Risk of HIV Transmission to Operating Room Personnel
From the beginning of the HIV pandemic, the risk of HIV transmission by contact with infected blood, a fortiori, in case of injuries was put forward. This fear was so high that some surgeons asked if it was possible to refuse an intervention in HIV-infected patients under the pretext that the risk to themselves was too high.
In France and in the majority of European countries, the law does not permit routine testing for HIV infection in all surgical candidates. At La Pitie Institute, we performed this test after the patient’s consent in more than 80% of cases; this test is always done before transplantation.Accidents involving exposure to blood are not rare during surgery and particularly cardiac surgery. For example, Trachiotis [7] reported six injuries with a solid needle during 37 cardiac operations, and three injuries occurred (one with a hollow needle, two with sternal wire) at La Pitie during 49 interventions. These accidents needed prophylactic antiretroviral therapy. It is now standard practice to prescribe a course of anti-HIV agents in the event of a percutaneous injury based on the evidence that early use after exposure to the virus reduces the chance of infection [35]. No cases of seroconversion were observed. Moreover, there continues to be no known case of transmission of HIV to personnel as a result of a solid needle injury.
According to Beekman et al. [36] and Klatt et al. [37], the risk of accidental infection to operating-room personnel through blood contact during surgical procedures is low and can be avoided by adherence to universal precautions with proper training of personnel.
The universal precautions are:
- Impermeable gowns.
- Two pairs of surgical gloves [38].
- Protective glasses.
- Reinforced masks.
- Needles and other sharp instruments should be handled cautiously (one operator, count of sharp tools, solid box for infected sharps tools).
- Knowledge of the serology of the patient. This point is questionable because the universal precautions should be precisely universal and thus followed independently of the serological status of the patient. Moreover, knowledge of the serological status can generate fear and stress and could be a risk factor for percutaneous injuries. Nevertheless, when a patient is known to be HIV-infected in our institution, this fact is clearly mentioned in the medical file. HIV testing is not systematic before cardiac surgery in our institution and this practice is very different from one center to another [39]. HIV testing in patients and personnel is systematic and urgently done in case of percutaneous injury with bleeding.
- Continuous training of the entire staff about these universal precautions.
- Continuous training of the entire staff about the procedure in case of percutaneous injury with blood from the patient.
- Antiretroviral therapy should be continued until the day of surgery and restarted as soon as possible.
- The patient should have a viral load as low as possible; the intervention can be reported in case of excessive viral load, nonurgent surgery, and high probability of reducing the viral load with antiretroviral therapy adaptation.
Because the risk of contact with the patient’s blood is higher during cardiac surgery, particularly in cases of extracorporeal bypass, special precautions have to be taken and if possible generalized to all patients:
- The kit for ECC is preconnected.
- The ECC machine is handled with gloves.
- Suturing and reparation of the sternum with steel wire should be done very cautiously and with only one operator (no tandem surgery) [40].
Videoscopic surgery, even robotically assisted surgery (Fig. 6), reduces the risk of percutaneous injuries compared to open surgery (0.01 vs. 1% for Kjaegard et al. [40] in thoracic surgery). The fear of HIV transmission should not divert the surgeon’s attention from the higher risk of acquiring other fatal infections such as HBV and HCV. This is why precautions against blood-borne infection have to be universal.