Surgical Gowns Research Articles

Surgical Gowns

Biomedical Safety & Standards: September 01, 2020 - Volume 50 - Issue 15 - p 116 doi: 10.1097/01.BMSAS.0000695348.72613.08

Bacterial contamination of protective lead garments in an operating room setting.

Protective lead garments (PLG) worn in the operating room are a potential source for bacterial colonisation and thus may increase the risk of intraoperative infection. The clinical significance of such bacterial contamination has yet been established. Although disinfection protocols have been employed, their effectiveness is also unknown. We sought to describe and compare the bacterial profile of PLGs with a focus on common pathogens involved in surgical site infections (SSI) and prosthetic joint infections (PJI). We studied body aprons and neck-thyroid protective shields. We sampled 20 body aprons and 21 neck PLGs, swabbing the inside and outside of the PLGs. Swabs were cultured on different media and the results were assessed and compared. Of PLGs, 87.8% were contaminated. The neck-thyroid shield PLGs was generally more contaminated than body apron PLGs and exhibited significantly higher loads of Staphylococcus epidermidis (P = 0.048). Other pathogen cultured were Micrococcus spp., Acinetobacter lwoffii (A. lwoffii), Bacillus species (Bacillus spp.), Moraxella osloensis (M. osloensis) and Pseudomonas stutzeri (P. stutzeri). No other common pathogens associated with SSI or PJI were detected. PLGs are heavily contaminated despite regular cleaning protocols. Neck PLGs are highly contaminated with potentially infectious agents. As neck PLGs are often directly exposed above the surgical sterile gown and the surgical field, measures should be undertaken to reduce their exposure and bacterial load, perhaps by suggesting users consider avoiding the use of intraoperative fluoroscopy when possible or alternatively supporting the use of body exhaust suits when PLGs are needed.

Operating Room Setup: How to Improve Health Care Professionals Safety During Pandemic COVID-19-A Quality Improvement Study.

Background: COVID-19 is a terrific pandemic and a potential risk for every health care professional (HCP), especially during emergency conditions where the right timing is essential for the correct treatment. During surgery the correct setting of operative room (OR) is mandatory to reduce the risk of contamination. Personal protection equipment (PPE), specific devices, and planned OR setting are essential during surgery in pandemic COVID-19. Methods: Medline, PubMed, Scientific societies recommendations, and guidelines were consulted to identify articles reporting the setup of OR during pandemic COVID-19. Results: OR must have a high-efficiency particulate air (HEPA) filter with negative pressure and a high air exchange cycle rate. Every supply kit should be packed and placed in the OR before patient arrival. A detailed checklist of equipment and devices is necessary. Personal PPE at the highest level should be provided to every HCP (Association of the Advancement of Medical Instrumentation [AAMI]-Level-III surgical gowns; double latex-free gloves with Acceptable Quality Level <1.0; FFP3 or powered air-purifying respirator masks with face shield). Anesthesia should be performed with a rapid sequence intubation. During surgery energy devices should be settled to the lower level in combination with a smoke evacuation switch pen with disposable smoke evacuation HEPA filter to minimize surgical smoke spread. During laparoscopy low pneumoperitoneum pressures and aspiration systems must be provided. Conclusions: Emergency surgery during pandemic COVID-19 increases the risk for every HCP in the OR. A theoretical risk of transmission from the surgical field exists. It is mandatory the adoption of strong strategies to reduce the risk of contamination in the OR.

Responsabilidad patrimonial de la Administración general del Estado: un estudio de la Orden SND/326/2020 del Ministerio de Sanidad, generada como consecuencia de la crisis por COVID-19

Este estudio pretende analizar la estructura de la responsabilidad patrimonial de la Administración Estatal como consecuencia de la introducción de la Orden SND/326/2020 del Ministerio de Sanidad. Esta orden permite la fabricación de mascarillas y batas quirúrgicas, durante la permanencia del estado de alarma, a personas físicas y jurídicas que así lo soliciten. Se trata de autorizar la producción de material sanitario a quien, entre otros, no lo haga consuetudinariamente de forma profesional o su profesión se dedique a la fabricación de otro tipo de producto. En caso de daños, la Administración General del Estado asumiría la responsabilidad extracontractual. La situación parece presentar ciertas incongruencias o dificultades interpretativas que ubican a las administraciones involucradas en el centro del debate.

