Perioperative Care of the Patient with Tuberculosis

Article Outline

• ABSTRACT
• History of TB
• Epidemiology of TB
• Pathophysiology of TB
• The Usual Course of TB
  • Transmission
  • Latency
  • Progression from latent TB infection to active TB
• Risk factors
• Symptoms of TB
• Methods of Testing for TB
• Multidrug-Resistant Pulmonary TB
• Extensively drug-resistant TB
• Treatment
  • Latent TB
  • Active TB
  • Drug-resistant TB
• Directly Observed Treatment
• Surgical Management of TB
• Nursing Care of Patients with TB Who Are Undergoing Surgery
  • Preoperative care
  • Intraoperative care
    • Scheduling procedures
    • Transmission of organisms
  • Problems specific to patients with TB
  • Postoperative care
• Suggestions for practice
• Examination
  • Perioperative Care of the Patient with Tuberculosis
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Perioperative Care of the Patient with Tuberculosis
• Learner Evaluation
  • Perioperative Care of the Patient with Tuberculosis
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

APPROXIMATELY 1.7 BILLION PEOPLE are thought to be infected with Mycobacterium tuberculosis. The estimated mortality rate is 3 million people per year.

MULTIDRUG RESISTANT-TUBERCULOSIS (MDR-TB) and extensively drug-resistant TB (XDR-TB) are serious problems that threaten global TB control. Patients who are inadequately treated remain chronic carriers and can spread the disease to family members and their communities.

TREATMENT RECOMMENDATIONS for TB include directly observed treatment and monitoring the patient's response to medications. Perioperative nurses must protect the patient and other health care workers when a patient with TB undergoes a surgical procedure. AORN J 88 (December 2008) 942–958. © AORN, Inc, 2008.

Approximately 1.7 billion people—nearly one-third of the world's population—are thought to be infected with Mycobacterium tuberculosis, which has an estimated mortality rate of 3 million people per year.¹ This represents more than a quarter of the world's preventable deaths.² Tuberculosis (TB) is the leading infectious disease cause of death, killing more people in the world every year than AIDS, malaria, and other tropical diseases combined.² It is the most common opportunistic infection associated with HIV.³

Drug-resistant TB is a very serious problem and a threat to global TB control.⁴ Patients who are inadequately treated remain chronic carriers and can spread the disease to their families and communities.³ People with tuberculosis, including those with multidrug resistant-TB (MDR-TB), may need surgery. Perioperative nurses must confidently apply the nursing process throughout the patient's perioperative experience to ensure the best possible outcome.

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History of TB 

Tuberculosis has been prevalent in humans since ancient times. Egyptian mummies from 2400 BC show signs of tubercular decay.⁵ In Greek literature, Hippocrates identified “phthisis,” a disease of wasting away, as the most widespread disease of the times and noted that it was almost always fatal.⁵ He warned his colleagues against visiting patients in late stages of the disease, because their inevitable deaths might damage the reputations of the attending physicians.

In the 17th century, descriptions of the disease began to appear. In his work Opera Medica in 1679, Sylvius identified encapsulated bacilli (ie, tubercles) as a consistent and characteristic change in the lungs and other areas.⁵ He also described the progression of tubercles to abscesses and cavities.⁵ The Italian medical literature of the 17th century referred to TB as an infectious disease and warned that, “henceforth, human health should no longer be endangered by objects remaining after the death of a consumptive. The names of the deceased should be reported to the authorities, and measures undertaken for disinfection.”⁵

In 1720, the English physician Benjamin Marten wrote in his book A New Theory of Consumption that TB could be caused by “wonderfully minute living creatures, which once they had gained a foothold in the body, could generate the lesions and symptoms of the disease.”⁵ He also said that by,

lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, a consumption may be caught by a sound person.… I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease.⁵

Koch identified Mycobacterium tuberculosis in 1882.⁶ With the discovery of x-rays by Roentgen in 1895, radiographic diagnosis of TB became possible.⁶

Treatment in the 1800s consisted of antiphlogistics (an older term for agents that reduce inflammation) and counter-irritant therapies (eg, emetics, cathartics, dietary manipulation).⁶ From the mid to late 1800s to the 1960s, patients were moved to sanitariums for TB treatment.⁷ The first sanitarium opened in Germany in 1850, and the trend quickly caught on worldwide in developed countries.⁶ The concept was that good nutrition, rest, and fresh air would aid in the treatment of TB, while keeping the patient isolated from the general population. Despite this, TB was fatal 60% of the time.⁶

