Sharpless Techniques Protect Surgeons From Pathogens

Surgeons' risk of exposure to blood-borne pathogens may be even higher than previously estimated, but the use of sharpless surgical techniques can reduce that risk substantially, according to a study by researchers at Johns Hopkins University, Baltimore.

A tendency to be somewhat dismissive about these risks prevails among surgeons, "in part because we have a high sense of duty to treat the patient regardless of blood-borne pathogens and in part because there are few interventions available to minimize our risk," said Dr. Martin Makary of the department of surgery at the university.

Dr. Makary and his colleagues found that 38% of surgical candidates tested during the observation period at Johns Hopkins were positive for a blood-borne infection (Ann. Surg. 2005;241:803-7). They are developing a protocol to increase the use of sharpless techniques--such as laparoscopy, electrocautery instead of scalpel incisions, and skin clips or glue instead of sewing to close or repair incisions and wounds--as a means of decreasing occupational exposure to blood-borne pathogens.

Prior to their study, there had been few estimates of the prevalence of blood-borne pathogens in surgical candidates, said Dr. Makary. But earlier research has shown that injuries occur in 7% of operations and that 87% of surgeons have a percutaneous injury at some point in their career.

The Johns Hopkins researchers looked at 709 consecutive cases from July 2003 to June 2004, including elective procedures but excluding trauma and bedside procedures. A total of 373 patients were tested for blood-borne pathogens, partly on the basis of their risk profile (for example, whether they acknowledged intravenous drug use). Of those patients, 26% had HIV, 4% had hepatitis B, 35% had hepatitis C, and 17% had coinfection with HIV and hepatitis C.

Almost half of the procedures were performed on men (334 out of the total 709), and 61% were on African Americans. Of all the patients, 11% had a history of intravenous drug use. The mean age of the patients was 51. HIV and hepatitis C were most prevalent in the 41- to 50-year-old age group. Infections were rare in patients under age 20 and over age 80.

Pathogens were found most commonly in soft tissue abscess procedures (71%) and lymph node biopsies (67%). Ironically, these procedures are most often performed by inexperienced surgeons-in-training, who have the least education on avoiding occupational exposure, according to the authors. With the finding that up to 40% of surgical candidates in an academic urban hospital may be infected with a blood-borne pathogen, the Johns Hopkins study "shows a significant risk for surgeons operating in an urban university setting that is greater than previously reported," wrote the authors.

The occupational exposure is expected to grow, partly because the number of Americans living with HIV continues to rise. But other infections may also be a threat. For instance, it is thought that 2% of Americans are infected with hepatitis C, but most have no signs or symptoms.

Dr. Makary and his colleagues suggested that hospitals test all patients with a history of intravenous drug use for HIV and hepatitis. And, since some procedures were shown to present a greater exposure risk, more effort could be put into reducing the danger in those particular operations, said the authors. At Johns Hopkins, that has meant using sharpless tools and techniques whenever possible.

"We know that using conventional techniques, surgeons get stuck about 1.8% of the time," said Dr. Makary in an interview. "With sharpless techniques, we completely eliminate the possibility of a needle stick." About 20% of all general surgery at the university is performed with sharpless techniques, he added.

In a comment accompanying the study, Dr. Martin A. Croce professor of surgery and chief of the division of trauma and critical care at the University of Tennessee, Memphis, said he thought the higher incidence rates might be due to patient selection, since half of the patients who were operated on were tested. But he also said, "The important message of this study is that blood-borne pathogens are everywhere."

Several other physicians who discussed the study in the comment commended Dr. Makary and his colleagues for quantifying the problem and agreed that sharpless techniques would likely help reduce exposure. But they also called on surgeons, nurses, and other health care professionals to make greater use of universal precautions.