A surgeon's risk of AIDS

Bloodborne pathogens and procedure safety in interventional radiology

Concern about possible transmission of bloodborne pathogens during medical procedures is growing among patients and healthcare workers alike. This fear has primarily been focused on nosocomial transmission of human immunodeficiency virus (HIV), but other bloodborne infectious agents may also be transmitted during procedures. Chief among these are the hepatitis viruses, particularly hepatitis B virus (HBV) and hepatitis C virus (HCV), both of which are significantly more widespread than HIV. Although radiology is not traditionally thought of as a field with significant risk for exposure to or transmission of pathogens, the expanding role of interventional procedures in recent years belies that perception. The potential for exposure to blood or other possibly infectious material exists in virtually any invasive radiological procedure, from arteriography to image-guided biopsy. Fortunately, the risk of such exposure is low, and the risk of actual transmission of a bloodborne pathogen, whether from patient to healthcare worker or vice versa, is even lower. Nevertheless, it is important for all radiologists who perform invasive procedures to be aware of these risks and to observe pertinent safety and infection control recommendations. This article will review these topics.

Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen

Eighty-five consecutive patients were randomized to undergo mass closure of the abdomen with no. 1 polydioxanone mounted on either a blunt-tipped (n = 46) or cutting (n = 39) needle. Gloves were changed before closure and tested for perforation afterwards using standard air or water techniques. Fourteen pairs of gloves were punctured when using a cutting needle, and three pairs when a blunt-tipped needle was used. The majority of punctures were to the non-dominant glove. The surgeon was aware of the puncture in eight of the 14 instances involving a sharp needle and in one of the three involving a blunt-tipped needle. Blunt-tipped needles, while not eliminating the risk, significantly reduced the incidence of surgical glove puncture (P < 0.001, Fisher's exact test). The use of cutting needles for abdominal closure should be abandoned.

Improvement in suction catheter efficiency and safety in arterial operations

The Blood Shield is a new device which has been developed to attach easily to the tip of a conventional suction catheter. Two experiments were performed to determine if the Blood Shield could limit the degree of splash which occurs during vascular graft flushing and whether it could increase the efficiency of a standard suction tip in collecting shed blood for autotransfusion. The results of the experiments indicate that the Blood Shield, when added to a conventional suction catheter, diminishes the amount of spray which may occur during anastomotic flushing. Secondly, it more effectively collects blood from a flushed anastomosis or arteriotomy in comparison with a suction catheter alone.

Use of double gloves to protect the surgeon from blood contact during aesthetic procedures

The potential for blood contact with nonintact skin puts operating room personnel at an increased risk of exposure to hepatitis or HIV virus. Frank needle-stick injury to the surgeon has been shown to occur once every 20-40 operations. It has been shown that blood contact exposure during aesthetic surgery occurs in 32% of the operations in which a single pair of surgical gloves is used (surgeon 39.7%, assistant 23%). The reduction of blood contact exposure during aesthetic surgical procedures by using two pairs of gloves was tested and demonstrated. Contact rates decreased by 70%. Outer-glove perforations occurred in 25.6% of the cases, while inner-glove perforations occurred in only 10% of the cases (surgeon 8.7%, assistant 3.5%). All of the inner-glove perforations occurred during procedures that lasted longer than two hours, and in no case was there an inner-glove defect without a corresponding outer-glove perforation. The nondominant index finger (33%) was the most common location. Double gloving during aesthetic procedures reduced the operating room personnel's risk of blood contact exposure by 70% when compared with single-glove use.

HIV infection and surgeons

The human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome, which remains uniformly fatal in affected individuals. A common route of HIV transmission is via inoculation of contaminated blood, which may occur during surgical procedures. Surgeons may estimate their risk of HIV infection over a 30-year surgical career based on HIV prevalence among surgical patients, percutaneous injury rate per operation, and seroconversion rate. Surgeons can reduce their risk by various means, but the most pragmatic is by reducing the rate of percutaneous injury through optimal surgical technique and proper precautions.