In the 1900s, pneumothorax and thoracoplasty were thought to be useful for collapsing diseased areas of the lungs.⁶ Streptomycin was discovered in 1946 and isoniazid in 1953. The two medications were combined for an 18-month treatment in the 1950s. Use of prazinamide, discovered in 1954, and rifampin, discovered in 1963, has decreased therapy time to six months.⁵, ⁷

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Epidemiology of TB 

Tuberculosis is twice as common in men and four times more common in non-Caucasian people.⁴ The highest incidence occurs in people living in crowded, poorly ventilated, and unsanitary conditions (eg, prisons, tenement houses, homeless shelters).⁴ Those who have been in close contract with or who have had TB before as well as those who have had multiple sex partners are at higher risk.⁴

The typical patient with TB is a single, non-white male. In the United States, the highest incidence is in black and Hispanic males between the ages of 25 and 44, with Hispanic people being the largest, single ethnic group affected. The states with the highest rates are California, Florida, Illinois, New York, and Texas. These states reported more than 500 cases each in 2007.⁸ In addition, these states accounted for more than half of all TB cases in the United States.

Foreign-born people and racial and ethnic minorities bear a disproportionate burden of TB in the United States (ie, 9.7% higher than for white people born in the United States). The highest percentage of foreign-born people who have reported TB in the United States are from Mexico, the Philippines, Vietnam, India, China, Haiti, and Guatemala.⁷ Recent immigrants from Africa, Asia, the Caribbean, Mexico, and South and Central America should be screened carefully.

Tuberculosis was on the decline in the United States until the early 1980s when the incidence of HIV began to increase.⁹ After the resurgence of TB in the United States from 1985 to 1992, the annual TB rate has declined, but the decrease has now slowed.⁸ In 2007, 13,293 cases of TB were reported in the United States,⁸ which was a 4.2% decrease from 2006.

In the early 1990s in New York City, New York, and Miami, Florida, a number of multidrug-resistant strains of TB were noted that mainly affected people with HIV.⁹ Multidrug-resistant TB accounts for only 1.1% of all cases, and only a few cases of extensively drug-resistant (XDR)-TB have been reported.⁸ In 2007, the World Health Organization reported the highest rate of multidrug-resistance in history, and XDR-TB is now being reported in 45 countries.⁸ Currently 98% of deaths from TB occur in developing countries. In sub-Saharan Africa, the incidence of TB has not declined to pre-HIV levels, and HIV continues to be a risk factor for TB and especially MDR-TB.⁹

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Pathophysiology of TB 

The term tuberculosis describes a broad range of clinical symptoms caused by Mycobacterium tuberculosis and several other organisms, including

These are collectively known as the Mycobacterium tuberculosis complex.⁷

Tuberculosis is an infection characterized by infiltrates (ie, air spacing filled with fluid, exudates, or red blood cells) and granulomas (ie, masses of inflamed granulation tissue) that can be seen as visual changes on a chest x-ray. In addition, caseation, consolidation, fibrosis, and cavitation occur.¹⁰ Caseation is a form of coagulation necrosis where tissue changes into a dry, cheese-like substance. Consolidation is a condition in which normally aerated lung tissue becomes a dense mass. Fibrosis is the formation of fibrotic tissue, and cavitation is the formation of cavities in the lung.

Although 15% of TB is extrapulmonary because Mycobacterium tuberculosis may affect any organ, pulmonary TB is the most common and communicable form.⁴ In the lung, the organism is taken up by alveolar macrophages and carried to lymph nodes, from which it may spread to multiple organs. Two to eight weeks after infection, cell-mediated immunity (ie, T-cell formation) and hypersensitivity develop. This causes the characteristic reaction to the Mantoux tuberculin test (ie, a skin hypersensitivity test). In people with intact immune systems, the infection usually is contained,¹⁰ but in people with compromised immune systems, inflammatory immune responses eventually may result in lung damage as tubercles form.²

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The Usual Course of TB 

The development of TB involves three phases. These are

Transmission 

Transmission of TB occurs primarily via an airborne route but also can occur via absorption through the gastrointestinal (GI) tract.² Typically, transmission occurs when one person coughs or sneezes aerosolized droplets containing infectious organisms that can remain suspended in the air for several hours and that then are inhaled by another person. Contact with an infected person, therefore, is not necessary.² Infection occurs if inhalation of these droplets results in the organism reaching the alveoli of the lungs. The likelihood that a person will become infected depends on the concentrations of the infectious droplet nuclei as well as the duration of exposure.⁷

Latency 

In the natural course of TB, most infected people never become ill. Only about 2% of infected people develop active TB within one year of exposure,⁴ and only 5% become ill during the first two years after infection. Another 5% become ill over the course of a lifetime. For most, the bacteria are dormant and become activated when the person is older or becomes immunocompromised.

