Hepatitis B and Hepatitis C: Occupational Considerations 357 for the Anesthesiologist Stephen H. Jackson and Eddie C. Cheung

Transcription

1 INFECTIOUS DISEASE AND BIOTERRORISM Foreword Lee A. Fleisher xi Preface Samuel C. Hughes and James D. Marks xiii Hepatitis B and Hepatitis C: Occupational Considerations 357 for the Anesthesiologist Stephen H. Jackson and Eddie C. Cheung Anesthesiologists routinely are exposed to occupational hazards, such as hepatitis B and C, which are potentially lethal. The development of a vaccine has virtually eliminated the hazard for hepatitis B, if the anesthesiologist undergoes a successful vaccination series. There is no vaccine for hepatitis C, which ultimately leads to liver failure and hepatocellular carcinoma. The most likely transmission source to anesthesiologists is their accidental exposure to the blood of patients infected with hepatitis C (2% of the US population). Early diagnosis and pharmacologic treatment of hepatitis B and C can significantly diminish or even cure these diseases. HIV and Anesthesia 379 Samuel C. Hughes Human immunodeficiency virus [HIV disease or acquired immunodeficiency syndrome (AIDS)] is the greatest health crisis of the twentieth and early twenty-first century. In sub-saharan Africa, the epidemic rivals the Black Death of fourteenth-century Europe. AIDS is a multiorgan disease that has broad implications for anesthesiologists. New drug therapies are highly effective in most cases and have significant potential for drug interactions. The purpose of this article is to help anesthesiologists better manage persons who have HIV/AIDS in the operating room, labor and delivery suite, and other areas in which this patient population will require an increasing amount of care. VOLUME 22 NUMBER 3 SEPTEMBER 2004 v

2 Methicillin-Resistant Staphylococcus aureus Infections in 405 ICU Patients Ramachandra R. Sista, Gina Oda, and Juliana Barr The incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in patients admitted to the intensive care unit has dramatically increased in recent years, with an associated increase in morbidity and mortality and the costs of caring for patients with MRSA infections. Although indiscriminate and inappropriate use of antibiotics has contributed to this phenomenon, horizontal transmission of MRSA between patients and health care providers is the principal cause of this observed increase. This article discusses the pathogenesis, epidemiology, treatment, and prevention of MRSA infections in critically ill patients. Severe Acute Respiratory Syndrome and Tuberculosis 437 Robin A. Stackhouse Respiratory infectious diseases such as severe acute respiratory syndrome and tuberculosis create unique risks for anyone who may be exposed. A brief history of each disease is discussed in this article. The pathogenesis, manifestations, and therapy (where applicable) are also addressed. Recommendations for limiting secondary transmission are given based on the Centers for Disease Control and Prevention guidelines on infection control in health care facilities. Hand Washing and Hand Disinfection: More Than Your 457 Mother Taught You Jonathan D. Katz Hand washing is considered the single most important intervention for prevention of nosocomial infections in patients and health care workers. Unfortunately, compliance with standard protocols for hand hygiene in the health care environment, and especially within intensive care areas such as operating rooms and post-anesthesia care units, has been generally poor. In this article, we consider the current standards for hand hygiene as they pertain to the practice of anesthesiology. We discuss the consequences of poor compliance with hand washing practices for patient and health care provider safety. And we describe modern innovations in hand washing procedures and products that improve the opportunities for anesthesiologists to employ safe hand hygiene. Perioperative Antibiotics and Practice: Little Things That 473 Make a Big Difference Mark T. Keegan and Daniel R. Brown Perioperative antibiotic administration and anesthetic practice have major impacts on infectious complications. Anesthesiologists need to place high importance on perioperative antibiotic administration vi