Migration Effects of Fluorochemical Melt Additives for Alcohol Repellency in Polypropylene Nonwoven Materials.

The use of bulk polymer melt additives provides a facile, industrially relevant approach to tailor properties of polymer surfaces for many different applications. These melt additives, when blended with polymers prior to melt spinning, migrate to the fiber surface and influence surface functionality. While the use of bulk polymer melt additives to impart hydrophilicity or oleophobicity is well studied, the impact of the fiber formation process on additive migration and resultant repellency of nonwoven media products remains largely unexplored. In this study, we produce fluorochemical melt additive containing meltblown nonwovens, and establish methods for characterization of fiber mat surface composition and repellency. Repellency of low surface tension fluids is a significant challenge and is of particular importance in the creation of medical garments such as surgical gowns and masks which must perform as liquid barriers even when exposed to alcohol based solutions. Similarly, melt additives are also used in the production of electret air filtration devices. Electret filters are imbued with charges to enhance particle capture performance, but this charge can be negated through wetting by low surface tension fluids. To address this challenge, the changing composition of fiber surfaces due to the migration of additives is monitored via X-ray Photoelectron Spectroscopy, then related to repellency of alcohol solutions by contact angle analysis. We demonstrate that for the samples tested a fluorine to carbon (F/C) ratio of 0.35 is sufficient to prevent wicking of isopropanol droplets, and higher surface tension fluids could be repelled by fiber mats with lower fluorine content. Through the use of cross-sectional ToF-SIMS analysis, we find that migration of additives is key to the performance of samples with low additive loadings, and that these phenomena are heavily influenced by many nonwoven manufacturing parameters including fiber size, die-to-collector distance, and polymer resin melt flow rates.

Developing a methodology to collect empirical data that informs policy and practices for stockpiling personal protective equipment

BackgroundPersonal protective equipment (PPE) are stockpiled across the nation to offset supply depletion during public health emergencies. Stockpiled PPE inventories vary across the United States by type, model, quantity, and the conditions in which they are stored. Over the past decade, federal, state, and local stockpile managers have had concerns for the viability of aging PPE. MethodsTo understand factors that may affect stockpiled PPE, we explored the breadth of stockpile storage conditions and respirator and surgical gown inventories through collaboration with the national PPE community, qualitative observations collected at 10 different US stockpiles, and by compiling stockpile PPE inventories and climate data from a convenience sample of US stockpiles. ResultsThe aggregated inventory from 20 stockpiles is reported, accounting for approximately 53 million respirators. Most respirators (69% or 35.8 million) have been stored between 5 and 10 years. Upon visiting 10 stockpile facilities, we report on the storage conditions observed and summarize the storage environment data collected. ConclusionsThis is the first study to identify common PPE types, inventories, and storage conditions across federal, state, and local government stockpile facilities as well as health care organization-managed caches. These findings will be leveraged to guide the development of sampling protocols for air-purifying respirators and surgical gowns in US stockpiles to understand the performance viability after long-term storage.

Survey of cataract surgeons' and nurses' attitudes toward operating room waste.

In an online survey of more than 1300 cataract surgeons and nurses, 93% believed that operating room waste is excessive and should be reduced; 78% believed that we should reuse more supplies; 90% were concerned about global warming; and 87% wanted medical societies to advocate for reducing the surgical carbon footprint. The most commonly cited reasons for excessive waste were regulatory and manufacturer restrictions on reuse or multiple use of devices, supplies, and pharmaceuticals. More than 90% believed that profit, liability reduction, and failure to consider carbon footprint drive manufacturers to produce more single-use products; more than 90% want more reusable products and more regulatory and manufacturer discretion over when and which products can be reused. Assuming comparable cost, 79% of surgeons preferred reusable over disposable instruments. In order of decreasing consensus, most were interested in reusing topical and intracameral medications, phacoemulsification tips, irrigating solutions/tubing, blades, cannulas, devices, and surgical gowns.