Progression from latent TB infection to active TB 

The infection may stay dormant for years.⁴ In most cases, the infection is asymptomatic, and the only evidence of the infection is a positive tuberculin test.¹ When the bacilli lodge in the alveoli,⁴ the immune system responds by sending leukocytes, lymphocytes, and macrophages to surround the bacteria. Local lymph nodes become inflamed.⁴ A cell-mediated immune response occurs in four to six weeks. At some point, tubercles rupture from the T-cell response, causing granulomas. At this point, the patient will test positive for TB.

Infection contaminates the surrounding tissue. In addition, the infection may spread through the blood stream and lymphatic tissue to distant sites, in a process known as hematogenous dissemination. The same phagocytic cycle occurs when bacteria spread to other sites such as the pleura, meninges, joints, lymph nodes, peritoneum, and GI tract. Pulmonary TB can cause massive pulmonary damage as inflammation and tissue necrosis occur, leading to respiratory failure. Bronchopleural fistulas can cause a pneumothorax. These fistulas also cause hemorrhage, pleural effusion, and pneumonia. Without treatment, TB has a 50% mortality rate.⁷

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Risk factors 

The most significant risk factor for progression from latent TB infection to active TB is HIV. In people with HIV, 40% develop TB with the initial exposure, and the risk of the dormant disease becoming full-blown TB is 50%.⁴ The Centers for Disease Control and Prevention (CDC) recommends routine TB screening for people with HIV.⁸ Other people who are at a higher risk of developing active TB are those who have or have had

People who are IV drug or alcohol abusers also are at higher risk,⁴ as are older adults and people who are malnourished, are immunosuppressed, or have chronic lung disease (Table 1).¹¹

Table 1. Conditions that Create a Higher Risk for Developing Tuberculosis

1 Esmond G, ed. Respiratory Nursing. Edinburgh, New York: Baillière Tindall; 2001:271.

2 Sheldon LK. Oxygenation. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2008:401.

3 Corbett L, Raviglione M. Historical perspectives. In: Cole ST, Eisenach KD, McMurray DN, Jacobs WR, eds. Tuberculosis and the Tubercle Bacillus. Washington, DC: ASM Press; 2005:3.

4 Springhouse. Respiratory Care Made Incredibly Easy! Philadelphia, PA: Lippincott Williams & Wilkins; 2005:344.

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Symptoms of TB 

People with TB often present with vague symptoms such as fatigue, anorexia, and weight loss. A cough, fever, and night sweats are also symptoms. In later stages, chest pain and hemoptysis are present. When a person starts coughing up blood, he or she often is driven to seek medical attention, but by then, caseation, consolidation, fibrosis, and cavitation usually are present. Health care providers note

Weight loss often is present in advanced stages.¹

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Methods of Testing for TB 

Tests are needed to distinguish TB from lung cancer; lung abscess; pneumoconiosis (ie, black lung disease); and bronchiectasis. Chest radiography, the gold standard, often reveals nodular lesions, patchy infiltrates mainly in the upper lobe, cavity formation, scar tissue, and calcium deposits.¹⁰

The Mantoux tuberculin skin test is the standard method of determining whether a person is infected with Mycobacterium tuberculosis.¹² Reliable administration and reading of this test, however, is imperative.¹² The test is performed by injecting 0.1 mL of tuberculin purified protein derivative (PPD) intradermally into the inner surface of the forearm. The test should be read between 48 and 72 hours after administration. If it is not read professionally in that period, a repeat test must be performed.