Reducing the risk of viral transmission at operation by electronic monitoring of the surgeon-patient barrier

A new electronic device designed to detect glove holes, wet gowns and glove permeability was assessed during 50 general surgical operations. The cause of each alarm was recorded and the surgeon's awareness of any breach noted. Some 266 alarms were recorded of which 45 were ascribed to glove holes, 86 to wet gowns, 115 to glove porosity and 20 to other causes. Glove holes occurred in 29 of the 50 procedures; the surgeon was unaware of the hole in almost 70 per cent of cases. Holes were more common in laparotomy than in laparoscopic procedures (P = 0.006). In 20 per cent of instances surgeons did not respond immediately to the alarm (median delay 16 min). Six of eight surgeons who used the device indicated that they would do so regularly for major abdominal surgery. The electronic system accurately detects breaches in the surgeon-patient barrier. Its use should improve surgical discipline in acting to restore the barrier, protecting patient and surgeon alike.

AIDS and the neurosurgeon--an update

Over the past decade, acquired immunodeficiency syndrome (AIDS) has become the leading public health crisis in the United States, Western Europe, and Africa. Despite improvements in the diagnosis and treatment of AIDS-related disorders, the number of people infected with the human immunodeficiency virus (HIV-1) continues to grow, requiring a greater proportion of limited financial, medical, and human resources. Since nearly one half of symptomatic AIDS patients have neuropathologic disease, clinicians must be aware of the myriad neurologic manifestations of AIDS and use the most effective methods to diagnose and treat them. The work-up of the AIDS patient with neurologic symptoms includes a careful history and physical examination, laboratory studies, and radiographic imaging. Gadolinium-enhanced magnetic resonance (MR) imaging has become the radiographic screening study of choice. MR imaging can be used to predict which patients should undergo stereotactic biopsy before an empirical trial of antitoxoplasmosis therapy. Any patient with a mass lesion that does not respond to empirical therapy for toxoplasmosis should also undergo biopsy to exclude another treatable disorder. While the number of patients with neurological complications can be expected to increase in the near future, better imaging techniques may obviate the need for biopsy in many of these patients. The increasing threat of HIV-1 infection in the workplace requires meticulous care both in and out of the operating room to minimize accidental exposure of health-care workers.

Procedure-specific infection control for preventing intraoperative blood exposures

Contemporary intraoperative infection control must address the risk of infection transmission to both patients and their providers. The patient must be protected from intraoperative wound contamination and exposure to blood-borne pathogens during procedures. Providers must be protected from injuries and mucocutaneous exposure to the patient's blood. Procedure-specific infection control precautions, or similar strategies that address this bidirectional potential for infection transmission, may prove successful in accomplishing improved safety for all.

Risk of blood contact through surgical gloves in aesthetic procedures

Evidence of glove perforation, and therefore blood contact, was evaluated in 100 consecutive pairs of gloves used in aesthetic surgical procedures. The surgeon (38.3%) was more likely than the assistant (22.5%) to have exposure. In only 15% of these cases were they aware of the exposure. The left index finger (44%) was the most common location of perforation and 29 of the 32 holes (90.6%) were in cases that lasted more than 2 hours.

AIDS and arthroscopic surgery

There are an estimated 8 to 10 million people worldwide infected with human immunodeficiency virus (HIV). The true extent of infection in the population is unknown, and many are unaware of their HIV status. Arthroscopic and arthroscopically assisted surgery is less invasive and bloody than other orthopaedic procedures, and seemingly less hazardous to surgeons. Nevertheless, the potential for exposure exists. Arthroscopic surgeons routinely experience gown, face-mask and shoe-cover saturation from the splashing of blood-tainted irrigation fluid. Glove perforations by needles, sharps, and bone fragments can occur. Bone and tissue allografts pose risks to both surgeon and patient, as HIV has been recovered from fresh, frozen and freeze-dried specimens. The process of cleaning and disinfecting arthroscopes adequately can damage these expensive devices. This article addresses the safeguards that arthroscopic surgeons should take to prevent exposure to HIV. Effective sterilizing and disinfecting techniques for arthroscopes are also discussed.