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Ann Thorac Surg 1999;67:1203-1204
© 1999 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
Address reprint requests to Dr Frater, Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, 1575 Blondell Ave, Bronx, NY 10461
as originally published in 1989:
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In November 1984 a patient with staphylococcal tricuspid endocarditis with 3-cm vegetations, multiple lung abscesses, and a failure to respond to antibiotics was referred to us. The patient was a bisexual heroin addict, and an enterprising infectious diseases fellow sent a blood specimen to the New York City Health Department where the just-introduced antibody test for HIV was performed and revealed that our patient had the antibodies and was therefore carrying the virus. A departmental meeting was held, which included anesthesiologists, perfusionists, and nurses as well as the surgical staff. The available information was reviewed: the virus was known to be spread by sexual contact and by entry of an infected person’s blood into another person’s blood or tissues; it was apparently not spread by the gastrointestinal tract or by inhalation, but there was uncertainty about its presence in various bodily secretions. We decided that careful and disciplined technique should minimize the risk to the staff. It was clearly acknowledged that if one of us did acquire the infection there would be no useful treatment; the incubation period was not known. The discussion then shifted to whether there could be any circumstance that would allow someone not to participate in the operation. One of the residents, who had previously been quite willing to do valve operations on patients with endocarditis and a history of drug abuse, now registered the view that this patient’s moral depravity had lost him his right to treatment. Others asserted the historic obligation of all members of the healing profession to provide care without favor or prejudice. The issue was settled by the statement of a Physician Assistant who had been a Special Services Medic in Vietnam and was not favorably disposed to either homosexuality or illegal drug use. He said "Every day I was in Nam I took worse risks getting men of all kinds out of the battle than we are going to take tomorrow with [the patient]. Yes he is a jerk but he is also a human being and I say we go ahead."
By 1989 when the survey was done and the results were published, knowledge of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) had increased. Criteria for differentiation between the patients carrying the virus and those who had advanced to AIDS had been defined. AIDS, once established, was fatal, sometimes in months, but usually in less than 2 or 3 years. Azothioprine was available but did not seem to prolong life. However, by testing blood that had been saved from the hepatitis vaccine studies conducted on homosexual men in the 1970s, it was found that the conversion rate was slightly more than 50% in 10 years. This meant that HIV patients with at least an urgent indication for cardiac operation could not be denied the operation on the grounds of having another disease with a poorer prognosis. Conversely, there was some suggestion that patients who had progressed to AIDS, died too soon after operations with cardiopulmonary bypass to make open cardiac operations worthwhile. There were no data on the risk of acquiring HIV infection from blood containing hollow needle sticks, but there had been no known cases of HIV transmission by surgical needle or knife point injuries [1]. The councils of the major professional societies had all made pronouncements on the moral obligation to provide care, including surgery, to patients with HIV infection [2]. The generation that had grown up during the brief "pax antibiotica" that had started after World War II, was often unhappy about being expected to follow the same ethical rules that the physicians of previous generations had taken for granted.
Two important facts had become apparent by 1989: (1) the 2- to 3-month window of negativity of the test for HIV antibodies made testing an inappropriate indicator for determining risk to the staff [3], and (2) the infection clearly was not confined to male homosexuals and intravenous drug users. The conclusion was clear: precautions against infection of the staff needed to be used universally [4].
Now in 1999, as can be expected in any matter that involves human beings, some things have changed dramatically and some have changed not at all. The enormous amounts of money that have been spent on AIDS research (more dollars per death in the United States than for any other disease in history), have begun to yield very encouraging dividends. Among the advances are the ability to detect HIV activity in the blood directly rather than by the presence of antibodies [5]. The armamen-tarium has dramatically increased and improved with the development of protease inhibitors and reverse transcriptase inhibitors that interfere with HIV replication [6]. Singly or in combination with older drugs, these agents appear to have produced prolonged disappearances of the HIV from the blood and even increases in the CD4 lymphocyte count. The cost of these agents and the complexity of their administration are problems, but, clearly, the indications for surgery in HIV-positive patients will need to be modified as these developments continue. There is also evidence that the early use of these agents after exposure to the virus reduces the chance of infection [7], and it is now standard practice to prescribe a course of azothioprine and a protease inhibitor after a needle prick injury. There have also been changes in public health policy; for instance, New York State Public Health Law (PHL) Section 2782.4 (a) (1–4) permits physicians to notify the partner or spouse of a HIV-infected individual without the patient’s consent under certain circumstances.
A surprising difference in our practice is that the HIV-positive intravenous drug user with endocarditis has all but disappeared from our surgical schedules (for reasons that can only be described as speculative). Other good news is that progression to AIDS after cardiopulmonary bypass in HIV-positive patients has been looked for but not shown. Transmission of HIV by solid needle sticks has not been seen, and no surgeon has been shown to acquire infection from a surgical procedure. The adoption of universal precautions with proper training of personnel has reduced the incidence of percutaneous injuries [8].
The bad news is that surveys of surgeons’ attitudes (not confined to cardiothoracic surgeons) continue to show fear of the risk of HIV infection, poor knowledge of the actual risk, poor knowledge of the Centers for Disease Control and Prevention guidelines for universal precautions, incomplete compliance with the guidelines, and unwillingness of a few surgeons to do needed operations on HIV-positive patients [9]. Additional bad news is that, in high-risk areas such as the South Bronx, 5% of emergency room patients with no suspicion of HIV infection have positive test results.
Even if the risk of infection for surgeons is vanishingly small, there can be no excuse for not following the Centers for Disease Control and Prevention guidelines. The irony is that the risk to health care workers of acquiring hepatitis B or C virus and dying from the infection is enormously higher than for the much feared HIV, and this alone should be reason enough to establish universal precautions [10, 11]. It is hoped that continued educational efforts will eventually result in the general adoption of good standards in all operating rooms.
References
This article has been cited by other articles:
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  V. L. Mahan, J. M. Balaguer, A. T. Pezzella, T. J. V. Salm, and B. J. Mady Successful coronary artery bypass surgery in a patient with AIDS Ann. Thorac. Surg., November 1, 2000; 70(5): 1698 - 1699. [Abstract] [Full Text] [PDF]
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