Safety – Not Just Success: Reducing Infection Risk with an Autoclave-Ready Reusable Laryngoscope

More than 100 years of innovations have indisputably improved the success of elective endotracheal intubation (asamonitor.pub/3YPxCVn). When considering the consequences of failure, it's not surprising that success rate has been the general benchmark for intubation safety, with infectious risks mostly a passing afterthought. Recently, however, hospital-acquired infection (HAI) and infection prevention (IP) have been initiatives of related professional organizations and regulatory bodies, including ASA, the Anesthesia Patient Safety Foundation (APSF), The Society for Healthcare Epidemiology of America (SHEA), and the Joint Commission (asamonitor.pub/49uoHgX; asamonitor.pub/3YyfbnR; asamonitor.pub/3NbVArd). The realities of laryngoscope and anesthesia work environment (AWE) contamination have proved to be considerable. Any efforts to reduce infectious risks to patients and clinicians must address the sterility limitations of the reusable intubating laryngoscope and the compulsory workflow it entails (asamonitor.pub/3NbVArd). It is time for a sterile, autoclave-ready, reusable rigid laryngoscope to be fully integrated into a specialized, preestablished central sterilization process in order to substantially improve patient protection from airway cross-contamination during elective intubation in the OR.Surgical procedures requiring endotracheal intubation are becoming more common, with current estimates of 30 million per year in the United States (JSLS 2020;24:e2020.00076). Evaluations and case reports have documented the added risk and complications of patient cross-contamination due to inadequately sterilized instruments and surfaces within the AWE (J Hosp Infect 2014;88:127-31; J Anesth 2018;33:85-89; Anesth Analg 2015;120:819-26). While adenosine triphosphate detection is nonspecific, it is dependable to detect pathogen colony forming units as low as x10-4 (sterility assurance level x10-6) and is considered a reliable monitor for qualitative cleanliness and burden of bio-contamination (J Food Prot 2022;85:1079-95; asamonitor.pub/4qglWaa). Subsequently, the reusable “ready for use” laryngoscope handle is the second most bio-contaminated surface in the OR, and up to 80% are culture positive for pathogenic organisms (some with antibiotic resistance) or test positive for occult blood in separate assessments. Additionally, bio-contamination levels in the AWE have been positively correlated with surgical site infections – 20% of all HAI (JSLS 2020;24:e2020.00076; J Hosp Infect 2014;88:127-131). A recent survey in Spain revealed that over 50% of anesthesia professionals are unaware of the level of laryngoscope reprocessing, and greater than 80% clean the handle component only when visibly soiled, as some laryngoscope instructions for use essentially consider acceptable today. Unfortunately, there also appears to be improper reuse of single-use device (SUD) laryngoscopes in 15% of users because of operator convenience and cost reduction (Healthcare 2023;11:1117). After evaluating the AWE cross-contamination risks in 2018, SHEA recommended that the intubating laryngoscope undergo high-level disinfection or sterilization between uses (asamonitor.pub/3Yyq215). State government concerns for public health made this recommendation a requirement in 2007. More recent endorsements by ASA, the APSF, Association of periOperative Registered Nurses, American Academy of Anesthesiologist Assistants, and the American Association of Nurse Anesthesiology have built a solid professional consensus supporting unambiguous and uniform high-level disinfection or sterility standards of a rigid laryngoscope (asamonitor.pub/3Yw4BxC; Anesth Analg 2018;127:576-79). Considering SHEA's 2018 convictions, it is unfortunate and regressive that a 2025 multidisciplinary recommendation from SHEA did not further address the ongoing inattention to laryngoscope handle high-level disinfection or sterility because they are indispensable components of a rigid laryngoscope (Anesth Analg 2015;120:819-26; AANA J 1997;65:241-46). Successful IP routines within the AWE are considered critical for patient safety, yet the absence of perceived immediate benefit can be debilitating to IP efforts (Psychol Rev 2020;127:945-71). Currently, professional guidance advocates a multi-faceted approach to reduce the