Control of infection issues

Many physicians, nurses, and other health care workers in the ICU are anxious about caring for HIV-infected patients, given the irreversible nature of AIDS and the fact that most patients with HIV infection, whether or not they know their status, are asymptomatic.

The risk to ICU staff of nosocomial transmission of HIV from a patient is very low but must not be ignored. HIV has been found in saliva, sputum, bronchial aspirate, and urine as well as in blood. Given the difficulties in accurately and rapidly identifying HIV-infected and at-risk patients, it is appropriate to have universal precautions for all staff in the ICU (Tabled (Layon,MM 1991; Miller.etal 1993).

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Table 3 Universal precautions in the care of HIV-infected and at-risk patients in the ICU

All physicians, nurses, and other health care workers must be educated about the modes of transmission, prevention, natural history, and epidemiology of HIV infection.

There is a need for routine use of barrier precautions when interacting with any patient in the ICU. Any health care worker, including doctors, nurses, physiotherapists, and health care assistants, with exudative skin lesions or 'weeping' dermatitis should not perform care duties in the ICU. Simple cuts and abrasions should be covered with a waterproof plaster or dressing. Latex gloves and a single-use disposable plastic apron should be worn to protect against accidental spillage when handling body fluids such as blood, feces, urine, or drain fluid. Clearly, wearing gloves does not reduce the risk of a needlestick or sharps injury, but it does dramatically reduce the risk of a splash exposure.

Additional precautions are necessary if suctioning is performed via an endobacterial tube or tracheostomy, or if chest physiotherapy is carried out. Even with rigorous attention to technique and the use of 'soft' suction catheters at low pressure, suctioning may cause bronchial secretions to become tinged with blood. Both suctioning and physiotherapy cause bronchial secretions to be aerosolized, and so health care workers performing these activities should wear a disposable face mask of the type used by surgeons and eye protection such as goggles or a visor, in addition to basic barrier precautions, in order to prevent the aerosol droplets from coming into contact with mucosal surfaces.

Health care workers performing invasive procedures, such as cardiac catheterization, transfemoral intra-aortic balloon insertion, vaginal or Cesarean section delivery, or endoscopy (including bronchoscopy), should wear a non-absorbing gown in addition to taking the precautions discussed above ( Tab|e,3).

If the skin or mucosal surfaces are accidentally contaminated by splash, the area should be washed with water immediately. If a needlestick or sharps injury is sustained, the area should first be washed with water and then rigorously manipulated in order to provoke local bleeding. After the accident the infection status (HIV and hepatitis B/C) of the patient can be explored. The event should also be reported in confidence to the hospital risk management team and/or occupational health department. The United States Centers for Disease Control and Prevention (CDC) has recently demonstrated that there is benefit from zidovudine if it is given to health care workers immediately following needlestick or splash exposure; many centers continue to offer immediate postexposure 'prophylaxis' with zidovudine (with or without didioxyinosine).

Infection control policies will vary from hospital to hospital, although certain basic principles apply. Patients with suspected or proven M. tuberculosis infection should be managed in cubicles, preferably with negative-pressure facilities, in respiratory isolation. As airborne pathogens such as M. tuberculosis may be exhaled from the ventilator in mechanically ventilated patients and may disseminate within the ICU environment, it is recommended that a filter be placed in the exhalation limb of the ventilator tubing. To reduce the risks of aerosolization of infectious airborne droplets further, closed-circuit suction systems should be used for performing endotracheal physiotherapy. Non-disposable equipment should be cleaned after use using local infection control policies.

An indwelling arterial cannula, while providing on-line information such as pressure and oxygenation, avoids the need for repeated arterial punctures (and the attendant risk of needlestick injury). After use, all needles and syringes should be disposed of in a rigid-walled puncture-resistant container and not discarded by the bedside or placed in clinical waste bags. Needles should never be bent, broken, or resheathed after used.

Although the HIV status of a patient may be known, admission to the ICU may be the first occasion that this diagnosis is made known to his or her partner and family. Identifying samples for laboratory analysis or requests for imaging investigations as 'high risk' or 'HIV/AIDS', although necessary for safe practice, provides an opportunity for a potential breach of confidentiality. Patients infected with HIV have the same rights to confidentiality as any human being, regardless of their ethnicity, color, religion, sexuality, or financial status ( Layonefal 1991).

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