in the perioperative time period and in the OR.

Before we dive further into today’s episode, we’d like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical Risk Retention Group- we wouldn’t be able to do all that we do without you!”

On July 29, 2021, the APSF published an article called, “Joint Statement on Covid-19 Vaccination of Health Care Personnel.”  Not only does the APSF strongly encourage all health care personnel to get vaccinated against Covid-19, but this is a joint statement from the following societies:

• The ASA
• The American Society of Regional Anesthesia and Pain Medicine
• The APSF
• The Society for Ambulatory Anesthesia
• The Society for Education in Anesthesia
• The Society for Neuroscience in Anesthesiology and Critical Care
• The Society for Obstetric Anesthesia and Perinatology
• The Society for Pediatric Anesthesia
• The Society of Academic Associations of Anesthesiology and Perioperative Medicine
• The Society of Cardiovascular Anesthesiologists
• And the Society of Critical Care Anesthesiologists

The statement supports that vaccines are safe, highly effective, and save lives and strongly encourages all health care workers and all eligible Americans to get fully vaccinated with one of the Covid-19 vaccines. Remember, widespread vaccination is the most effective way to reduce illness and death related to this virus as well as decrease the impact of the pandemic.  Here is a quote from ASA President Beverly Philip:

“As physician anesthesiologists and anesthesiology professionals, we provide care for patients in the operating room, delivery room, critical care unit and ambulatory settings. We also served on the front lines throughout the pandemic and have seen firsthand the devastating impact of this virus….The health and safety of our members, our colleagues, and our patients are our highest priority and we urge closing the vaccination gap.”

Dr. Philip continues, “Vaccination is critical for everyone, but is especially essential for health care personnel because it reduces the likelihood of unintentionally spreading COVID-19 to our patients, especially those who may have weakened immune systems…We stand with all of our medical colleagues and offer our support and strong encouragement for COVID-19 vaccination.”

I will include a link to the Full Joint Statement on Covid-19 Vaccination of Health Care Personnel in the show notes as well so that you can check it out and share it with your colleagues.

Okay, next up we are going to be talking about something that you may see frequently in the preoperative holding area and have questions about? That’s right we are talking about body piercings. This is a Q and A article from the Fall 2013 APSF Newsletter. To follow along, click on the Newsletter heading. 5^th one down is Newsletter Archives. From here, scroll down to 2013 and click on Fall 2013. In the left sided column, the featured article is the 2^nd one down. It is called “Body Piercing and Electrocautery Risks” by Ursula Class and Jan Ehrenwerth.

Ursula Class writes, “Dear Q and A, It seems to me that I encounter more patients with all kinds of body piercing, and I am not exactly sure what the implications are if/when the surgeon plans to use electrocautery.” Class continues by asking a question about the following situation. “Electrical current enters the patient’s body and leaves it via the grounding pad, because that is usually the path of least resistance. However, in patients who have earrings (or some other form of body piercing), the path of least resistance could be the path through the earring and the electrical current could cause a burn at that site. Is that correct?”

Jan Erhenwerth provides helps to clarify the situation. The return plate for the electrosurgical unit is a large surface area, low resistance pathway for the energy to safely return to the machine. While it is frequently called a grounding pad in the OR, it is not a grounding pad. It may also be called a return electrode. When the return plate is functioning normally the energy will go through the return plate as intended, but if the pad is dislodged or the gel has dried out, then body piercings could serve as a return pathway for the energy and put the patient at risk for a burn injury.

The next question involves placing tape over the earring. Does this help to protect the patient? Unfortunately, the tape will not help protect against a burn injury, but it will help to prevent the piercing from being lost.

Question 3 asks about the use of metal retractors and electro cautery in the OR. Can a metal retractor act as a diverting medium for the energy and why do metal retractors and earrings pose different risks during the use of electrocautery in the OR? Keep in mind that metal retractors do not usually cause a problem, but the retractor could conduct electrical current. Surgeons may experience this as a hole in their glove when holding a retractor and activating the electrocautery. The difference is in the size and the smaller the surface area, the worse the burn injury which is why the same current delivered to a small earring would cause a more significant burn.

Let’s move on to the next question. For anesthesia professionals who have provided anesthesia for patients with earrings covered with tape and the use of electrocautery during the surgery and no burns have occurred, are these anesthesia professionals and their patients just lucky? The answer to this question is that there is likely a small risk of the patient experiencing a burn if metal body piercings are left in place, but modern electrosurgical units and the return pads are improved pieces of technology with less risk of malfunction than order devices. The bottom line is that the safest course of action is for patients to remove all piercings prior to surgery and anesthesia.

Wow, we are really on a roll.

