Wednesday, June 24, 2009

Surgical Glove Perforation and the Risk of Surgical Site Infection – article review

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to ACP Internist for bringing this article to my attention (see full reference below).
It's best not to get holes in one's surgical gloves in the middle of a procedure, as this leads to a higher risk of infection for the patient, the Archives of Surgery reports in a study about the effect of ripped gloves. …… Which is, perhaps, why the surgeons put on the gloves in the first place?
For me, I found nothing new in this article.  Yes, surgeons wear gloves to both protect the patient and him/herself.  Gloves are part of the universal precautions. 
It is well known that the risk of getting a hole in one’s glove increases with the length of the surgery (especially when over 2 hours) or when dealing with spiked bone fragments.  The authors of the article felt they had a new angle --
The frequency of glove perforation during surgery has been studied extensively and found to range from 8% to 50%.  The impact of glove perforation on the risk of surgical site infection (SSI), however, is unknown. The present study was conducted to test the hypothesis that clinically visible surgical glove perforation is associated with an increased SSI risk.

I think most surgeons change their gloves if the hole is visible.   It is intuitive that the patients who are not on antimicrobial prophylaxis would be at the greatest risk of surgical site infection when a defective glove is involved.  This holds true with the authors’ findings: 
In the presence of surgical antimicrobial prophylaxis, the rate of SSI (6.9% vs 4.3%) was higher in procedures involving perforated gloves compared with procedures with maintained intraoperative asepsis.  After adjusting for 6 confounders in multivariate logistic regression analysis, however, the odds of contracting SSI in the event of glove puncture were not significantly higher when compared with procedures with intact gloves.
In the absence of surgical antimicrobial prophylaxis, glove leakage was associated with an SSI rate of 12.7%, as opposed to 2.9% when asepsis was not breached.  This difference proved to be statistically significant.

Double gloving may decrease the risk of transfer of germs (either direction:  patient to surgeon or surgeon to patient), but it is not always the answer.  I have tried all the combinations:  both gloves the same size, the outer one a smaller size, the outer one a larger size.  In all cases, my hands go numb.  Numb hands is not a good thing in a surgeon.
Routine changing of one’s gloves might capture some of the “un-caught” glove perforations and therefore decrease the risk of SSI in patients.  The authors even suggest doing so every two hours.  It would be interesting to figure up the costs of all the glove changes compared to the SSI costs.  Would it be cost effective?
The use of surgical microbial prophylaxis for all cases is still controversial.  The risk of SSI with clean surgical procedures is considered too low to be worth the risk of “side effects” from the antibiotics or the possibility of contributing to “super bugs.”  As pointed out in the article, indications for prophylactic antimicrobials approved by the CDC are clean operations involving prosthetic material and any operation in which a potential SSI would pose catastrophic risk (ie all cardiac operations, most neurosurgical and major vascular operations, and some operations on the breast).

Surgical Glove Perforation and the Risk of Surgical Site Infection; Arch Surg. 2009;144(6):553-558; Heidi Misteli, MD; Walter P. Weber, MD; Stefan Reck, MD; Rachel Rosenthal, MD; Marcel Zwahlen, PhD; Philipp Fueglistaler, MD; Martin K. Bolli, MD; Daniel Oertli, MD; Andreas F. Widmer, MD; Walter R. Marti, MD

Related post
Needle Sticks (January 2008)

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