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National Institute for Occupational Safety and Health (NIOSH)

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- federal agency responsible for ensuring that workers have a safe and healthful working environment - establishes occupational health standards

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Occupational Safety and Health Administration (OSHA)

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- responsible for enacting: job health standards, investigating work sites to detect violation of standards, and enforcing the standards by citing violators - provides information on each chemical used in the OR

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OSHA requires verification that:

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- employee chemical exposures are kept below permissible exposure levels

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Chemical safety frequent monitoring

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- used to verify that hazardous chemicals remain at safe levels in the OR

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Toxicity

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- the ability of a chemical substance to cause harm

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Hazard

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- likelihood a material will cause harm under the conditions of use - with proper handling, even highly toxic chemicals can be used safely - less toxic chemicals can be extremely hazardous if handled improperly

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Exposure to toxic chemicals

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- have severe consequences, including death - injuries can occur where chemicals are handled

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Most chemical injuries could have been avoided if:

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- proper equipment was used - proper techniques were employed - adequate knowledge of the hazards were known

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Permissible Exposure Limit (PEL)

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- regulatory limits set by OSHA on the amount or concentration of a substance in the air - essential to keep anesthesia providers exposure below this - also designated as parts per million (PPM)

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Plan in advance for potential hazards by:

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- designating a person to manage chemical safety - train and inform anesthesia personnel - label all chemical containers - keep file of MSDS for all chemical used

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Material Safety Data Sheet

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- all Ors have this book or online list for all chemicals in the work area - standard operating procedures - exposure control measures - fume hood and personal protective equipment - information and training - operating room plan for emergencies

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Being familial with chemicals in the OR

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- know and prepare for hazards in advance - review material safety data sheets - read all labels - know your protocol/procedures - some chemicals may have delayed toxic effects on the body

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Flammable

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catches fire easily and burns rapidly

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Combustible

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will burn under most conditions

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Explosive

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will explode/detonate releasing hot gases

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Oxidizer

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- yields oxygen to enhance combustion - may cause ignition of combustibles with no external source

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Organic peroxide

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uniquely hazardous, potentially explosive

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Unstable

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tends to decomose during normal handling and storage

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water reactive

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reacts with water to release flammable gas, causes fire or prevents a health hazard

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Carcinogen

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cause cancer or suspected to cause cancer

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Toxic agent

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poisonous/cause acute or chronic effects

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Reproductive toxin (teratogenic)

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could have harmful effect on male or female reproductive system or on developing fetus

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Irritant

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can cause inflammation of skin or eyes

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Corrosive

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cause irreversible damage to living tissue

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Sensitizer

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cause exposed person to develop allergies to the substance

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Target organ-specific agents

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hazardous to specific organs in body (ex: lungs, liver, blood, kidneys, nervous system)

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Inhalation/breathing

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most common route, gases/vapors can pass to blood, solid particles inhaled into lungs

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Absorption through the skin

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many solids, liquids, vapors and gases can be absorbed through the skin

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Ingestion/Swallowing

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while not intentional, failure to wash hands, eating in contaminated environments

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Injection

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accidents handling glass, sharps, etc

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Eye contact

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either physical damage or absorption

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Dictates selection of protective equipment

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the route of entry

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Dose

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- amount of chemical absorbed depends upon chemical strength/concentration, exposure duration, frequency of exposure - in general, the greater the dose, the more severe the health effects

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Acute effects

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occurs rapidly following brief exposure (ex: acid burn)

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Chronic effect

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- develops/recurs slowly, over long period following repeated, long-term, low-level exposure (ex: benzidine linked to bladder cancer)

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Individual variability

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not all people exhibit the same signs and symptoms (especially to chronic effects)

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Common chemicals in the operating room

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- methyl methacrylate (bone cement) - halothane (linked to hepatitis) - latex - glutaraldehyde (Cidex) - formaldehyde (Formalin) - cavi-wipes

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Methyl Methacrylate

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- bone cement - very strong when used in orthopedic surgery - used to cement prostheses to bone repair bone defects - risk for surgical patients ( cardiovascular=pulmonary embolism, hypotension, bradycardia, and cardiac arrest) - effects from occupational exposure to operating room personnel are less well documented - cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty - can be seen in the post-op period in a milder form causing hypoxia and confusion

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Symptoms of BCIS

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- hypoxia - hypotension - both - unexpected loss of consciousness occurring around time of cementation, prosthesis insertion, reduction of the joint or, occasionally limb tourniquet deflation in a patient undergoing cemented bone surgery

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BCIS Grading system

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Grade1-3

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Grade 1

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- moderate hypoxia (SpO2 94%) - fall in systemic blood pressure 20%

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Grade 2

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- severe hypoxia (SpO2 88%) - fall in BP 40% - unexpected loss of consciousness

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Grade 3

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- Cardiovascular collapse requiring CPR