So, what is the weather in your area today? How humid is it? While you may check on the humidity levels outside prior to your next outdoor adventure, when was the last time you thought about the humidity levels in the operating rooms? This is an important consideration for anesthesia professionals that we are going to review now. So, let’s head back into the Newsletter archives and scroll down until you get to June 2019. Then, scroll down looking in the left column until you get to the rapid response section. Our next featured article is called, “Humidity Levels in the OR” by De-an Zhang who writes the following:

“Dear Rapid Response: At our institution, we recently encountered an issue with our HVAC system that left the operating room humidity at approximately 70%. Our operating rooms were closed because of this, and no cases were done while we were out of compliance. A joint statement published by multiple societies in 2015 recommends a relative humidity of 20%-60%.^1–7 My question has two parts: (1) how was the upper limit of 60% decided, and (2) what are the real-life dangers of delivering an anesthetic and performing an operation in a setting with a humidity greater than 60% or less than 20%? Thank you again for your time.”

And thank you to Zhang for submitting this rapid response question. Has this situation ever occurred at your institution where the humidity level in the operating room was too high and the room was temporarily closed?

Loeb and Pollitt provide a response. Does a high humidity level in the OR, above the limit of 60%, put patients at risk during anesthesia care? In the short term, this is unlikely to be a big threat to patient safety, but for longer durations of high humidity levels, there may be an impact on the operating room and instrument sterility. The standard for OR relative humidity levels is between 20 and 60% and this was set by the American Society of Heating, Refrigeration, and Air Conditioning. This standard is supported by the National Fire Protection Association and the Facility Guidelines Institute. In addition, the Centers for Medicare and Medicaid Services and the Joint Commission uphold the same standard for OR humidity levels and require that the temperature and humidity levels be monitored continuously in the operating room. Keep in mind that certain supplies and equipment may require a narrower range of relative humidity levels for storage and use. This means that it is also important to monitor the temperature and humidity levels in storage areas as well. Thus, in the original rapid response, temporarily closing the OR until the humidity levels returned to within the accepted range was appropriate.

Let’s take a look at the rationale for the lower limit of 20% for relative humidity. Humidity levels below this level may have the following impact:

• decreases the shelf life of certain supplies including biological indicators and chemical indicators used for sterilization monitoring. EKG electrodes may also be affected in this way.
• increases the chance of electrostatic discharge that could harm or interfere with electromedical equipment which could increase the risk for a fire in the OR. (However, the authors remind us that the risk is low and sparking a fire may be even less likely with nonflammable anesthetics and antistatic surgical gowns).

Let’s raise the bar and take a look at the rationale for the upper limit of 60% for relative humidity. At higher relative humidity levels, the following may occur:

• increased chance of surface mold and mildew growth
• possible increase in the risk of wound infections;
• discomfort for the members of the operating room team.

Now, what is the evidence that helped to support setting these specific levels? Unfortunately, there is not robust evidence in the literature, but we are going to take a look at what’s out there. In 2008, the standard for humidity levels in the OR changed from 35-60% to a wider range from 20-60% in light of the high expenses for HVAC equipment and fuel costs. Ten years later, a review was completed of reports made to the FDA MAUDE database, or the Manufacturer and User Facility Device Experience database, on electrostatic discharge by medical devices when the relative humidity level was found to be less than 30% as a contributing factor. In addition, in the instructions for use or IFU, for many electronic devices there is a recommended minimum relative humidity level of 30%. This is notable because CMS requires the personnel follow the IFU recommendations appropriately. At the time of this Rapid Response in 2019, the American Society of Heating, Refrigeration, and Air Conditioning had not changed the standard for humidity levels to be aligned with the manufacturer recommendations.

Before we wrap up for today, let’s do a dive into relative humidity which is the amount of water vapor that is in the air and expressed as a percentage of the amount needed for saturation at the same temperature. The relative humidity depends on the temperature and the pressure of the system. If the relative humidity level exceeds the upper limit, it may be lowered by either removing water vapor or increasing the temperature. Keep in mind that cold operating rooms have a higher relative humidity than warm operating rooms even when the absolute humidity is the same. Check out Figure 1 in the article to see a graph of the relationship between relative humidity and temperature. There are times when the relative humidity may be above the upper limit depending on the geography and type of cases. For example, northern and western climates may have low relative humidity in the winter with difficulty maintaining the relative humidity above the lower limit. On the other hand, in southern and coastal areas there is higher relative humidity requiring the removal of humidity from the fresh air. During a case in the operating room with the temperature set at 70 degrees and 50% relative humidity level, if the room temperature is decreased to 60 degrees, then there is a risk that the relative humidity would increase to above 60%. The authors recommend a risk assessment by physicians, surgical staff, infection control, OR management, Clinical Engineering, supply chain, and facilities engineering personnel when the relative humidity exceeds the upper limit of 60% to make sure that there is no adverse effect. This risk assessment is important to help keep the patient in the OR safe.

If you have any questions or comments from today’s show, please email us at [email protected].

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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