Glove perforation in orthopaedic and trauma surgery. A comparison between single, double indicator gloving and double gloving with two regular gloves

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving. We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02). We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures.     

Electronic evaluation of the value of double gloving

BACKGROUND: Breakdown of the surgeon-patient barrier represents a risk for transmission of infectious disease. Such breakdowns are frequently not recognized by the surgical team. The protection afforded by double gloving under normal operating conditions was evaluated. METHODS: An electronic device detected breakdown of the surgeon-patient barrier in a series of 80 surgical procedures, randomly assigned to either double or single gloving. Fluid contact due to glove perforation, porosity or gown wetting was recorded during 151 individual surgeon episodes covering 238 operator-hours. Surgical procedures were called superficial for incisions of less than 10 cm. RESULTS: Double gloving reduced the number of perforation and porosity alarms twofold in both superficial and deep surgical procedures. Deep procedures carried a sevenfold increased risk of barrier breakdown compared with superficial procedures, the risk being greatest for the principal operator. CONCLUSION: Without electronic detection, a large majority of barrier breakdowns would remain undetected by the surgical team and lead to prolonged contact with potentially contaminating body fluids. The use of double gloving provides real protection against such contamination risks.     

Double gloving. Protecting surgeons from blood contamination in the operating room.

Health care workers, particularly surgeons, understand the importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.     

Glove punctures in major and minor orthopaedic surgery with double gloving

We assessed the frequency of glove perforation during major and minor orthopaedic surgeries, in order to determine the efficacy of double gloving. A total number of 1528 gloves (622 inner and 906 outer) used in 200 procedures (100 major-100 minor), and 100 pairs of unused gloves were examined. Glove perforation rate, incidence among surgical team, location of perforation and duration of surgery were compared. The overall perforation rate was 15.8% (242/1528). Perforation rates for major versus minor surgical procedures were 21.6% and 3.6%, respectively. The perforation rate for the unused control group was 1% (2/200). Inner-outer gloves perforation rates were 3.7% (23/622) and 22.7% (206/906), respectively. Surgeons had a higher perforation rate compared with the other staff. The right thumb and left index finger had more punctures than other fingers. Routine use of double gloving during orthopaedic procedures is recommended, because this significantly reduces the perforation of inner gloves.     

Glove perforations in open and laparoscopic abdominal surgery: the feasibility of double gloving.

BACKGROUND AND AIMS: According to the traditional view, the glove protects the patient from the bacterial growth of the surgeons' hands and doing so prevents infections. Today, with growing incidences of HIV and Hepatitis B and C, surgical gloves are also important as protection for the surgeon. We compared the safety of double indicator gloves to standard single surgical gloves by investigating how often surgical gloves are punctured in laparoscopic and open gastrointestinal surgery. STUDY: As study material we gathered all gloves that had been used in gastrointestinal surgery in Satakunta Central Hospital during two months. 814 gloves from 274 operations were tested by using standardized water filling test method. RESULTS: In open surgery 67 gloves out of 694 had been punctured (9.6 percent). Puncture occurred in 22.5 percent of operations (53 out of 236). During open surgery 24 holes out of 35 were undetected with single gloves (69 percent). With double indicator gloves, only 3 out of 31 holes were unnoticed (10 percent). Long duration of operation increased the risk of puncture. In laparoscopic operations 4 gloves out of 120 had been perforated (3.3 percent). CONCLUSION: Double surgical gloves give markedly better protection in surgery. This is important especially in high risk operations.     

Impact of single clamp versus double clamp technique on neurologic outcome

BACKGROUND: Atherosclerotic disease of the aorta has been identified as a risk factor for neurologic complications following coronary artery bypass grafting (CABG) due to the use of aortic clamping and manipulation. We reviewed a change from double clamp to single clamp technique to determine its impact on neurologic outcomes. METHODS: Patients undergoing isolated CABG by a single surgeon were identified as having double clamp technique (DCT) (aortic cross clamp + sidebiting clamp) or single clamp technique (SCT) (aortic cross clamp only). Data were collected by study personnel and clinicians to determine stroke and neurologic injury (confusion, delirium, seizure, altered mental status, and agitation) outcomes for 461 patients. RESULTS: Two hundred seventy-two patients had DCT and 189 patients had SCT performed. There were no differences in mean age, previous stroke, hypertension, or diabetes. Intraoperatively, patients with SCT had shorter bypass times (115 minutes vs 128 minutes, p = 0.001), longer aortic cross clamp time (89 minutes vs 80 minutes, p = 0.001), fewer coronary grafts (2.8 vs 3.1, p = 0.001), and had higher mean arterial blood pressure on cardiopulmonary bypass (76 mm Hg vs 69 mm Hg, p = 0.001). Postoperatively, the SCT group had fewer strokes (1.1% vs 2.9%, NS), and neurologic injuries (3.2% vs 9.6%, p = 0.008). By multivariate analysis, the factors that were related to neurologic injury were DCT (p = 0.04), age (p = 0.001), and number of coronary grafts (p = 0.03). CONCLUSIONS: This experience suggests that the use of the SCT may be important in reducing neurologic injury following CABG.     