3 to allow patients to receive optimal benefit from this therapy and to minimize risk. Many aspects of perioperative care ranging from thermoregulation to glycemic control may have profound longterm affects on infection rate and thereby patient outcome. This article provides an overview of aspects of anesthetic practice that affect infectious disease and patient outcome. Needle Stick and Other Safety Issues 493 Arnold J. Berry Percutaneous injuries such as accidental needle sticks are associated with the greatest risk for occupational transmission of blood-borne pathogens such as hepatitis B and C viruses and HIV. This article presents data on the risk of transmission of these viruses after needle sticks, offers strategies for prevention of injuries from sharp objects, and discusses postexposure prophylaxis recommendations. Medical Aspects of Biologic Toxins 509 James D. Marks Biologic toxins are molecules produced by living organisms that are poisonous to other species, such as humans. Some biologic toxins are so potent and relatively easy to produce that they have been classified as biothreat agents. These include the botulinum neurotoxins, ricin, staphylococcal enterotoxin B, and Clostridium perfringens epsilon toxin. This article focuses on these four biothreat toxins and their medical aspects. The majority of the article is spent on the botulinum neurotoxins, because these are the most poisonous substances known and are the only toxins classified as Category A threat agents the highest level of threat agent. The remainder of the article is devoted to sections on the other three biothreat toxins: ricin, staphylococcal enterotoxin B, and C perfringens epsilon toxin. Anthrax 533 Alicia Gruber Kalamas Anthrax is an often fatal bacterial infection that occurs when Bacillus anthracis endospores enter the body through one of three major routes: inhalational, cutaneous, or gastrointestinal. Before the anthrax terrorist attacks in the United States in 2001, there was very little interest in anthrax as a serious human pathogen; anthrax was viewed mainly as a veterinarian problem of minor importance, with most cases attributed to occupational exposure. However, this cavalier attitude toward anthrax changed following the 2001 terrorist attacks. Although the number of cases was relatively small, the attacks have heightened concern about the feasibility of large-scale aerosol bioweapons attacks by terrorist groups. Many, if not most patients, would require some degree of critical care in the form of ventilator or hemodynamic support. It is for this reason that anesthesiologists and other critical care physicians have specific knowledge of the diagnosis, treatment, and prevention of anthrax. vii

4 Smallpox in the 21st Century 541 Helene Lupatkin, Joel F. Lupatkin, and Andrew D. Rosenberg The viral disease, smallpox, was well known through the end of the 20th Century. Because it has been eradicated from natural populations, the present clinical experience with managing the disease is limited. Similarly, research in the pathophysiology, treatment, and prevention of the disease has recently become a priority. Concerns regarding smallpox as a weapon of bioterrorism have led to the implementation of a new prophylactic vaccine program, a renewal in variola vaccine research, and treatment regimens against variola infection. Bioterrorism and Children: Unique Concerns with 563 Infection Control and Vaccination Kay B. Leissner, Robert S. Holzman, and Mary Ellen McCann Treatment of child victims of a bioterrorism attack is complicated because they may be more vulnerable to the agents used and may suffer more complications from the treatment strategies. Isolation and other infection control measures can be psychologically harmful to young children and may require that they undergo sedation. Most of the recommended antibiotics and antiviral treatments for bioterror agents have not been approved for use in children, and children undergoing smallpox vaccination have a higher incidence of complications than adults. Pediatric anesthesiologists should expect to be part of the pediatric care team and must be careful to observe infection control procedures to limit the spread of disease caused by bioterror attack. Cholinergic Symptoms Due to Nerve Agent Attack: A Strategy 579 for Management William P. Schecter This article provides a brief history of nerve agent development and use and discusses the pharmacology, symptoms, signs, and treatment of nerve agent exposure. In addition, this article discusses the challenges of mass-casualty triage, decontamination, resuscitation, and intensive care. A Therapeutic Strategy Against the Shared Virulence Mechanism 591 Utilized by Both Yersinia pestis and Pseudomonas aeruginosa Teiji Sawa and Jeanine P. Wiener-Kronish Yersinia pestis, which causes pneumonic plague in healthy individuals, has the potential to be used for biologic warfare. Pseudomonas aeruginosis is an opportunistic pathogen that causes severe pneumonia in immunocompromised patients. There is viii

5 evidence that these two pathogens use a highly homologous virulence mechanism, the type III secretion system. The type III secretion systems of both Yersinia and P. aeruginosa possess a protein named V-antigen which can be used as a target for immunotherapy against bioterrorism and opportunistic infections. This article summarizes the recent progress of V-antigen studies in Yersinia and P. aeruginosa. Index 607 ix