Highly effective antibacterial zeolitic imidazolate framework-67/alginate fibers

Antibacterial fibers have great potential in many applications including wound dressings, surgical gowns, and surgical sutures, and play an important role in our daily life. However, the traditional fabrication method for the antibacterial fibers shows high cost, complexity, and inferior antibacterial durability. Herein, we report a facile and scalable fabrication of highly effective antibacterial alginate (SA) composite fibers through blend spinning of zeolitic imidazolate framework-67 (ZIF-67) particles and SA. The fabricated ZIF-67@SA composite fibers show high tensile strength and initial modulus. More importantly, the ZIF-67@SA composite fibers demonstrate excellent antibacterial properties, and the antibacterial efficiency reaches over 99% at ultralow ZIF-67 loading (0.05 wt%). In addition, the ZIF-67@SA fibers show good antibacterial durability even after five laundering cycles. The excellent antibacterial performance of the ZIF-67@SA fibers is attributed to the synergistic effects of the highly effective antibacterial ZIF-67 particles, swelling of alginate, and immobilization of ZIF-67 particles both inside and outside the fiber surface. This work may shed light on the antibacterial mechanism of metal organic frameworks and pave the way for the development of high-performance antibacterial textiles.

Thyroid radiation shields: A potential source of intraoperative infection

IntroductionThyroid radiation shields are often uncovered by the surgical gown and may represent a preventable source of wound contamination. The aims of this study are to define the common pathogens found on thyroid radiation shields and evaluate the effectiveness of a simple cleaning method. MethodsSamples were obtained from 29 community thyroid shields collected from the operating theatres of 3 teaching hospitals. Each shield was swabbed under strict sterile technique using a separate swab for each of 4 designated zones. After sampling, shields were cleaned with a readily available disinfectant and sampling was repeated after 5 min. All swabs were cultured in ambient air at 37 °C on 5% sheeps blood agar for 48 hrs and subsequent growth was identified by a MALDI-TOF Walkaway mass spectrometer. ResultsBefore cleaning, 100% of thyroid shields (29/29) and 68% of shield zones (79/116) grew at least 1 type of bacteria. Coagulase negative staphylococci, including S. epidermidis, S. capitis, S. cohnii, S. haemolyticus and S. hominis, were most commonly isolated. Enterobacteriaceae and S. aureus were also cultured. After cleaning, culturable contamination was reduced by 86.3% and 64.5%, respectively (p < 0.001). ConclusionThe most common pathogens associated with SSIs can be isolated on thyroid radiation shields. Appropriate cleaning of thyroid shields with readily available disinfectant can significantly reduce the bacterial burden as detectable by culture. Hospitals should facilitate staff education and reinforce their policies on cleaning these shields which may often be overlooked.

Navigating the COVID-19 Pandemic: Lessons From Global Surgery.

Many hospitals in HIC rely on just-in-time inventory management, which can be an effective method to cut down on costs, as it calls for minimal reserves of healthcare supplies However, the widespread use of such strategies, which are reliant on consistent and tightly controlled supply chains, have made HIC vulnerable to PPE and supply shortages should demand sharply increase, as has been seen with the COVID-19 pandemic In some HIC hospitals, healthcare workers facing PPE shortages have already had to adopt common practices from LMIC, such as using bin liners instead of gowns and wearing reusable cloth masks HIC providers have also implemented evidence based adaptations, such as creating reusable elastomeric respirators, the development of open source ventilators, and reprocessing N95 masks using the hydrogen peroxide vapor sterilization technique Learning how LMIC providers manage resource limitations through global surgery collaborations can give surgeons working in HIC valuable perspective that has become increasingly relevant during the COVID-19 pandemic The rapid expansion of social media has facilitated such collaborations, and is a valuable tool for networking, mentorship, and information sharing Additionally, the rapid sharing of research findings via social media is enhancing our ability as a global health community to respond to this pandemic in a strong evidence based manner However, it is essential that social media be used responsibly, and that precautions are taken to prevent the spread of misinformation The most vulnerable populations, often linked to the underlying social determinants of health such as poverty, food security, literacy, sex, and racial and ethnic factors, are most at risk of adverse outcomes during these health and social shocks There is already data demonstrating that racial and ethnic minorities in the US and UK are at increased risk of death from COVID-19 Difficulty in accessing care for emergent conditions exists at baseline for these populations, and extensive backlogs for essential operations are commonplace, especially in LMIC This is likely only to get worse during the current crisis and underscores the importance of our professional commitment to health equity - regardless of geography New estimates of the "collateral damage" caused by the pandemic are very concerning and also illustrate the urgent need to mitigate this impact through local and global coordinated action