Safety in the operating room: team approach saves lives

Improvements in technology, classic peer review, and even relentless determination of the individual practitioner have proven insufficient to eliminate adverse events in surgical patients. Preventing avoidable harm must focus on changing the operating room culture from one of separate--and well-meaning individuals--to a cohesive approach by surgeons, anesthesiologists, nurses, and associated or health staff. Neily and colleagues report the results of a comprehensive team training program implemented across 74 Veterans Health or facilities, which was associated with an 18% reduction in annual mortality (rate ratio = 0.82; P = 0.01).     

双钢板与单钢板固定骨折脱位型胫骨内侧平台骨折的比较

[目的]分析双钢板内侧入路内固定治疗骨折脱位型胫骨内侧平台骨折的效果。[方法]回顾性分析2007年10月~2014年10月本院收治的50例骨折脱位型胫骨内侧平台骨折患者临床资料。依据患者实施的手术类型将其分为双钢板组及单钢板组。其中,双钢板组患者27例,接受双钢板内侧入路内固定治疗,单钢板组患者23例,接受前内侧入路钢板联合前后位拉力螺钉内固定治疗。比较两组患者的治疗效果。[结果]两组在手术时间、术中失血量和住院时间方面差异无统计学意义(P0.05)。两组患者Rasmussen放射学评分术后均较术前显著增加,不同时间点间差异有统计学意义(P0.05);术前两组间Rasmussen放射学评分差异无统计学意义(P0.05),但术后1 d和术后3个月,双钢板组显著高于单钢板组,两组间差异有统计学意义(P0.05)。与之类似,术后两组患者Harris评分均较术前显著改善,(P0.05)。术前两组患者Harris评分的差异无统计学意义(P0.05),但术后3个月,双钢板组高于单钢板组,差异有统计学意义(P0.05)。双钢板组患者术后1 d、术后3个月胫骨平台后倾角(PTSA)及内翻角(MPTA)均显著优于单钢板组,两组间差异均有统计学意义(P0.05)。两组患者并发症总发生情况的差异无统计学意义(P0.05)。[结论]双钢板内侧入路内固定治疗骨折脱位型胫骨内侧平台骨折,可有效维持膝关节力线,固定稳定。     

Haemodialysing infants: theoretical limitations, and single versus double lumen lines

Haemodialysing small infants is difficult because of vascular access limitations. We show that Poiseuille’s law (that flow through a tube varies with its radius⁴) makes it inevitable that the blood flow that can be achieved in smaller patients will fall disproportionately compared to their need for dialysis. Poiseuille’s law also predicts that for single and multiple lumen cannulae of the same outside gauge, blood flow through the single lumen will be several times greater. Measurements confirmed this. It is argued that haemodialysis efficiency will therefore be improved by using a single lumen cannula to alternately withdraw and return blood, compared to sampling and returning continuously through a multiple lumen cannula, despite only withdrawing for half the time. Received: 23 May 2000 / Revised: 15 November 2000 / Accepted: 17 November 2000     

