18. Needlestick injury

Question 1

Needlestick injury

Answer 1

Needlestick injury can have huge implications for the individual involved, not only in terms of disease transmission and the effect it may have on employment but also because of the anxiety and psychological strain it can cause while waiting for test results. This question requires you to demonstrate knowledge of associated risk factors and
methods used to minimise them. It may explore your management of the event, which should focus on ensuring your safety and that of your patient, using local guidelines.

Question 2

You are suturing a central
venous line in a 36-year-old male
diagnosed with pancreatitis
when you inadvertently sustain a
needlestick injury. What immediate
action would you take?

Answer 2

> Call for help so that someone can relieve you and look after the patient.

> Encourage free bleeding of the wound.

> Immediately wash the wound with soap and water (do not scrub or suck).

> Follow local policy and inform occupational health to report the incident and to seek further advice (out of hours go to your A&E department).

> Establish whether you should start to take post-exposure prophylaxis

(PEP) to HIV by performing a risk assessment of the patient.

Question 3

How would you perform a ‘risk assessment’ of your patient?

Answer 3

A risk assessment aims to identify those individuals who are more likely to

be infected with
HIV,
hepatitis B (HBV) or
hepatitis C (HCV).

Transmission rates are
0.3% for HIV,
3% for HCV and

30% HBV.

Explain to the patient what has happened and that for your safety,
a formal risk assessment is very important.

Ensure that this is done in private to maintain confidentiality.

If the patient lacks capacity to give consent to testing, e.g. is sedated on ICU, then current GMC guidance counsels against testing until consent can be gained. This is a contentious area and local policy should be followed.

> History:
• HIV, HBV and HCV status

• Sexuality: homosexual intercourse or casual partners including prostitutes
• Use of intravenous drugs and needle sharing
• Tattoos
• Blood transfusions abroad or multiple blood transfusions
• History of jaundice
• Recent holiday or residency in a country with a high HIV incidence.

> Examination:
• Tattoos

• Needle track marks
• Lymphadenopathy.

> Investigations: Gain the patient’s consent to take blood for HIV, HBV and HCV testing (the patient must be given appropriate counselling prior
to this – follow your local hospital protocol on ‘donor’ counselling).

Question 4

What further steps would you

undertake?

Answer 4

> Have your blood taken shortly after the injury to confirm your current
status (follow-up blood tests will be required later).

> Commence PEP if patient deemed to be high risk. Ideally, this should be started within 1 hour of injury, and should consist of a triple-therapy

regime of
zidovudine,
lamivudine and
indinavir that is taken for 4 weeks.

Unfortunately, these agents can cause serious side effects such as jaundice, diabetes, vomiting and profound fatigue.

> Establish your hepatitis B status.
All healthcare professionals should
be vaccinated prior to starting work.

If you are a known responder, you
should be given a hepatitis B vaccine booster.
If you are susceptible, youshould be given an accelerated hepatitis B vaccination course along with
hepatitis B immunoglobulin.

There is currently no official treatment for
suspected or confirmed exposure to hepatitis C.

> Inform your clinical lead, as a suspected exposure to HIV, HBV or HCV may preclude you from performing certain exposure-prone procedures.

The Department of Health has stated airway manipulation using gloves is not an exposure-prone procedure.

> Seek counselling.
Complete a critical incident form.

Question 5

What are the major risk factors
associated with the transmission
of blood-borne viruses?

Answer 5

> Exposure to high-risk fluids:

• High-risk fluids: blood, amniotic, peritoneal, pleural, pericardial and cerebrospinal fluid, semen and vaginal secretions
• Low-risk fluids: faeces, urine,
saliva and vomit

> M echanism of injury

• Percutaneous injury (e.g. with needles)
• Exposure of broken skin (e.g. cuts)
• Exposure of mucous membrane (e.g. splash on the eye).

> Type of instrument: Hollow bore needles carry higher risk than solid needles.

> Patient: Blood or fluid from terminally ill patients or those with a high viral load is more contagious.

Question 6

What precautions can be taken

to reduce risk of infection?

Answer 6

> Universal precautions when performing any exposure-prone procedures:
gloves, mask and goggles.

> Avoid resheathing needles and use sharps bin to dispose of equipment promptly.

> Cover open skin lesions
(but ideally avoid patient contact).

> Avoid mouth-to-mouth ventilation.

> Use of HMEF filters on breathing circuits between patients.

> Hepatitis B vaccination of healthcare professionals.

> Exposure protection plan and management plan