A positive tuberculin test reveals exposure but not necessarily active disease. A positive test is one in which there is an induration of more than 10 mm in people without immune deficiency and more than 5 mm in immunocompromised patients or those who have known exposure to people with TB.¹⁰, ¹² In addition, patients would be considered positive with an induration of 5 mm or more if they

A person who has been exposed to TB will show a positive reaction two to 10 weeks after exposure. Other tests for TB include cultures and stains of

These tests will reveal heat-sensitive, nonmotile, aerobic, acid-fast bacilli. Computed tomography (CT) scans and magnetic resonance imaging (MRI) reveal lung damage or confirm a diagnosis.¹⁰ False positives can occur with infections of nontubercular mycobacteria.⁹ Bronchoscopy is performed if a more accurate sputum specimen is needed or the patient cannot produce an adequate sputum sample.⁴ This usually involves bronchoalveolar and transbronchial lung biopsy or needle aspirations and biopsy of lesions.⁹

In some countries, vaccination against TB is practiced routinely. The Bacille Calmette-Guérin (BCG) vaccine is a live, attenuated strain derived from Mycobacterium bovis, which was introduced in 1922. The true efficacy of BCG, however, is unknown. Early clinical trials in Europe indicated that people who were vaccinated had up to 80% protection, but more recent trials in India and Africa showed the vaccine had little value.² People who have received the BCG vaccine may have a reaction to a Mantoux tuberculin test.

The QuantiFERON®-TB Gold test is a whole blood test that can be used as an aid in diagnosing Mycobacterium tuberculosis infection, including latent TB.¹⁴ Blood samples are mixed with an antigen and incubated for 16 to 24 hours. The amount of interferon (IFN)-gamma present in the sample then is measured. In people with TB, white blood cells release IFN-gamma in response to contact with the TB antigens.¹⁴ This blood test is useful because results are available in 24 hours and it does not boost responses measured by subsequent tests. It also is not subject to reader bias that can occur with tuberculin skin tests. Furthermore, BCG inoculation does not affect the test results.¹⁴

The limitations of this test include the need to process the blood samples within 12 hours and limited data on its use with children younger than 17 years of age, people who are immunocompromised, and those who are taking immunosuppressive medications.¹⁴, ¹⁵ This test is relatively new, so arrangements with a qualified laboratory should be made in advance to ensure prompt and proper processing. The results are reported as “positive” or “negative.”¹⁴

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Multidrug-Resistant Pulmonary TB 

Multidrug-resistant TB, which is caused by strains of Mycobacterium tuberculosis resistant to at least isoniazid and rifampin, is a huge threat to global TB control.¹, ⁷, ³ Multidrug-resistant TB also is characterized by prolonged treatment, high morbidity and mortality, and high relapse rates.³ Drug resistance is a step-wise process—before someone is extensively-drug resistant, he or she probably was multidrug-resistant.⁷

There are two types of resistance—primary and secondary. Primary resistance occurs because someone with resistant TB coughs, spreading it to others. Secondary resistance occurs because a person with drug-sensitive TB develops resistance over time as a result of

The problem with drug-resistant TB is that there is reliance on second-line medications that require 24 months of treatment, are more costly, are more toxic, and are less effective. Furthermore, because the disease is drug resistant, the mortality rate is higher.⁷

Treatment of latent TB (ie, infection without active disease) has been a key to the prevention and spread of TB. However, MDR-TB is essentially a man-made disease, which is spreading, and people are dying from it in increasing numbers.¹ Exposure to a single medication—whether as a result of

suppresses the growth of bacilli susceptible to that medication but permits the proliferation of preexisting, drug-resistant mutants. The patient then acquires resistance, and the bacilli that he or she transmits to other people may lead to a disease that is resistant from the outset.¹ The CDC recommends that treatment of latent infection in people known to be exposed to MDR-TB include a regimen of two medications—ethambutol and pyrazinamide or a quinolone and pyrazinamide.¹

A huge challenge is rapid detection of cases of MDR-TB. Suspicion should arise when it is noted that a patient had an inadequate regimen of TB medications, there were errors in therapy prescription, or there was evidence of noncompliance or intermittent ingestion of medications.³ People with HIV may have reduced bioavailability related to malabsorption issues.³ Clinical indicators that the patient has MDR-TB include a fever that continues for several weeks after therapy began and sputum that is persistently positive two to five months after a four-medication regimen was prescribed. In addition, the patient may have worsening symptoms and radiological parameters.³ Drug resistance is more likely if the patient is not on directly observed treatment (DOT) or combination medication therapy.³

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Extensively drug-resistant TB 

The World Health Organization issued a warning that XDR-TB is now present in many places in the world.¹⁶ These strains are virtually untreatable because they are unaffected by the two most important first-line medications used to treat TB¹⁷ (ie, isoniazid, rifampin) and have resistance to the two most important second-line medication combinations (ie, fluoroquinolone and amikacin, kanamycin and capreomycin),⁷ and XDR-TB has a strong association with HIV.