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report.

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report.

The effect of the type of protective suit on the thermophysiological comfort of surgeons in an operating room

Surgical gowns and medical clothing have to protect the surgeons from the patient and vice versa. However, all players in the operating room (OR) have to be in a state of thermophysiological comfort. The comfort of the surgeons is of special importance, as they are exposed to stressful situations, which could influence their performance negatively. The study presents an analysis of the thermophysiological comfort of the surgeons in an OR, using protective clothing ensembles with different clothing insulation and protection: a surgical scrub suit (SSS) and a clean air suite (CAS). The analysis is based on the calculation of PMV-PPD indexes, following Fanger’s model. Different combinations of thermal environment parameters and clothing insulation are tested and analysed.

Coronavirus disease 2019 (COVID-19): challenges and management of aerosol-generating procedures in dentistry.

Data sources Experimental investigation.Study design A retrospective review to evaluate the use of a negative-pressure otolaryngology viral isolation drape (NOVID) system to reduce cross-infection through aerosol. The apparatus consists of a plastic drape suspended over the surgical field in the head and neck region with a smoke evacuator suction placed inside the chamber with an ultra-low penetrating air (ULPA) efficiency rating and a fluid suction high-efficiency particulate air (HEPA) filter compartment. Spread of patient secretions and droplet formation was evaluated using 1% fluorescein dye in 10 ml of normal saline and ultraviolet light. The dye was applied topically in the nasal cavity and nasopharynx preoperatively and intraoperatively prior to the use of instruments such as micro-debrider, electrocautery and high-speed drilling. Following completion of the surgical procedure, an ultraviolet Wood's lamp was used to evaluate the presence of droplets on the surgical drapes and surgical gowns of the operating team.Results The study sample consisted of four patients who underwent endonasal endoscopic surgical procedures; two of these patients required concurrent endoscopic sinus surgery. A micro-debrider was used in three cases; electrocautery in three cases, while a high-speed drilling was employed in two cases. Presence of fluorescein was identified around the patients' nares; on the chest wipe and instrument tray in all four patients. Dye contamination was noted on the gauze placed over the smoke evacuator (two cases of skull base surgery); no fluid droplets were identified beyond the nares or the smoke evacuator (two cases of sinus surgery). However, fluid contamination was identified underneath barrier several centimetres away from the nares (one case of trans-sphenoidal surgery). Droplets were also identified on the surgeon's gown in the abdominal region in all cases and on the arm region in one case. In one case, droplets were also identified on the abdominal region of the nurse, but this was attributed to cross contamination from surgical gauze and instruments. Conclusions This retrospective study provides preliminary data on aerosol and droplet contamination during endonasal and transoral surgery performed under a negative pressure isolation drape system. Although the authors did not screen patients for SARS-CoV-2, they propose smoke evacuator ULPA filter attachment is appropriate to capture particles down to 0.1 microns including SARS-CoV-2 which is 0.125 microns. It would be helpful to see direct evidence to support this claim in future studies. The authors have not provided details regarding set-up time and training requirements for effective application of the isolation drape apparatus or the associated costs etc. It would have also been helpful if the authors could comment on any potential difficulties in undertaking the surgical procedure with the isolation system in place. The sample size is limited to four patients and variations in the magnitude and extent of aerosol contamination needs to be investigated further before drawing any conclusions. Although unlikely, this study design did not capture the presence of aerosol/droplets in the air within the operating room which may follow removal of the isolation drape system or from exposed surgical instruments. Notwithstanding the limitations of the design, negative-pressure aspiration of air under a chamber barrier is likely to minimise the contamination from aerosol and droplet during endonasal and transoral surgery.

