Precautions for Operating on an HBsAg-Positive Patient

1. Pre-operative Assessment

• Check HBeAg and HBV-DNA level - higher viral load means higher transmission risk; HBeAg-positive patients are the most infectious.
• Assess liver function (LFTs, coagulation profile, bilirubin, albumin) - HBsAg-positive patients may have impaired hepatic synthetic function affecting drug metabolism and coagulation.
• Optimize coagulation status before elective surgery (correct coagulopathy with FFP/Vitamin K as needed).
• Assess for signs of chronic liver disease / cirrhosis / portal hypertension which significantly raise anaesthetic and surgical risk.

2. Personal Protective Equipment (PPE) for the Surgical Team

• Double gloving - mandatory for all team members; gloves should be changed every hour during prolonged procedures (re-gloving schedule).
• Waterproof gowns and aprons to prevent blood soaking through to skin.
• Full-face shield or goggles + surgical mask - protects eyes and mucous membranes from splatter; standard surgical masks alone are insufficient.
• Enclosed hood and face masks (for very high-risk/Category I procedures such as cardiothoracic, major abdominal, orthopaedic, obstetric, and oral-maxillofacial surgeries).

3. Sharps and Instrument Safety (Intraoperative)

• No-touch technique for sharps - instruments should be passed using a neutral zone/kidney dish, not hand-to-hand.
• Blunt-tipped suture needles where feasible to reduce needlestick risk.
• Avoid manual needle re-capping; use a one-handed scoop technique or needle holder.
• Minimise the number of sharp instruments in the field at any one time.
• Count and account for all sharps before closure.
• Consider stapler devices instead of sutures where possible.
• Consider laparoscopic/minimally invasive approaches - reduces blood exposure and the number of open instrument-to-tissue contacts.

4. Theatre Environment and Scheduling

• Schedule at end of operating list - allows thorough terminal cleaning of the theatre afterwards.
• Limit personnel in the theatre to essential staff only.
• Mark the patient clearly as a biohazard/infection risk in theatre documentation and on the surgical checklist.
• Use a dedicated operating table and equipment set where practicable.

5. Vaccination of the Surgical Team

• All operating team members should have received the hepatitis B vaccine series and confirmed protective titre (anti-HBs ≥ 10 mIU/mL).
• Unvaccinated or non-immune staff should ideally not perform elective procedures on HBsAg-positive patients unless unavoidable; if they do, HBIG (Hepatitis B Immune Globulin) prophylaxis post-exposure must be available.

6. Anaesthesia Considerations

• Use disposable anaesthetic equipment (breathing circuits, airway devices) or ensure high-level disinfection/sterilization of reusable items.
• Avoid unnecessary invasive lines if feasible; each line is a potential sharps injury risk.
• Beware of reduced drug metabolism in patients with significant hepatic dysfunction (adjust doses of hepatically-metabolized drugs like opioids, benzodiazepines, neuromuscular blocking agents).

7. Post-Exposure Protocol (if needlestick or splash occurs)

1. Immediately wash the wound with soap and water; flush mucous membranes with water.
2. Report to occupational health immediately - do not delay.
3. If the injured person is non-immune or has unknown status:
   • HBIG 0.06 mL/kg IM - administered as soon as possible (ideally within 24 hours, up to 7 days).
   • HBV vaccine dose simultaneously at a different site (if not previously vaccinated or incompletely vaccinated).
4. Baseline and 6-month follow-up testing for HBsAg and anti-HBc.
5. According to CDC guidelines, the exposed clinician should refrain from donating blood, plasma, organs, or tissue during the follow-up period but does not need to modify patient care responsibilities.

8. Disinfection and Sterilization of Equipment

• All instruments must undergo full sterilization (autoclave) before reuse - HBV is resistant to many disinfectants but is reliably destroyed by autoclaving.
• Contaminated surfaces should be disinfected with:
  • 10% household bleach (sodium hypochlorite 0.5%)
  • 70% ethanol or isopropanol
  • 2% glutaraldehyde
  • 4% formaldehyde, or 6% hydrogen peroxide
• All blood-soaked linen and waste should be treated as biohazardous; double-bag and label appropriately.
• Reusable endoscopes or instruments that cannot be autoclaved must receive high-level disinfection before reuse.

9. Post-operative Considerations

• Dispose of all waste (drapes, drains, blood-soaked dressings) as clinical/biohazardous waste.
• Terminal clean of the theatre with an HBV-effective disinfectant before the next case.
• Document the case clearly; notify pathology lab of specimen biohazard status.
• Monitor wound for bleeding complications given possible coagulopathy.