These strains are especially prevalent in Asia and the former Soviet Union, particularly in the Baltic States.¹⁷ Control of TB deteriorated in the Baltics with a resurgence of the disease at the end of the Communist era. The newly independent states became rapidly impoverished, and health system fragmentation occurred. This led to MDR-TB with subsequent XDR-TB.⁹ The CDC is collaborating with other federal agencies as well as international partners to raise awareness and enhance strategies to prevent XDR-TB by working together when outbreaks occur.¹⁸

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Treatment 

Table 2 presents the most common medications used to treat TB including the newest medications that are under investigation. With treatment, the prognosis is excellent except in some cases of MDR-TB and XDR-TB.⁴ The benefits of treatment should be evaluated according to the risk of the individual developing TB. Then, the level of patient commitment to therapy should be assessed.¹⁹ Although treatment differs for latent TB, active TB, and drug-resistant TB (ie, MDR-TB, XDR-TB), effective treatment recommendations for all types of TB include

Table 2. Medications to Treat Tuberculosis

1 Lalloo UG, Naidoo R, Ambaram A. Recent advances in the medical and surgical treatment of multi-drug resistant tuberculosis. Curr Opin Pulm Med. 2006;12(3):179–185.

2 Sheldon LK. Oxygenation. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2008:401.

3 Hodgson BB, Kizior RJ. Saunders Nursing Drug Handbook 2009. Philadelphia, PA: Elsevier Saunders; 2008:1362.

4 Fact sheets: treatment options for latent tuberculosis infection. Centers for Disease Control and Prevention. http://www.cdc.gov/tb/pubs/tbfactsheets/LTBItreatmentoptions.htm. Accessed October 2, 2008.

5 Capreomycin injection. Medicinenet. http://www.medicinenet.com/capreomycin_injection/article.htm. Accessed October 2, 2008.

6 Trecator. RxList. http://www.rxlist.com/cgi/generic/trecator_ad.htm. Accessed October 2, 2008.

7 Common antibiotics. Thinkquest. http://library.thinkquest.org/25462/list.html. Accessed October 2, 2008.

8 Cycloserine. Medicinenet. http://www.medicinenet.com/cycloserine_capsule_oral/article.htm. Accessed October 2, 2008.

9 Alvarez-Elcoro S, Enzler MJ. The macrolides: erythromycin, clarithromycin, and azithromycin. Mayo Clin Proc. 1999;74(6):613–634.

10 Clofazimine. Medicinenet. http://www.medicinenet.com/clofazimine-oral/article.htm. Accessed October 2, 2008.

11 What are the advantages of rifapentine in the treatment of TB? US Pharmacist. http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Drug/dif499.cfm&pub_id=8&article_id=366. Accessed October 2, 2008.

No matter what type of TB is identified, all cases of TB must be reported to the local health department.¹⁰

Latent TB 

The preferred treatment for latent TB is isoniazid daily or twice weekly for nine months.⁸, ¹⁹ Another regimen is rifampin once daily for four months.¹⁹ Medication therapy may have to be altered, however, related to comorbid conditions, age, medication resistance, and the particular strain of TB. Patients with impaired immune systems may require multiple-medication therapy.⁴

Active TB 

Active TB is treated with three to four medication combinations for two months, followed by two medications for another four to seven months.²⁰ The first line of defense includes isoniazid, rifampin, ethambutol, and pyrazinamide.²⁰ Hospitalization often is required for patients with active TB. The patient is placed on respiratory isolation in a room with negative air pressure to minimize air flow and bacillus flow out of the room. The patient's hospital room door must be kept closed and traffic must be kept to a minimum. The patient must wear a mask if he or she leaves the room. The patient must stay in isolation until his or her sputum shows a decreasing bacterial count, which usually takes approximately two weeks of antimicrobial therapy, at which point the disease is no longer infectious and the patient can resume normal activities while continuing to take the medications. In addition, the patient should be prescribed a healthy diet and vitamin B6 (ie, pyridoxine) supplements to prevent isoniazid-peripheral neuropathy.¹⁰

