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Page updated 9 October 2007

6.0. Procedures

Precautions to be taken from known, suspect or at-risk patients with TSE.

When procedures are undertaken which carry a risk of contamination with CSF, brain, blood or lymphoid tissue, the following precautions must be taken.

Ward Procedures

Access to CSF (eg by lumbar puncture)

All Patients

All lumbar punctures and access to cerebrospinal fluid must be performed with "single use only" equipment. This applies to all procedures involving access to the subarachnoid space and, for example, access to ventriculo-peritoneal shunts. The rule includes spinal anaesthesia and diagnostic neuroradiology.

All brain biopsies for diagnostic purposes (whatever the clinical diagnosis) will be performed with a disposable set of instruments with the exception of the Pistol drill. Turbine drills must not be used.

The disposable instruments will be destroyed by incineration. The Pistol drill will be washed under water by a trained operative wearing full protective clothing (including domestic rubber gloves, apron and visor), and then sent for routine processing in CSSD.

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Other surgery on patients with known or suspected CJD

Known cases of classical CJD (or GSS or FFI)

OR

Known case of variant CJD

For surgical procedures on classical CJD patients involving brain or spinal cord, eye, and excluding invasive dental procedures and

For surgical procedures on vCJD patients involving CNS, brain, spinal cord, the eye and lympho-reticular system; (e.g. tonsillectomy, appendicectomy);

Dress code:

Members of the operating team should wear the following single use, disposable protective clothing:

The procedure should be scheduled last on the list.

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Instruments and drapes

Disposable drapes and dressings must be used and destroyed after use. All instruments must be disposed of in plastic sealable containers after use. These will be incinerated.

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Additional measures

Where the surgical procedure involves the brain (e.g. cortical biopsy), spinal cord or eye, the following additional precautions should be taken:

These are sensible precautions in any event.

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Suspected case of CJD (all forms including GSS or FFI)

The precautions above must be observed when neurological procedures, or procedures where lymphoreticular tissue is involved are carried out on patients in whom the possibility of any form of CJD enters into the differential diagnosis. All re-usable instruments must be placed in quarantine (see below) until a confirmed diagnosis is obtained.

Patients with classical CJD and inherited forms: the prion protein has not been found in reticulo-endothelial tissue so the instruments may be re-used after normal decontamination. However, it would be wise to check this before performing a procedure, then quarantining the instruments before re-use.