What_advice_would_you_give_to_the_ward_and_theatre_staff on_the_management_of_an_HIV-positive_haemophiliac_patient admitted_for_abdominal_surgery?
An HIV-positive haemophiliac patient admitted for abdominal
surgery would pose a considerable problem for the ward and
theatre staff. Being haemophiliac, he would be much more at risk
of haemorrhage during and after the surgery, and thus would pose
a considerable risk to the staff. The following advice should be
given to the staff. Before surgery, the patient should be given
an adequate quantity of factor VIII. Intramuscular heparin for
the prophylaxis against deep vein thrombosis would probably not
be a good idea although the surgical must weigh out the risks on
an individual basis. An opinion from a haematologist may be
useful. The following advice should be given to the staff.
A high degree of theatre discipline is essential in order to minimize the risk of blood contact to the staff involved. It would be prudent not to use inexperienced personnel such as medical students and student nurses to assist in the operation. Unnecessary instruments should be removed from the theatre in order to avoid contaminating these instruments and also in order to make the operating theatre less cluttered so that the staff will be able to concentrate better. Although not strictly necessary, disposable anaesthetic circuitry would be a bonus.
The staff involved in the operation should wear double gloves,
plastic aprons, boots, eye goggles and masks. All cuts and wounds
on the staff should be covered. Sharps should not be passed hand
to hand. Needles should not be guided with fingers and hand
needles should not be used in the operation. For the purpose of
wound drainage, closed apparatus should be used. Any blood
spilled in the theatre should be decontaminated by chlorous as
soon as possible. The use of disposable surgical instruments in
the theatre would be of great help. After use, disposable
surgical instruments should be disposed of properly in well
marked sharps containers. Non-disposable instruments should be
handled carefully after use and sterilized properly. Well marked
disposable bags should be used for the collection of waste from
the theatre and the waste should be incinerated.
It would be prudent to put the patient into a single room after the operation so that the risk to other patients in the ward is minimized. It would be advisable for the room to have attached toilet facilities, to make the disposal of excretions easier. Negative pressure ventilation is not necessary. Unnecessary equipment and furniture should be removed from the room in order to simplify decontamination procedures. As in the case of the operating theatre, only trained staff should be used and they should be instructed on the use of techniques which minimize contamination with the patient's blood, body fluids, secretions and excretions, in particular measures to prevent percutaneous injuries. Where possible, disposable clinical equipment should be used.
Whilst looking the patient, masks would not be necessary except for procedures such as endotracheal aspiration or changing the drainage bottle, where there is risk of splashing. Plastic gloves should be worn at all times and any cuts and bruises covered adequately. Any blood spilled onto the floor should be decontaminated with chlorus immediately. Extra care must be observed if blood is to be taken from this patient using venepuncture so that needle stick injuries are avoided. The same vigilance applies to the insertion of IV lines. The used needle should not be resheathed and be disposed of safely in an approved sharps container. Any waste material taken from the patient, such as wound dressings should be discarded into well marked leak-proof disposal bags and incinerated. It would be advisable to have a separate set of eating utensils for the patient although for the maximum "peace of mind", disposable utensils may be used. Contents of bedpans and urinals can be flushed down a sluice as there is no need to treat waste before disposal. The usual bedpan disinfector would be sufficient, although it may be wise to use the same bedpans for the patient throughout the whole period. Soiled linens should be placed in a labelled bag, the usual hot-wash cycle would be sufficient for disinfection. Autoclaving may be used for heavily contaminated linens.
If despite all the above precautions, an accident involving a blood contaminated sharp take place in the theatre or in the ward, the following action should be taken: a baseline blood specimen should be taken from the member of the staff involved and another taken at 3 and 6 months afterwards for HIV antibody testing. In addition, the hepatitis B and C status of the patient as well as the affected member of staff should be determined. In the meantime, the member of staff should be counseled and offered zidovidine prophylaxis if he or she desires.
To conclude, the highest level of discipline should be
observed in the theatre and in the ward in order to minimize the
risk of accidents involving blood and other body fluids from this