You are supervising a registrar who suffers a needle stick injury during the insertion of a central line in a patient with a history of intravenous drug use.

Outline your approach to this problem. 

[Click here to toggle visibility of the answers]

College answer

Immediate Response: 

  • Stop the procedure 
  • Ensure patient is safe 
  • Takeover / delegate patient management as required

Further response: 

  • Wash the registrar’s wound immediately with soap and water
  • Express any blood from the wound
  • Initiate injury-reporting system used in the workplace
  • Patient may need to be consented and then tested for HIV, hepatitis B, Hepatitis C 
  • Refer registrar to designated treatment facility: Emergency Department / Infectious Disease
  • Physician / Immunology as per hospital protocol 
  • With consent, registrar to be tested immediately and confidentially for HIV, hepatitis B and C
  • Document the exposure in detail for your own record and for the employer 
  • If the patient is HIV positive, post exposure prophylaxis needs to be started within two hours of the exposure. 
  • For possible Hepatitis C exposure, no treatment is recommended but advice must be obtained from Infectious Disease Specialist 
  • If the source patient tests positive for HIV, hepatitis B, hepatitis C, get post-exposure prophylaxis in accordance with CDC guidelines and as per recommendations from Infectious Disease Specialist or another expert. 
  • Registrar to have follow up with post exposure testing 
  • Advise re: taking precautions (including safe sex) to prevent exposing others until follow up testing is complete. 
  • If exposed to blood borne pathogen, he/she should not donate blood for six months until cleared

Counselling: While definitive testing is essential, counsel the registrar that the risk factors for infection are: deep injury, visible blood on devices, and needle placement in a vein or artery, lower risk with solid suture needle. Related to procedure: Review of registrar’s technique, equipment used, unit policy for procedural training, assessment of competency, etc. 

Discussion

This question is identical to Question 5 from the first paper of 2015 and very similar to Question 25 from the first paper of 2007, except in 2007 this patient was not yet an IV drug user. The answer to these questions is reproduced here with minimal modification, reflecting the fact that the college examiners had also cut and pasted their model answer from the first paper of 2015.

Immediate management:

  • Abort the procedure
  • Ensure the patient is safe:
    • Take over the procedure and finish it yourself; or
    • Delegate the task to a competent staff member
  • Ask the registrar to express blood from the wound
  • Wash the punctured area with soap and water
  • Report the incident

Risk assessment:

  • Is the patient known to have Hpe B, C, or HIV?

The following are associated with an increased risk of transmission:

  • Hollow needle
  • Large needle diameter
  • Needle was previously in an artery or vein
  • Absence of gloves 
  • Depth of wound 
  • Into artery or vein
  • Exposed to a large volume of blood
  • High blood titre of HIV, Hep B or C

Management

  • Document the Hep B immunisation status of the staff member
  • Perform antibody tests of both the staff member and the patient, with written consent
  • If the source is known to be Hep B C or HIV positive,
    • Solicit advice from infectious diseases authorities
    • Arrange appropriate vaccinations, antiretroviral prophylaxis and councelling
    • Arrange follow-up for the patient and staff member
  • Possible management strategies:
    • For Hep B, IV immunoglobulin may be appropriate
    • For Hep C, there is nothing.
    • For HIV, postexposure antiretroviral therapy is helpful (and needs to be commenced within 2 hours!)
  • Safe sex for 6 months
  • Follow-up testing: 6 weeks and 6 months 
  • Review unit guidelines and compliance
  • Offer emotional support to the staff member, and get help from infectious diseases authorities to aid post-exposure councelling

References