Unique operation hub for super-resistant TBC

News

Bright yellow, fully-protective clothing and an operation room at negative pressure. This is what the working environment looks like for the highly-specialised surgical team at Karolinska that operated on a patient with super-resistant pulmonary tuberculosis.

"It's a bit weird not using mouth protection, but otherwise it feels nice and safe in here," says the theatre nurse Maire Sillanpää Roosmann from behind her transparent plastic "helmet" above her protective suit.

This is only the third time a procedure has been performed on a patient with super-resistant pulmonary tuberculosis at Karolinska in Solna. It is a procedure that requires collaboration between several teams at the hospital in order to prevent the spread of resistant bacteria.

The foreign patient, who was successfully treated with TBC medication at the infection clinic at Östra hospital in Gothenburg, had been infected by an extensively resistant form of tuberculosis, also known as super-resistant tuberculosis. This means that it was resistant to two of the most important first-line drugs against the infection, and also two of the most important second-line drugs.

"While the patient has responded well to medicinal treatment and was no longer contagious, the damaged upper lobe in one of the patient's lungs had to be resected, among other reasons in order to reduce the risk of relapse once the treatment was stopped. There was a risk of live, resistant bacteria remaining and spreading when the ribcage was opened during the operation, and so we opted for a high safety level," explains Judith Bruchfeld, a consultant in charge of tuberculosis patient flow and a national expert on the disease who coordinated the team that prepared for the operation.

Dressed to provide care, with special protective suits. Anders Tunström helps Maire Roosmann with a protective suit for a high-risk TBC operation.

A high-level isolation team from the Infection patient area, Huddinge, is therefore present under the direction of nurse Katherine Nyberg. She has provided the surgical team with fully-covering suits like the ones used for Ebola infection, for example. At the same time, ventilation experts check that the negative pressure in the operation room is working perfectly – all to prevent the risk of the super-resistant bacteria spreading in the hospital's ventilation system.

"Tuberculosis, with or without resistance, requires highly-specialised care and cooperation across multiple specialisms. Where surgery is required, as is the case here, cooperation is even more important, if that's possible," adds Judith Bruchfeld.

This new procedure was implemented in 2014 for an operation on a previous patient with super-resistant tuberculosis.

"This time we were able to further refine the cooperation by having a team consisting of a patient flow manager for TBC in adults, the high-level isolation team from the Infection patient area, Care hygiene, Thoracic surgery, Thoracic anaesthesia, Perioperative Medicine and Intensive Care Abdominal Surgery, as well as ventilation engineers and technicians," she says.

As of next year, once all the activities have moved into the new hospital building in Solna, it will also be possible to perform high-level isolation operations there. Two operating rooms, with airlocks and specialised ventilation allowing the creation of negative pressure, will soon be ready. Another room of this kind will be built in the new hospital building in Huddinge.

The procedure performed was what is known as a thoracotomy, open surgery in which the surgeon, Mamdoh Al-Ameri gained access to the pleural cavity via the ribs to surgically remove the damaged pulmonary lobe.

"There were difficult adhesions in the lung due to chronic inflammation, which is a well-known problem with TBC. As a result, the operation took a long time and required a high level of caution in order to avoid damaging the undamaged parts of the lung. But everything went well and the patient is now stable," says Mamdoh Al-Ameri following the operation.

In addition to being experienced, the members of the surgical team are also used to working closely together. Christiane Bröcker, who is a nurse-anaesthetist, thinks that with high-risk operations of this kind, the fact that the members of the surgical team know each other so well produces substantial benefits both for the patient and the staff.

Working in protective suits is a major departure from the normal routine. The suit is both unwieldy and restricts the healthcare personnel's field of vision and acuity. However, anaesthetist Mark Larsson confirms:

"Even though the fan in the suit makes it difficult to hear each other, communication worked as well as usual."

The surgeon Mamdoh Al-Ameri agrees:
"It was tough on the back, because that's where the fan and the air filter are, but everything went really well."

The theatre nurse Jenny Persson coordinated the unique operation, with preparations taking a little over two weeks. Ventilation, protective equipment, theatre personnel and surgical equipment had to be thought through and prepared down to the last detail:
"Once we were wearing protective and sterile clothing and had gone into where the patient was, no one could enter or leave the room until it was all finished. When the operation on the patient was over, which was late in the afternoon, we then had to deal with anything that might be contagious," explains Jenny Persson.

In addition to the entire surgical team being sprayed with spirit when they left the room, there was also thorough disinfection of walls, floor, cables, apparatus, machines – quite simply every last thing that was in the room during the operation. After this, the room was misted with hydrogen peroxide to penetrate into and disinfect places that were hard to get to. Only then could the ventilation system be re-set to normal operation.

"There were a lot of preparations and follow-up work in order to be able to operate on the patient to clear out the disease, and also to minimise the risk of airborne contagion. But I felt really safe, and it all went extremely well," says Jenny Persson.

Text and photos: Carin Tellström

FACTS ABOUT MULTIRESISTANT TUBERCULOSIS

TBC is an infectious airborne disease that is spread from individuals with active TBC in their lungs and symptoms in the form of coughing.

About ten percent of people infected with TBC die. This usually happens within two years of infection.

It is relatively difficult to become infected, often requiring close and long-term contact with a contagious person.

In 2016, just over ten million people in the world fell ill with active TBC, and about1.5 million of these people died of it. This makes TBC the ninth leading cause of death and the infectious disease that causes the most deaths worldwide.

The World Health Organization, WHO, estimates that about 500,000 of the active cases in 2016 were a multiresistant form of TBC.

700-800 cases of active TBC are diagnosed in Sweden every year. In 2016 there were 22 reported cases of multiresistant TBC, two of which were extensively resistant cases.

Karolinska University Hospital is a national centre for TBC, providing training for healthcare personnel from Sweden and abroad.

TBC was common in Sweden at the start of the last century, after which it became less common. At the end of the 1980s it again became more common.

TBC infection can remain dormant in the body for decades.

In 1921 came the TBC vaccine, which is the best protection we currently have. However, according to the experts there is no 100-percent protection.