Walking the line between benefit and harm from tracheostomy in COVID-19

Walking the line between benefit and harm from tracheostomy in COVID-19

Operating in a Pandemic: Lessons and Strategies from an Orthopaedic Unit at the Epicenter of COVID-19 in Singapore.

➤With severe limitations in manpower, facilities, and equipment, and the concern for nosocomial transmission, operating in a pandemic is fraught with danger from multiple fronts.➤Strategies to mitigate nosocomial spread include prioritization of existing patients, triaging and treatment of new patient encounters, infection control protocols, perioperative considerations, manpower management, and novel strategies for interdisciplinary interaction and education.➤The decision to proceed with or postpone surgery should be based on the urgency of the surgical procedure and the physiological health of the patient.➤When performing an operation on a patient who has suspected or confirmed infection with novel coronavirus disease 2019 (COVID-19), personal protection equipment should include hair covers, face shields or goggles, N95 respirator masks, a blood-borne pathogen-resistant surgical gown, shoe covers, and double-gloving with single-use gloves.➤Loose-fitting, powered air-purifying respirators should be considered for prolonged surgeries.➤An astutely formulated and comprehensive business continuity plan is an orthopaedic unit’s best strategy for maintaining critical standards, discipline, and morale in severe and prolonged outbreaks.

Surgical Infection Society Guidance for Operative and Peri-Operative Care of Adult Patients Infected by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2).

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated viral infection (coronavirus disease 2019, COVID-19) is a virulent, contagious viral pandemic that is affecting populations worldwide. As with any airborne viral respiratory infection, surgical and non-surgical patients may be affected. Methods: Review and synthesis of pertinent English-language literature pertaining to COVID-19 infection among adult patients. Results: COVID-19 disease that requires hospitalization results in critical illness approximately 25% of the time and requires mechanical ventilation with positive airway pressure. Acute kidney injury, a marked hypercoagulable state, and sometimes myocarditis can be features of COVID-19 in addition to the characteristic severe acute lung injury. Even if not among the most seriously afflicted, older patients with medical comorbidities are both predisposed to infection and risk increased morbidity and mortality, however, all persons presenting for surgical intervention should be suspected of infection (and thus transmissibility) even if asymptomatic. Although most elective surgery has been curtailed by administrative or governmental fiat, patients will still need urgent or emergency operative intervention for time-sensitive disease processes such as malignant neoplasia or for true emergencies such as perforated viscus or traumatic injury. It is possible to provide safe surgical care for SARS-CoV-2-positive patients and minimize nosocomial transmission to healthcare workers. Conclusions: This guidance will facilitate appropriate protection of patients and staff, and maintenance of infection control measures to assist surgical personnel and facilities to prepare for COVID-19-infected adult patients requiring urgent or emergent operative intervention and to provide optimal patient care.

Occupational Heat Stress, Thermal Comfort, and Cognitive Performance in the OR: An Integrative Review.

Heat may cause a stress response in perioperative personnel who wear impervious protective surgical gowns that can trap body heat. Responses to heat may include changes in cognitive function, which may affect performance during operative and other invasive procedures. This integrative literature review sought to identify research articles investigating associations among occupational heat stress, thermal comfort, and cognitive performance. The review found that there is a paucity of research on this topic; however, articles that assessed cognitive performance under heat stress for foundry workers (n = 70), cyclists (n = 10), and untrained participants in simulated settings (n = 32) showed that heat may have negative effects on cognition by affecting memory, reaction time, and complex motor skills. Whether heat affects the cognitive performance of perioperative personnel is an important topic for future research.

COVID-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon.