Drug-resistant TB 

The treatment of MDR-TB is complex, costly, and associated with lower cure rates, relapses, increased toxicity, and high morbidity and mortality.³ The cost of treating MDR-TB is 100 times that of drug-sensitive TB.³ Care providers should consult with a TB expert if the patient is from a country with a high incidence of drug-resistant TB or if the patient has been exposed to a known drug-resistant case.⁷ It is vital to consult with a TB expert as soon as possible because MDR-TB and XDR-TB are caused by failed treatment of TB with limited drug resistance that eventually develops into multidrug resistance.¹⁹

After the clinician obtains and correctly interprets TB sensitivity results, treatment should begin with at least three new medications, two of which must be bacteriocidal.³ Atypical TB or drug-resistant strains may require second-line medications such as capreomycin, streptomycin, para-aminosalicylic acid, pyrazinamide, and cycloserine.⁴ Many regimens include four to five oral medications combined with an aminoglycoside or capreomycin for 24 months.³

Patients with HIV require case management to oversee both the treatment of the HIV and TB. Providers must monitor the interactions among many of the antiretroviral medications and the selected TB medications. Specifically, rifampin should not be used; rifabutin should be used as a substitute.²¹

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Directly Observed Treatment 

Directly observed treatment should always be used with drug-resistant TB to ensure compliance with therapy.²¹ The World Health Organization encourages DOT four days a week to help prevent development of multidrug-resistant strains.²² The patient must come to the health care facility to receive his or her TB medications, and health care personnel observe the patient taking the medications. In some areas of the world, this has greatly decreased the incidence and spread of TB, and prevents the development of MDR-TB.⁹ This is especially useful for people who may have problems complying with therapy and those who are alcohol or drug abusers.¹⁰ Health care personnel carefully monitor the patient's liver enzymes because TB medications increase a patient's risk of acquiring medication-induced hepatitis.¹⁰

The World Health Organization outlined a five-point strategy for implementing DOTS (ie, directly observed treatment, short-course).²² The DOTS programs refers to a system to manage MDR-TB with second-line medications and access to low cost medications. The DOTS program includes:

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Surgical Management of TB 

In the past, surgical interventions for TB involved collapse therapy with therapeutic pneumothoraces. The emergence of MDR-TB has refocused attention on the role of surgery in treatment. The goal of surgery is to remove diseased tissue and cavities to enhance the effectiveness of medications.³ Although long-term follow-up is needed to determine the value of surgery, it may become an adjunct to antimicrobial therapy in challenging populations with drug-resistant types of TB.³ Surgery may be performed on patients who

Preoperative preparation includes providing the patient with nutritional supplements and chest physiotherapy to minimize the risk of pulmonary sepsis.³ The median sternotomy approach has been used but it only allows limited exposure for left-sided resections so performing a posterolateral thoracotomy is the most common approach. The surgeon resects the affected lung segment(s) and places a chest tube to drain the pleural space postoperatively. The surgeon also may place an intercostal drain. Specimens should be handled carefully and all appropriate cultures and cytology requests should be collected preoperatively, intraoperatively, and during postoperative treatment.³

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Nursing Care of Patients with TB Who Are Undergoing Surgery 

Patients with TB who need surgical or endoscopic procedures may have several underlying risk factors along with TB; therefore, nurses must have a basic knowledge of the immune system and TB. To protect their patients and themselves, perioperative nurses must confidently apply the nursing process throughout the patient's perioperative experience (Table 3).

Table 3. Nursing Care Plan for Patients with Tuberculosis (TB) Who Are Undergoing Surgery [applicable PNDS code]

Many patients with TB have lived in poor socioeconomic environments that place them at risk. These environments also can result in malnutrition and severe weakness, which further increases the risk of acquiring TB. Typically, an intact immune system protects a perioperative patient from invading organisms and infection.²³ Patients who are HIV positive or who have AIDS, therefore, have the added risk factors involved with a depressed immune system.²³

Preventing the spread of TB to health care workers requires use of an N95 respirator as described by the National Institute for Occupational Safety and Health.²⁴ This is a type of mask that prevents 95% of particles that are 0.3 microns or larger from passing through the mask. Regular surgical masks will not block aerosolized particles as small as the TB bacillus. The N95 respirator has a rubberized strap that fits around the head and a rubberized border around the mask filter that creates a snug fit.²⁵ Personnel must be “fit tested” by occupational health department personnel to ensure that the respirator fits tightly and correctly.²⁴, ²⁵

Staff members working with patients who have TB should have up-to-date TB screening tests (ie, annual tuberculin skin tests), and it may be advisable for them to have a tuberculin test eight weeks later, especially if exposure is suspected.²⁶ If a staff member's test is positive, close contacts (eg, family members, friends) should also be assessed at regular intervals.²⁷

