Despite the many benefits of neuromonitoring, it is a fact that surgery gets more complicated whenever we are involved in the case. Patient prep time increases, anesthetic requirements change, there’s more people and equipment in the room, the risks are altered and additional consents are required. The risks associated with neuromonitoring are mostly benign from the patient’s perspective; however, the risks to the OR staff change and your team needs to be made aware of the risks.
Neuromonitoring often requires placement of needle electrodes in the major muscles of the upper and lower extremities, and on the head and face. In some cases, a patient have 40-50 individual needles placed on their body. If a wire is accidentally pulled out, or if the skin is compressed, a needle can become dislodged and pierce the skin of an OR staff member. This increases the risk of transmitting infection and, if the needle happens to retract back into the patient, to the patient from the clinician.
By virtue of the fact that you work in surgery, you are exposed to patients who have HIV, Hepatitis B/C and other communicable diseases. Every precaution must be made to protect yourself and those around you.
Unfortunately, one of the most common intraoperative complications associated with neuromonitoring (aside from negligent monitoring) is needle stick injuries to OR staff. EEG/EMG electrodes are your weapon, and they pose great risk to your team.
Imagine the following scenario:
A CRNA is preparing the place a radial arterial line. He gathers his supplies, lays them out carefully, he grabs the patient’s hand to expose the wrist and OUCH! An EMG electrode embedded in the hand pierce the CRNA’s finger. On top of that, when he let go of the hand, the needle retracted back into the patient’s hand. Now, they’re blood brothers. The CRNA has to leave the surgery immediately to wash his hands with soap and water, and inform his supervisor. Then, it’s on to occupational health for evaluation and treatment. Surgery is delayed as his replacement is located and now anesthesia is under-staffed. Labs have to be drawn from the patient and the CRNA. The family must be informed of the error. Anxiety is heightened as the CRNA awaits blood test results from the patient. The circulating nurse has to fill out an Event Report, maybe you do, too. If everyone is lucky, your teammate is fine, the patient is fine. Best case scenario, the OR scrambled to cover the loss of personnel, you feel terrible and your colleague will likely be angry with you. Worst case scenario… you know…sickness, lawsuits, etc.
One positive factor is that EMG needles are not hollow, but solid, which significantly reduces the probability of transmitting infection. Nevertheless, needle stick injuries shouldn’t happen. Needle stick injuries are totally avoidable with a combination of communication, education, teamwork and perhaps some adjustments in your placement methods.
In my anecdotal experience the most common point in surgery during which needles stick occur are, in order of frequency:
- During positioning of the patient.
- Just after the drapes come down.
- During surgery, when anesthesia is working on something under the drapes.
I have also found that the most common sites on the patient where needle stick injuries occur to OR staff are, in order of frequency:
- Hands (during IV and arterial line placement)
- Upper arms (around the blood pressure cuff).
There are some recently published data on needle stick injuries from IONM electrodes. Tamkus and Rice (2014) found that the incidence of needle stick injury over the course of 55,665 surgeries was 0.34%. The personnel injured included IONM clinicians (43.1%), anesthesia personnel (21.8%), nurses (19.5%), surgeons (9.2%), and other staff (6.3%). No infectious disease transmission was reported. Fifty-seven IONM clinicians incurred expenses totaling $24,174 (average $424 per exposure). The cost for non-IONM personnel was not available. Most needle sticks for IONM clinicians occurred during the removal of needles (52.0%) and during patient positioning (67.7%) for non-IONM personnel.
It is your responsibility to take every precaution to protect yourself and your team. There are lots of steps that you can take to reduce or eliminate the risk of needle sticks in the OR. I have compiled the following list:
1. Place EMG needles in muscles at ≥ 20° angle.
Frequently people place intramuscular needles superficially or subdermally. Superficially placed needles increase the risk of a “through and through” needle stick, which is what I described in the scenario above. In most cases you should be able to apply light pressure on the skin over the needle site and not feel the sharp below. Exceptions may include needles placed in facial muscles, for example.
2. Use transparent tape to secure needles.
Many people use Durapore tape because it is readily available in the OR and it sticks very well, but this tape obscures needle locations and increases the risk of skin tears (see below).
Clear tape helps people to see the point of electrode insertion. I recommend Transpore or Blenderm.
3. Use stress loops.
I can’t stress this enough! Stress loops help to keep needles from easily withdrawing if one of the wires gets pulled/yanked by accident. See image above for example.
4. Never use straight needles in the head.
Lots of people do this and it is so dangerous. Use bent needles or corkscrews. Better yet, use gold cup electrodes…there’s no risk of injury. If you use bent needles, insert all needles toward the vertex, twist them up and apply tape. If a wire gets tangled and pulled, it will actually force the needle into the skin.
5. Braid your head electrodes.
This helps to reduce noise, but also helps to control your wires so they don’t get tangled in hair, anesthesia lines, etc. I frequently see wires tangled in anesthesia lines, crossing the airway, etc. To me, this is dangerous, and also vexing to the anesthesia team.
6. Direct your wires through the Mayfield.
When the patient is in a Mayfield head-holder, run your EEG/SSEP recording wires through the Mayfield, not around it. If you run wires around the Mayfield, it is likely that one will get pulled as the surgeon fixes the head in position. In addition to that, there is risk that your wires will get cut during neurosurgery when neuronavigation devices and retractors are affixed to the Mayfield. So, keep your wires inside the Mayfield.
7. Inform your team.
Announce locations of needles to all staff when preparing to flip a patient. Say something like, “Everyone, remember that there’s EMG needles in the arms and legs, anesthesia…there are needle electrodes in the head, please be careful.” Also, when all of your needles are removed, tell the room, “Everyone, all needles are out.” I do this in every surgery, and I always get thanked. Your team will really appreciate you doing this.
8. Control your wires.
Don’t flip the patient with wires hanging loose, or already plugged in. They should all be bundled and secured tightly to the patient for positioning.
9. Make your wires visible.
When cutting electrodes in preparation for their removal, wires should be cut no less than 12” from the needle. That will help to make them visible to staff and reduce the risk of injury and needle retention.
10: Talk to people about the risks.
When transporting needles across the room to the sharps bin, inform OR staff of your approach by saying, “Sharps behind you.”
11. Count your needles.
You should have an exact count of all electrodes placed and all electrodes removed. This is a critical step that most people skip in their rush to turn over the room, or go home. Electrode counts ensure that nothing is retained in the patient following the procedure. What if the rest of the surgical team didn’t count their supplies? Wouldn’t you think that’s crazy? Don’t be crazy.
12. Check and double-check.
Double check your needle sites after removal! Don’t just rely on your count, but go back and physically inspect each needle location. Also, take the opportunity to clean up blood or excess tape that you may have left behind.
13; Place your electrodes in an approved sharps container.
Sometimes I see people remove needles and place them on the bed, or on the floor, in piles so they don’t have to make multiple trips to the sharps contained. Don’t be that guy. Put them in the sharps container immediately. Make 10 trips if you have to.
Do you have a checklist? Do you have a way to document placement and removal of sharps? If not, you should. Why not start today?
So, what steps do you take to avoid needle sticks in the OR? I’d love to hear your recommendations. Feel free to comment.
- Tamkus A, Rice K. Risk of needle-stick injuries associated with the use of subdermal needle electrodes during intraoperative neurophysiologic monitoring. J Neurosurg Anesthesiol. 2014 Jan;26(1):65-8.
- Adib-Hajbaghery M, Lotfi MS. Behavior of healthcare workers after injuries from sharp instruments. Trauma Mon. 2013 Sep;18(2):75-80.