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BCIS treatment

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- FALL IN END TIDAL CO2 concentration (may be the FIRST indicator) of clinically significant BCIS - increase in FiO2 to 100% and supplementary O2 should be continued into the post-op period - it has been suggested that cardiovascular collapse in the context of BCIS be treated as RV failure - AGGRESSIVE RESUSCITATION with IV fluids has been recommended

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Methyl Methacrylate occupational exposure effects

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- allergic reactions - asthma - dermatitis - eye irritation - corneal ulceration - headache - neurological signs and symptoms * significant lower limb neuropathy

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Halothane Hepatitis

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- rare condition - repeated bouts of hepatitis (in anesthesia providers) have been attributed to hypersensitivity reactions - associated with an increased prevalence of autoantibodies to CYP450 enzymes and hepatic endoplasmic reticulum proteins - believed to be a immune mediated response directed at hepatocytes

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Diagnosis of exclusion of halothane hepatitis

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- RULE OUT OTHER CAUSES - post-op jaundice - high fever within 3-14 days - recent exposure to halothane - eosinophilic leukocytosis (increase WBC) - patients with prior exposure to halothane are increased risk of developing

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Treatment of Halothane Hepatitis

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- corticosteroids are not beneficial - in the setting of acute liver failure fatality rates as high as 80%

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Latex

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- complex substance composed of polyisoprenes, lipids, phospholipids, and proteins - the PROTEIN IN LATEX is responsible for vast majority of generalized allergic reactions

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Types of reactions of latex gloves

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- irritant contact dermatitis - type IV - type I

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Type IV Type I

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- delayed hypersensitivity - immediate hypersensitivity (localized contact urticaria, generalized reaction)

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Irritant Contact Dermatitis

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- S/S: scaling, drying, cracking of skin - cause: direct skin irritant by gloves, powder, soaps - management: identify reaction, avoid irritant, possible use of glove liner, use of alternative product

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Type IV

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- S/S: itching, blistering, crusting (delayed 6-72hrs) - cause: chemical additives used in manufacturing (such as accelerators) - management: identify offending chemical, possible use of alternative product without chemical additive, possible use of glove liner

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Type I

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*localized contact urticaria - S/S: itching, hives in area of contact with latex, runny nose, swollen eyes, generalized rash, bronchospasm, anaphylaxis, immediate - cause: PROTEIN IN THE LATEX - management: antihistamines, topical/systemic steroids

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Cidex

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- used for cold sterilization of instruments in endoscopy and surgical units - not seen much anymore - workers can be exposed to cidex breathing it or by skin contact during the following procedures: solution poured into or out of the sterilization; when sterilized equipment is removed from sterilizing pans

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Cidex is dangerous with:

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- CONTACT OR INHALATION - eyes, nose and throat: teary eyes, bring nose, sore throat, coughing, and headache - max exposure limit is 0.2ppm

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Direct contact with Cidex

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- severely irritates eyes and can cause permanent eye damage - IN CASE OF CONTACT IMMEDIATELY RINSE THE EYES WITH WATER FOR 15MIN AND THEN SEEK MEDICAL ATTENTION - lungs: bronchospasm, irritate, causing chest pain, shortness of breath - skin: dermatitis, dryness, redness, flaking, cracking of skin, burns, allergic skin reaction

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Dangers of Cidex

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- asthmatics are very sensitive to very small amounts of cidex or other irritants - cancer - reproductive system: not conclusive

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Protection from exposure

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- OUTSIDE EXHAUST VENTILATION SHOULD ALSO BE USED - use local exhaust ventilation (CAPTURE VELOCITY AT LEAST 100 FEET PER MIN) - keep cidex baths UNDER FUME HOOD (always take object to cidex)

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Formaldehyde

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- COMMONLY USED IN ENDOSCOPY - nearly colorless gas/liquid - usually in a 30-50% solution (formalin) - pungent and irritating odor at very low concentrations - flammable, explosive, highly toxic - SHOULD NEVER BE ABLE TO SMELL

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Cavi-wipes

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- health hazards - skin (not considered an irritant) - eyes (can cause reversible damage) - inhalation (low or mild irritation) - wash hands after contact - IF EXPOSED IN EYES, WASH WITH WATER FOR 15 MIN

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Chemical emergency Classification

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- simple spill (clean up yourself) - major emergency or high hazard spill (cannot clean up yourself)

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To clean up a simple spill

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- notify your fellow worker and supervisor - control access to the area, prevent contact or speed of spill - call OSHA for advice and to report as soon as possible

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Emergency eye wash/ safety shower

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- keep area around safety equipment clutter free - portable squeeze bottles are NOT acceptable - flush affected area for at least 15 min - for spill on clothing/skin: remove clothes, wash with soap and water, follow info on MSDS for decon steps, seek medical advice

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