Guidelines for Suspected CJD Cases in the Operating Room

Purpose: To provide guidelines for the management of suspected Creutzfeldt-Jakob Disease (CJD) biopsy cases.

Scope: OR staff, physicians, infection control, safety, pathology, pharmacy, environmental services, occupation health, sterile processing

Policy: Whenever possible, performing neurosurgical procedures on patients with suspected CJD should be avoided. All suspected CJD cases that are scheduled for brain biopsies will be managed according to the following guidelines, which are intended to reduce the risk of contamination of the surgical instruments and possible exposures to prion diseases.

Definitions: CJD is a prion-transmissible neurodegenerative disease with an incidence of one per million. In most cases, the cause of the disease is unknown. Sterilized instruments have been implicated in intracranial transplantation or inoculation with CJD. It is currently unknown if sterilization practices used at this time are effective against prions and, therefore, equipment having direct contact with brain tissue will require special handling to reduce the potential risk of transmission.

Materials: Disposable gowns, drapes, and personal protective equipment

Equipment: Minimized instrumentation, whenever possible; sodium hydroxide and sodium hypochlorite

Surgery scheduling: When the surgeon’s office calls to schedule a case for brain biopsy, the scheduler will inquire as to the etiology, i.e., tumor vs. rapidly progressive dementia, and identify patients with known, suspected or family history of CJD. The scheduler also will screen neurosurgical patients who have received human cadaveric growth hormones, pituitary gonadotropin, or intracranial dura mater grafts. If the diagnosis is unknown or suggestive of CJD, the scheduler will notify the clinical coordinator, book the case for the end of the day, and the following guidelines will be activated:

Preoperatively (OR case, room, and equipment prep):

• Notify all units potentially involved of possible CJD case – sterile processing, nursing units, environmental services, pharmacy, infection control, etc.

Remove all extraneous equipment from the room (as possible) and increase the distance from the operating field for items that cannot be relocated.

Do not carry the drug cassette into the OR suite. Obtain only the medications necessary for the case.

Cover all surfaces (including respiratory and anesthetic equipment) and OR table with impervious sheets, drapes, and/or Mayo covers.

Cover electrical cords with sterile sleeves/plastic.

Intraoperatively:

• Staff attire: Personnel will wear hats, impervious gowns, double gloves, masks, face shields, and knee-high impervious shoe covers.

Limit traffic in the suite.

Use manual saws, etc., and avoid the use of power tools (to decrease the risk of splattering) when possible. Minimize the number of instruments used, whenever feasible.

Avoid the use of instrumentation that requires ETO or cold sterilization, i.e., stealth. No flashing of instruments will be done.

Use no-touch technique when passing sharps or instruments, i.e., neutral basins.

Clean spills with sodium hydroxide, as they occur.

Specimens should be placed "fresh" (do not use formalin) in a container and labeled with biohazardous signage and noted as possible CJD agent. Pathology should be notified and appropriate requisitions should accompany the specimen for analysis. (The lab will use special containment procedures for transporting specimens outside the facility and will arrange for incineration of the specimen upon disposal.)

The biopsy/specimen should be of adequate size for examination (consult pathology for specifications) and once it has been obtained, the surgeon should change to new sterile gloves prior to completing the procedure.

The patient’s head may be cleansed with 1 Molar sodium hydroxide at the completion of the case, per physician order.

A resource nurse will be available outside the room during the case, and the infection control coordinator may be contacted as necessary.

Postoperatively:

• Instrument handling: Reusable instruments should be placed in an impervious container, red bagged and labeled as biohazard. These instruments should remain separate from other waste to facilitate handling after the biopsy is processed. (Contact infection control for removal.)

Body fluids/liquid waste: Waste should be collected, solidified, labeled, and bagged as biohazardous, and segregated from other red bag waste so that it can be incinerated. (Contact infection control for removal.)

Other disposable supplies: Surgical attire will be collected for possible later incineration. Contaminated trash, drapes, mayo covers, gowns, gloves, face shields, disposable sharps (such as blades and bits, which have been placed in a sharps container), etc. used for the suspected case should be placed in biohazardous waste containers. Infection Control should be notified for removal and incineration.*

All actions described above will be clearly documented in the patient’s OR records.

Standard precautions should be used in the post-op care of the patient’s wound.

Environmental cleaning:

• Decontaminate surfaces at end of procedure by continually wetting all exposed surfaces with 1 Molar sodium hydroxide for 60 minutes. Rinse thoroughly with water, then proceed with regular cleaning.

Environmental surfaces contaminated with visible tissue should be decontaminated with 1:10 dilution of 5.25% sodium hypochlorite, followed by routine cleansing with disinfectant.

Disposition:

• Infection control (IC) will sequester the instruments and waste from the suspected case until diagnostic reports are obtained and further disposal determinations can be made.

• In the event that IC is not available, the house supervisor will leave a message for IC, collect the above items, and sequester them in the IC office for appropriate disposal.

Exposures:

• Percutaneous exposure to blood, cerebrospinal fluid, or tissue (especially brain) of an infected person should be immediately followed by gently encouraging the site to bleed and irrigation of the wound with 0.5% sodium hypochlorite. Any skin contact with possibly infectious materials should be followed by washing with 1N sodium hydroxide. Any mucous membrane contact with possibly infectious materials should be followed by washing with soap and water. Reports and follow-ups will be in accordance with current policies for employee exposures and handled through the occupational health department.