PurposeWith the COVID-19 crisis, recommendations for personal protective equipment (PPE) are necessary for protection in orthopaedics and traumatology. The primary purpose of this study is to review and present current evidence and recommendations for personal protective equipment and safety recommendations for orthopaedic surgeons and trauma surgeons.MethodsA systematic review of the available literature was performed using the keyword terms “COVID-19”, “Coronavirus”, “surgeon”, “health-care workers”, “protection”, “masks”, “gloves”, “gowns”, “helmets”, and “aerosol” in several combinations. The following databases were assessed: Pubmed, Cochrane Reviews, Google Scholar. Due to the paucity of available data, it was decided to present it in a narrative manner. In addition, participating doctors were asked to provide their guidelines for PPE in their countries (Austria, Luxembourg, Switzerland, Germany, UK) for consideration in the presented practice recommendations.ResultsWorld Health Organization guidance for respiratory aerosol-generating procedures (AGPs) such as intubation in a COVID19 environment was clear and included the use of an FFP3 (filtering face piece level 3) mask and face protection. However, the recommendation for surgical AGPs, such as the use of high-speed power tools in the operating theatre, was not clear until the UK Public Health England (PHE) guidance of 27 March 2020. This guidance included FFP3 masks and face protection, which UK surgeons quickly adopted. The recommended PPE for orthopaedic surgeons, working in a COVID19 environment, should consist of level 4 surgical gowns, face shields or goggles, double gloves, FFP2-3 or N95-99 respirator masks. An alternative to the mask, face shield and goggles is a powered air-purifying respirator, particularly if the surgeons fail the mask fit test or are required to undertake a long procedure. However, there is a high cost and limited availabilty of these devices at present. Currently available surgical helmets and toga systems may not be the solution due to a permeable top for air intake. During the current COVID-19 crisis, it appeared that telemedicine can be considered as an electronic personal protective equipment by reducing the number of physical contacts and risk contamination.ConclusionOrthopaedic and trauma surgery using power tools, pulsatile lavage and electrocautery are surgical aerosol-generating procedures and all body fluids contain virus particles. Raising awareness of these issues will help avoid occupational transmission of COVID-19 to the surgical team by aerosolization of blood or other body fluids and hence adequate PPE should be available and used during orthopaedic surgery. In addition, efforts have to be made to improve the current evidence in this regard.Level of evidenceIV.

Implementation of an Abdominal Closure Bundle in Patients Undergoing Cesarean Section—A Randomized Control Trial [15P

INTRODUCTION: Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. Literature in Colorectal Surgery and Gynecologic Oncology have suggested lower SSI rates among patients who receive closure bundles. This study investigated whether implementation of an abdominal closure bundle reduces SSI rates in patients undergoing cesarean section. METHODS: We conducted a prospective randomized controlled trial of patients who underwent a scheduled cesarean section. Enrolled patients were randomized to either standard operative procedure or the abdominal closure bundle. The bundle included changing of the surgical gown and gloves, repeat scrub, and usage of new instruments for closure of fascia, subcutaneous tissue, and skin. SSI rates were assessed and predictors of SSI were determined. RESULTS: 241 patients were included in this interim analysis. No difference in SSI was found between the control (3/130, 2.3%) and closure bundle (2/111, 1.8%) groups (P=1.00). Logistic regression indicated that smoking status and number of prior cesarean sections were statistically reliable predictors of SSI (P=.009). Former or active smokers were 8.3 times more likely to have an infection (CI 1.61 – 43.3, P=.012). Those with prior cesarean sections were 2.5 times more likely to have an infection (CI 1.0 – 6.1, P=.045). CONCLUSION: Implementation of an abdominal closure bundle for patients undergoing scheduled cesarean sections did not significantly reduce SSI rate. We plan to investigate the impact of the abdominal closure bundle in a higher risk population as completion of this study as designed is unlikely to reach statistical significance.

Preparing to Perform Trauma and Orthopaedic Surgery on Patients with COVID-19.

Preparing to Perform Trauma and Orthopaedic Surgery on Patients with COVID-19.