Bridging the communication gap in the operating room with medical team training

BACKGROUND: In the operating room (OR), poor communication among the surgeons, anesthesiologists, and nurses may lead to adverse events that can compromise patient safety. A survey performed at our institution showed low communication ratings from surgeons, anesthesiologists, and OR nursing staff. Our objective was to determine if communication in the operating room could be improved through medical team training (MTT). METHODS: A dedicated training session (didactic instruction, interactive participation, role-play, training films, and clinical vignettes) was offered to the entire surgical service using crew resource management principles. Attendees also were instructed in the principles of change management. A change team was formed to drive the implementation of the principles reviewed through a preoperative briefing conducted among the surgeon, anesthesiologist, and OR nurse. A validated Likert scale survey with questions specific to effective communication was administered to the nurses, anesthesiologists, and surgeons 2 months after the MTT to determine the impact on communication. Data are presented as mean +/- SEM. RESULTS: There was a significant increase in the anesthesiologist and surgeon communication composite score after medical team training (anesthesia pre-MTT = 2.0 +/- .3, anesthesia post-MTT = 4.5 +/- .6, P <.0008; surgeons pre-MTT = 5.2 +/- .2, surgeons post-MTT = 6.6+/-.3, P <.0004; nurses pre-MTT = 4.3 +/- .3, nurses post-MTT = 4.2 +/- .4, P = .7). CONCLUSIONS: Medical team training using crew resource management principles can improve communication in the OR, ensuring a safer environment that leads to decreased adverse events.     

Mechanical testing of a single rod versus a double rod in a long-segment animal model

This study involved the mechanical testing of single-rod segmental hook fixation and double-rod segmental hook fixation in a long-segment animal model. The goals were first to compare the flexibility of a single-rod scoliosis construct with that of a double-rod construct when tested in torsion, and second, to determine the effect of not using instrumentation with every vertebral segment for the single rod. Another study found that the single-rod construct was as stiff in torsion as the standard double-rod construct in a model of 10 vertebral segments. The amount of neutral zone (NZ) rotation was tested in five calf spines using an MTS (Material Testing System) machine. Five constructs were tested and included 1) a single rod with hooks at every level except the apex; 2) a single rod with two fewer hooks; 3) a single rod with four fewer hooks; 4) a double-rod construct; and 5) no instrumentation. The amount of NZ rotation between vertebral segments was measured over 12, 10, 8, 6, 4, and 2 vertebral segments. An analysis of variance with all constructs showed that the instrumented spines had significantly less movement than did the uninstrumented spine. Statistical comparison using analysis of variance of constructs (constructs 1 to 4) showed that over 12 vertebral segments (T4-L3), all single-rod constructs (constructs 1 to 3) allowed more NZ rotation than did the standard double-rod construct. This testing indicated that over 12 vertebral segments the single rod allowed more NZ rotation than a double-rod construct.     

Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting

BACKGROUND: The long-term benefits of double versus single internal mammary artery (IMA) coronary bypass grafting have not yet been established. METHODS: Six hundred patients were studied retrospectively 10 years after coronary revascularization using saphenous vein grafts (SVGs) only or single or double IMA grafts. RESULTS: Patients with double IMA grafts were younger and were more likely to have diabetes, left main coronary stenosis, and three-vessel coronary artery disease than patients with SVGs or single IMA grafts. Patients with SVGs and double IMA grafts had a greater number of diseased coronary vessels and a greater number of coronary bypass grafts per patient than patients with single IMA grafts (mean +/- SEM, 2.8 +/- 1.0, 2.8 +/- 0.7, 2.1 +/- 0.8 grafts per patient, respectively, p < 0.0001). Actuarial survival rates 10 years after placement of SVGs and single and double IMA grafts averaged 83% +/- 6%, 90% +/- 4%, and 87% +/- 8%, respectively (p = 0.03). Cox regression analysis showed that diabetes (relative risk, 2.03; 95% confidence interval, 1.55 to 2.66) and chronic pulmonary obstructive disease (relative risk, 2.20; 95% confidence interval, 1.58 to 3.80) increased, whereas an IMA graft on the left anterior descending coronary artery significantly decreased, the risk of death after operation (relative risk, 0.45; 95% confidence interval, 0.36 to 0.57) throughout the follow-up period. CONCLUSIONS: Use of an IMA graft on the left anterior descending coronary artery improves survival compared with use of an SVG. Although patients with double IMA grafts had a greater number of poor prognosis risk factors before operation, their 10-year survival rate was similar to that of patients with a single IMA graft.     

