Safety Concerns Of The Autopsy Service

GENERAL PRECAUTIONS Autopsy rooms should be clean, spacious, properly ventilated (3) and well lit. Safety-oriented design of the autopsy undoubtedly is part of the general precautions. For example, the level of the autopsy tables should be adjustable to the height of the prosector. It is preferred to have dissecting tables separate from the autopsy table. The autopsy laboratory also should have a safety-oriented design. These and other features are illustrated in Figs. 16-2 and 16-3. Morgue and other laboratory personnel at risk should receive annual instructions in infection precautions and receive appropriate immunizations and tests for the agents handled or potentially present in the autopsy area (e.g., hepatitis B vaccine and skin testing to detect tuberculosis).

Access to the Autopsy Area The morgue area and all adjacent laboratories and storage facilities should be locked at all times so that only authorized persons can enter—for example, with a card key. Other persons would have to ring and use an intercom to gain access. Most important, the morgue area should be off limits for all persons who have not donned proper protective gear (see above, "Maintenance of Autopsy Facilities"). Appropriate warning signs should be posted. Also, in the autopsy laboratory, warning signs should be posted for toxic hazards such as formalin fumes.

Protective Garments Although the chance of nontrau-matic infection is minimal, any contact between skin and body fluids should be avoided as much as possible. Therefore, appropriate gear should be donned for all autopsies. Caps or hoods are part of these garments; they should completely cover the hair. Disposable space suits and forearm guards should be worn and discarded after each high-risk autopsy. Waterproof disposable plastic aprons and disposable water-impermeable shoe covers are needed also.

Face Protection Plastic face shields covering the entire face and neck region should be worn. Alternatively, surgical masks can be used with safety goggles that have a cushion that seals the skin around the eyes. During autopsies of patients with tuberculosis or other highly infectious conditions, morgue

Fig. 16-3. The autopsy laboratory. Upper, Working space with manometers and other equipment for vascular injections and related procedures. Note organ perfusion apparatus in the background (also shown in Fig. 4-4). Lower, Shelves for plastic containers with specimens in formalin solution.

personnel now carry powered-air purifying respirators or HePa respirators (the latter must be individually fitted and training for using this equipment must be provided). Face protection is particularly important when aerolization hazards are great as during the opening of the cranial vault. For additional protection, this latter procedure should be performed with the saw inside a plastic bag as discussed in Chapter 6.

Gloves Powdered or powder-free latex gloves are most commonly used. During the actual autopsy, double gloves (one on top of the other) should be used. The inner glove may be a surgical glove and the outer, a heavy rubber autopsy glove. Steel-mesh cloves may provide the most effective protection, particularly in high-risk autopsy cases. Unfortunately, they greatly reduce the "feel" that is needed to dissect properly and to evaluate the texture of organs and lesions. If a rubber or latex glove gets torn, it should be replaced immediately. If both gloves are torn, the hand should be washed and inspected carefully in order to detect wounds, particularly puncture wounds (see below). Disposable gloves, once removed, should not be reused.

Instruments Proper care of autopsy instruments reduces the risk of accidents. Knives and saw blades should be kept sharp (blunt knives require undue force during cutting and thus are more prone to slip). In our opinion, scalpels should only be used if absolutely necessary. Cleaning should be done after each autopsy session; the methods are described above. See also Chapter 8 under "Autopsy Saws."

Only needle-locking syringes or disposable syringe-needle units should be used for aspiration of body fluids and infectious material. Used disposable needles must not in any way be manipulated by hand but placed in a nearby puncture-resistant container used for "sharps" disposal. Nondisposable sharps must be placed in a plastic or metal container for transport to the decontamination process, generally autoclaving.

Protection From Toxic Fumes In the autopsy laboratories, this involves primarily formalin fumes. Their concentration in the air must be monitored intermittently, as described earlier under "The Institutional Tissue Registry."

Protection From Irradiation The risk most commonly comes from exposure to radioactive isotopes. This is discussed in detail in Chapter 13.

Shipping This is discussed in Chapter 14. Tissues and body fluids should be placed in containers that will not leak during collection, handling, processing, storage, transport, and shipping.

Injuries Each autopsy facility should have clearly posted or otherwise accessible outlines of the procedures that must be followed after an injury has occurred. Most injuries involve the hands. In these cases, remove gloves immediately, allow wound to bleed while flushing it for several minutes under running water. Some authors (4) suggest to treat injuries immediately with iodine or phenol-containing preparations, O.5 M NaOH or 1:3000 potassium permanganate. If potentially contaminated material made contact with the eye, it should be flushed immediately, preferably under a properly installed eye flush device. Flushing should be continued for 15 min. In most instances of injury, persons are sent to the Employee Health Service for further advice, observation (e.g., repeated testing for HIV), or treatment. Also, a detailed Employee Incident—Injury/Illness Investigation Report is filed (in triplicate) in each case because all accidents of this type must be documented in permanent records. Workmen's compensation and other proceedings may rely on such records.

POLICIES FOR HIGH-RISK AUTOPSIES Of course, all autopsies are potentially high-risk procedures and thus, the work routine in the autopsy room should provide reasonable protection, whether or not a special risk had been identified. Nevertheless, careful review of the clinical charts may reveal warning signs that a patient might have had a disease in the high-risk category, such as tuberculosis, the acquired immunodeficiency syndrome, or Creutzfeldt-Jakob disease. (See also under these entries in Part II.) Although most of these condi tions do not appear to be very contagious (5,6), needle-stick injuries and comparable trauma (7) or other forms of exposure (8,9) can lead to clinically manifest infections or even fatalities. Risks and safety precautions have been discussed in numerous publications, particularly for HIV (6,7,10-14), tuberculosis (5,8,9,15), and Creutzfeldt-Jakob disease (4,14,16). However, hepatitis viruses and bacteria causing septicemia, meningitis, or gastrointestinal diseases also may fall into this category (17).

We recommend in these cases to limit the number of persons in the autopsy room to: 1) the prosector, 2) a technician who assists the prosector on the autopsy table, and 3) a "clean" assistant who completes paper work and all other assignments that do not require contact with body fluids, tissues, instruments, or other potentially contaminated surfaces. It is important that the prosector and the assistant work apart so that they cannot injure each other. Proper face protection, gloves, and garments, cleaning procedures, and waste disposal are discussed above.

Blood Pressure Health

Blood Pressure Health

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