Preoperative care 

A patient with TB presents a challenge for nurses. Care begins with a thorough and accurate assessment. The preoperative nurse should review the patient's medical history and physical examination results and note the signs and symptoms of TB and their onset. The nurse should ensure that chest x-ray, CT scan, and MRI results also are available.³

The nurse should review the patient's laboratory test results and particularly focus on liver function tests because antitubercle medications may be toxic to the liver. Pulmonary function tests and arterial blood gas results along with ventilation and perfusion scans often are performed, and the nurse should ensure that the test results are on the preoperative chart.³ Conducting a thorough medication history that includes medications to which the patient is resistant also is essential.

Tuberculosis can be transmitted by contaminated particles (eg, dust, lint, glove powder) floating through the air; therefore, it is imperative that the nurse institute or continue respiratory and airborne precautions. Mycobacterium tuberculosis particles are less than 5 microns in size and contain up to three bacteria, which allows them to stay airborne for longer periods of time.²⁸ The preoperative nurse must ensure that the infected patient is isolated in a negative-air-pressure room.

Before the day of surgery, the nurse should ensure that the patient rests and receives a high-calorie diet with small, frequent feedings. Isoniazid usually is administered with food because it can cause gastric distress and with vitamin B6 because it may cause peripheral neuritis.⁴ Antituberculosis agents may be ordered the day of surgery to keep blood levels constant and, if ordered, may be administered with a small amount of water.

The nurse must ensure that the patient wears a mask when leaving the room. If possible, the patient should wear the mask until he or she undergoes induction of anesthesia. Procedures should be performed at the bedside in a negative-air-pressure room, if at all possible, to avoid exposing other patients and personnel.

Before transferring the patient from the preoperative area or patient room to the OR, the preoperative nurse provides the circulating nurse with a hand-off report that includes the patient's medical conditions, comorbidities, and infections; the status of the patient's TB; and the planned surgical procedure.

Intraoperative care 

Perioperative personnel may not know what type of TB a patient has (ie, MDR-TB, XDR-TB) especially when the scheduled procedure is diagnostic in nature. Large numbers of organisms may be released into the air during aerosol-generating procedures, such as bronchoscopy, endotracheal intubation, endotracheal suctioning, induced sputum collection, administration of medication by nebulizer, and open-abscess irrigation.²⁷ It is imperative that perioperative personnel and other patients are protected from the tubercle bacillus, which can remain airborne for hours.¹⁰

Scheduling procedures 

It is advisable that any aerosol-generating procedure be scheduled as the last procedure of the day.²⁷ The procedure should be performed where there is exhaust ventilation. If possible, it is best to perform the procedure in the patient's room on the medical/surgical unit if the room has negative air pressure. Personnel should be kept to a minimum necessary for the procedure. No visitors or observers should be permitted in the procedure room even if it is the patient's room on the medical unit.

Transmission of organisms 

Organisms can be transmitted by improperly disinfected equipment and instruments used previously on a patient with TB²⁸ so care must be taken to sterilize or properly disinfect instruments before and after the procedure. According to AORN's “Recommended practices for high-level disinfection,” a minimum of high-level disinfection is recommended for items that come in contact with nonintact skin and mucous membranes immediately before use.²⁹ Intact mucous membranes generally have a barrier to bacterial spores except the tubercle bacillus and viruses.³⁰ Items contaminated with Mycobacterium tuberculosis complex (eg, respiratory therapy equipment, anesthesia equipment, bronchoscopes, GI endoscopes) should receive a minimum of high-level disinfection.²⁹

It is imperative that the anesthesia care provider use disposable anesthetic equipment if at all possible; care must be taken to prevent contamination of the nondisposable anesthesia equipment and machines. If there is a possibility of anesthesia machine contamination, formaldehyde gas can be used for sterilization.²⁷

AORN's “Recommended practices for prevention of transmissible infections in the perioperative practice setting” indicates that airborne precautions must be instituted for a patient with a known or suspected infection by microorganisms that can be transmitted by the airborne route.³⁰ Droplet nuclei can be dispersed widely by air currents and remain suspended in the air for extended periods, which can affect a large number of patients and staff members. Airborne precautions should include use of N95 respirators. Masks must be placed on patients during transport, and rooms with special air handling that allow ventilation for areas outside the surgical suite also must be used.²⁵, ²⁹, ³⁰

Problems specific to patients with TB 

All patients experience risks when undergoing surgery. Patients with TB who must undergo surgery, however, are at particular risk for hyperthermia, hypothermia, deficit oxygenation, and decreased inspiratory and expiratory effort.

