Avoidable with blunt needles

Last year a BBC investigation suggested that two young women in Kent had died from generalised surgical herpes infection, contracted from an infected surgeon, due to a needlestick injury at Caesarean section (click here).

The evidence was compelling. Herpes contracted this way is rare, but often fatal. Neither woman had a previous history of herpes, so would likely not have had prior immunity. Both were operated on in the same trust, albeit different hospitals, by the same unnamed surgeon. Kim Sampson gave birth on 3 May 2018, and Samantha Mulcahy on June 26 the same year. Both developed overwhelming herpes infections shortly after birth and died soon after.

According to emails seen by the BBC, the partial viral genome from both infections was not only identical, but also “rare”, compared with the previous 10 years of herpes samples collected by Public Health England’s North London lab. Although the surgeon was questioned, and denied having a herpetic lesion (a whitlow) on his finger, such lesions can be small and missed.

Needlestick injuries at Caesarean are common – the BBC quotes a 50 percent glove perforation rate. It was not reported whether the surgeon used a sharp or blunt needle, but the former is likely. If so, an easy opportunity to prevent the deaths of two young women was missed.

There is overwhelming evidence that blunt needles reduce needlestick injuries. It not only accords with common sense, but there have been ten randomised trials, two involving Caesarean section, and 2,961 operations included in the latest Cochrane review in 2011 (click here).

The use of blunt needles reduced the risk of glove perforations (RR 0.46; 95% CI, 0.38 to 0.54) compared to sharp needles, and self‐reported needle stick injuries (RR of 0.31; 0.14 to 0.68). It is unlikely that future research will change this conclusion.

This was followed by a Cochrane editorial (click here) in which the review was cited as an example of one “that can and should change practice”. The authors wrote “where they can be used they should be used”. They are recommended by the US Centers for Disease Control, the US Food and Drug Administration (click here), and the National Institute for Occupational Safety and Health (click here)”.

However, for some reason, NICE (click here for the March 2021 guidance), still doesn’t recommend them, and in my experience, few UK obstetricians use them. Despite the FDA and CDC recommendations things are not much better in the US. In a recent survey only 17% of fetal medicine trainees used them, and many were not even aware such needles existed (click here).

The reason for such reluctance to implement a simple safety step is unclear. They need a little more pressure to penetrate tissue, and some surgeons argue, mistakenly, that needlestick injuries matter less when everyone is screened for Hep B, Hep C and HIV. Nothing could be further from the truth. Each of these viruses caused many surgical infections until screening caught up, and if the last two years have taught us anything, new viruses are appearing all the time!

The inquest opened this week (click here) and has been adjourned to February 21. Let’s hope the coroner, Ms Katrina Hepburn, asks if the surgeon used blunt needles, and if not, why not.

This is an avoidable harm. If NICE’s recommenation had been evidence-based, maybe two young women would be alive today.

Jim Thornton