Results of internal thoracic artery grafting over 15 years: single versus double grafts

One hundred consecutive patients who had coronary artery bypass grafting using both internal thoracic arteries (ITAs) and saphenous veins, operated on during a 3-year period between 1972 and 1975, have been compared retrospectively with a series of 100 patients operated on during the same period who had one ITA graft along with saphenous vein grafts. The two groups were similar with respect to age, sex, risk factors for coronary artery disease, angina class, extent of coronary artery disease, left ventricular function, number of coronary bypass grafts performed, and completeness of revascularization. Single ITA operative mortality was 2% and double ITA, 9% (p = NS). The mean follow-up of hospital survivors was 14.4 +/- 2.7 years; all but 7 patients had follow-up for at least 10 years. At 13 years, the actuarial patency of the right ITA was 85% and the left ITA, 82%. These data strongly suggest a survival benefit for patients with double ITA grafts among hospital survivors (74% versus 59%; p = 0.05). Patients receiving two ITA grafts had a significant freedom from subsequent myocardial infarction (75% versus 59%, p less than 0.025), recurrent angina pectoris (36% versus 27%, p less than 0.025), and subsequent total ischemic events (32% versus 18%, p less than 0.01). These data also suggest improved freedom from coronary artery interventional therapy (percutaneous transluminal coronary angioplasty and reoperation) when two ITA grafts were used. These results support the use of bilateral internal thoracic artery grafting in selected patients.     

Efficacy of single versus bilateral internal mammary artery grafting in women: a long-term study

Background. Coronary artery bypass grafting carries a higher operative mortality and less favorable long-term benefit in women than in men. Bilateral internal mammary artery grafting (BIMA) has been shown to yield excellent perioperative and long-term results in both women and men. However, controversy continues to exist as to the benefits of a second internal mammary artery graft in women.

Methods. A retrospective analysis was performed comparing 261 consecutive women from a single surgical practice receiving BIMA and supplemental vein grafts between January 1972 and October 1994 with a computer-matched cohort of 261 women receiving single internal mammary artery (SIMA) and vein grafts during the same period. Univariate analysis confirmed the homogeneity of the two groups based on nine preoperative variables.

Results. Operative mortality was comparable in the two groups, 3.8% (10 of 261 patients) in the SIMA and 3.4% (9 of 261 patients) in the BIMA group, with a markedly reduced mortality in both groups since 1990, 2.3% (2 of 86 patients) in the SIMA and 1.3% (1 of 78 patients) in the BIMA group. The mean number of distal grafts (2.78, SIMA; 3.14, BIMA), perfusion time (104 minutes, SIMA; 108 minutes, BIMA), and cross-clamp time (58 minutes, SIMA; 66 minutes, BIMA) were all comparable. There was no significant difference in the incidence of postoperative complications, including sternal wound infection. Patient follow-up ranged from 1 month to 27 years, with a mean of 10.0 years in the SIMA group and 9.1 years in the BIMA group. Clinical results were excellent, with 100% (136 of 136 patients) of the SIMA and 100% (167 of 167 patients) of the BIMA patients in Canadian Cardiovascular Society class I or II at follow-up. Rates of late myocardial infarction, percutaneous transluminal coronary angioplasty, and reoperation were similarly low in both groups: 3.7% (5 of 136 patients) versus 1.8% (3 of 166 patients), 5.4% (7 of 136 patients) versus 4.8% (8 of 166 patients), and 3.7% (5 of 136 patients) versus 1.8% (3 of 166 patients), for SIMA versus BIMA survivors, respectively. No significant difference was found in the long-term and event-free survival or in any of the eight subscales of the SF-36 quality of life survey for the two groups.

Conclusions. Excellent short- and long-term results have been demonstrated with internal mammary artery grafting in women. However, the addition of a second internal mammary artery graft does not appear to confer any additional clinical benefits in a comparably matched cohort of patients.     

The importance of a double team in brachial plexus surgery

AimBrachial plexus surgery constitutes a long and complex procedure. The aim of our study is to assess the interest of having a double operating team throughout the duration of this surgery.Patients and methodsSeventeen patients with brachial plexus palsy underwent surgery operated by a double team. The operating time corresponding to each step of the procedure and the total operating time were measured for each patient. The separate values were added so as to obtain a simulation of the total duration value for a single surgeon. The operative time of this virtual group of patients (Group I) was compared to that of the real group operated by the double team (Group II). Both values were compared to assess any statistical significance.ResultsThe mean operating time was 259 min with surgery operated by a double team and 371 min in the group I, a difference found to be statistically significant (p < 0.05). Exploration and preparation of the cervical region lasted 70 min in average with the double team versus 132 min in the group I (p < 0.05). No perioperative complications were noted.Discussion and conclusionBrachial plexus surgery performed by a double team allows the reduction of the operating time and thus minimizes the drawbacks associated with lengthy surgery such as perioperative bleeding and infection. Microsurgical suturing which is the crucial part of the surgery is easier when performed at the end of a shortened intervention and shared by two senior surgeons with, subsequently, less fatigue. This new organization that improves the operating conditions guarantees best results.