Fever increases the metabolic rate and cardiac output, which taxes a patient who already is burdened with the complications of TB. If the patient begins to shiver as a result of hyperthermia or hypothermia, the patient's metabolic rate may increase by 200%. Anesthesia also can cause a rise in body temperature.³¹ Nurses should implement interventions to promote normothermia.

Deficit oxygenation or carbon dioxide elimination at the alveolar-capillary membrane may occur because of tubercles and obstructions related to necrotic lung tissue. Patients with TB may have an inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway and may have pneumonia as a result of retained secretions.³¹ Patients with TB also may have an ineffective cough as a result of malnutrition and weakness. These problems may be manifested as abnormal blood gases, abnormal breathing (eg, adventitious breath sounds or abnormal rate, depth, or rhythm); abnormal skin color; confusion; cyanosis; dyspnea; excessive sputum production; hypoxia; orthopnea; or restlessness.³¹

Patients with TB also may have decreased inspiratory and expiratory effort that does not provide adequate ventilation. In addition to the other symptoms of respiratory problems, diminished inspiratory and expiratory effort may be manifested by nasal flaring, a prolonged expiratory phase, tachypnea, and use of accessory muscles to breathe.³¹ Before discharge to the postanesthesia care unit (PACU), the circulating nurse provides the PACU nurse with a hand-off report that includes the patient's medical condition, comorbidities, infections, and risk of postoperative infection; the status of the patient's TB; and specifics about the surgical procedure performed.

Postoperative care 

All airborne and contact droplet precautions must be continued in the PACU. The PACU nurse ensures that the patient is recovered in an isolation room with negative air pressure. When the patient arrives, the PACU nurse initiates supplemental oxygenation and takes the patient's initial vital signs including oxygen saturation. After elevating the head of the bed 45 degrees to optimize respiratory efforts, the PACU nurse auscultates breath sounds, noting the patient's respiratory patterns (eg, rate, depth, ease of respirations), and monitors arterial blood gases as ordered.

As the patient awakes from anesthesia, the PACU nurse instructs the patient and assists with deep breathing and coughing exercises and use of the incentive spirometer. The PACU nurse assesses and treats the patient's pain. Before discharge to the postoperative medical/surgical unit, the PACU nurse gives the assigned nurse a hand-off report that details the patient's medical conditions, comorbidities, infections and risk of postoperative infection; the status of the patient's TB, including medications to which the patient is resistant; and any needed antituberculosis medication ordered to keep blood levels constant.

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Suggestions for practice 

Health care providers are practicing in a changing health care environment. A collaborative approach is paramount when dealing with a client with TB. Not only does a patient with TB have a potentially fatal disease, but care must be taken so others are not infected with what could be an incurable type of TB. Care management is crucial in this often complex patient population who may suffer from other underlying pathologies such as ineffective gas exchange and airway clearance. Recognition of untoward events is the first step in incorporating strategies during the perioperative period. The patient with TB presents many challenges to the perioperative team in preventing infection and transmission of organisms. The nurse with a basic knowledge about TB can provide a safe perioperative experience without causing the patient further harm from untoward events.

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Examination 

Perioperative Care of the Patient with Tuberculosis 

Purpose/Goal 

To educate perioperative nurses about caring for patients with tuberculosis (TB) throughout the perioperative process.

Behavioral Objectives 

After reading and studying the article on TB, nurses will be able to

Questions 

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Answer Sheet 

Perioperative Care of the Patient with Tuberculosis 

Event #08131

Session #1320

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Learner Evaluation 

Perioperative Care of the Patient with Tuberculosis 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about caring for the patient with tuberculosis (TB) throughout the perioperative process.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ______________________________________________________________________________________________________________________

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References 

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16. World Health Organization  . Emergence of XDR-TB . http://www.who.int/mediacentre/news/notes/2006/np23/en/index.html Accessed October 3, 2008.
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23. Neil JA . Perioperative care of the immunocompromised patient . AORN J . 2007;85(3):544–560
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25. Inside Surgery  . TB patient Andrew Speaker's mask won't stop spread of TB . http://insidesurgery.com/index.php?itemid=404 Accessed October 2, 2008.
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