risk of anesthesia-related HAI utilizing education, gloving methods, and frequent hand hygiene (HH) episodes. Regrettably, the most rigorous IP habits in the AWE are routinely interrupted or diverted due to laryngoscope non-sterility and its workflow limitations along with the unique circumstances every patient brings to the OR. As a result, while AWE biocontamination levels are directly correlated with a lack of HH, increasing HH episodes, from once per hour to eight per hour, as defined by the World Health Organization (WHO) The Five Moments of Hand Hygiene (asamonitor.pub/49vz8Rq), are destined to be a perpetual vision rather than an outcome (Am J Infect Control 2014;42:698-701; Int J Occup Med Environ Health 2013;26:257-64). The most successful method of habit formation requires small, repetitive changes with measurable results to build lasting effects (asamonitor.pub/3N4hPPQ). Therefore, is it realistic to expect that effective HH and workflow be standardized during the unpredictable, high-contact patient encounters within the AWE when strong evidence reveals that, without feedback, compliance rates to mandatory hand hygiene are as low as 9%-26% in a controlled environment (Int J Occup Med Environ Health 2013;26:257-64; Am J Infect Control 2025;53:53-57)? Some audits suggest that recommended HH compliance to be as low as 2%-3% during induction and intubation, the most critical time for potential cross-contamination of the airway (Antimicrob Resist Infect Control 2015;4:5). It appears that the relative urgency of intubation success continues to overshadow IP efforts since 2018. Comparatively, improved tools can facilitate lasting improvements for IP in the AWE by linking structured workflow to a readily reprocessed autoclaved laryngoscope. Sterile syringes and intravenous access equipment are examples of successful IP efforts using sterility requirements that affect operational workflow (Anesthesiology 2009;110:978-85; MMWR Morb Mortal Wkly Rep 2003;52:901-06; MMWR Recomm Rep 2002;51:1-29). A sterile laryngoscope for every intubation can be a starting point to guarantee a significant reduction of cross-contamination risks originating from the AWE. Consequently, the increasing use of SUD laryngoscopes directly supports IP efforts, and they are now used in approximately 50% of all OR intubations. The sterility of SUDs, however, trades improved patient protection and regulatory compliance for higher cost, lower quality, supply chain dependency, and the negative public health impact from infectious waste, estimated to be 3 million pounds (about 1,360,776 kg) of SUD laryngoscopes per year into the U.S. environment alone. Additionally, without compulsory workflow changes compelled by the instrument itself, placing a contaminated SUD back into the AWE is counterproductive to IP efforts regardless of HH frequency or gloving maneuvers. In addition to the benefits to our environment and public health, life-cycle evaluation suggests clear economic rewards when using reusable laryngoscopes in place of SUDs (Anesth Analg 2018;127:434-43). The relative cost and the logistical differences between SUDs and autoclave sterilization of complex reusable laryngoscopes continue to be debated. Therefore, prioritizing reusable devices must encourage and support a fundamental redesign of the laryngoscope to be autoclave-ready. A seamless integration into an efficient, preexisting surgical instrument sterilization platform with verifiable and easily audited results, such as a central sterilization process, should be a priority to effectively address the long-overlooked intubation safety concerns of laryngoscope cross-contamination. The growing attention to HAIs should caution us that the reusable laryngoscope is currently the only invasive medical instrument without clear reprocessing protocols and that this is an opportunity for building an IP strategy within the AWE for protecting patients, clinicians, and the environment. Hand hygiene is a great start. However, if today's highly contaminated reusable laryngoscope can be replaced with cost-effective, secured sterility during intubation, then indeed, “what are [we] waiting for” (asamonitor.pub/3NbVArd)? Disclosure: Dr. Vargo is cofounder of Vyve Medical, LLC, a medical device company focused on creating an autoclave-ready laryngoscope.Bradley J. Vargo, DO, Staff Anesthesiologist, University Hospitals, Cleveland, Ohio.