Hydrocephalus

Protection provided by double gloving

Journal of the National Medical Association December 2003

Glove failure represents a significant risk of exposure to bloodborne pathogens for perioperative personnel. Such failures are more likely to occur during procedures where shearing of glove material is likely and contact with sharp-edged items is common (eg, orthopedic surgery). The purpose of this prospective study was to determine whether double gloving (ie, wearing two pairs of gloves) during orthopedic procedures is effective in protecting the wearer against exposure to blood. (1)

Blood exposure was defined as contact of the skin of a gloved hand with blood. Procedures involving bone manipulation, an implant, or an external fixator were classified as bone procedures. All other procedures were classified as soft-tissue procedures. Gloves (n = 596) used by 170 surgeons and assistants during 71 consecutive orthopedic procedures, each lasting more than 30 minutes, were assessed, as were the hands of the surgeons and assistants.

At the end of each procedure, single or double glove use was documented, and each glove was evaluated for perforation via a water leak test (ie, filling the glove with water). The surgeons' and assistants' hands were visually inspected for blood. The site and number of perforations and exposures were recorded. Common statistical methods, including the Fisher's exact test, were used to analyze the data and compare observed differences.

Findings. Fifty-one (72%) of the procedures were classified as bone procedures and 20 (28%) were classified as soft-tissue procedures. Seventy-five percent (n = 128) of the surgeons or assistants wore double gloves, and 25% (n = 42) wore single gloves. Seventy-three perforations (ie, 70 in double gloves, three in single gloves) occurred for an incidence rate of 12% (73 of 596). The blood exposure rate per procedure was 13% (nine of 71--six double gloves, three single gloves). Significantly more perforations occurred during bone procedures compared to soft-tissue procedures (68 versus 5; P < 0.0001, relative risk [RR] = 4, 95% confidence interval [CI] 1.87-8.55). If double gloves were not used, the blood exposure rate would have been 87% (62 of 71; all outer-glove and single-glove perforations).

Clinical implications. This study showed that double gloving could provide surgical team members with additional protection from intraoperative exposure to blood during orthopedic procedures. Perioperative nurses should seriously consider using double gloves when assisting surgeons at the surgical field during orthopedic and other procedures where shearing of glove material is likely and contact with sharp-edged items is anticipated.

Smoking and risk of fracture

Journal of Internal Medicine December 2003

Smoking is known to have detrimental effects on bone metabolism, and women who are smokers often are considered to have a higher risk of hip fracture and reduced bone mass than nonsmokers. The objective of this meta-analysis was to determine if smoking was associated with an increased risk of fractures. (2) A literature search was conducted using the keywords smoking and fracture for all study types (ie, cohort, case-control, cross-sectional) that reported on risk estimates of fractures in smokers compared to nonsmokers. Common statistical techniques, including pooled risk estimates, attributable risk, trending, comparison of the slope of linear regression curves, and funnel plots were used.

Findings. Fifty studies that included a total of 512,399 participants were analyzed. There was no major difference in risk for fractures between male and female current smokers (P = 0.11). Current smoking was associated with a significant increase in risk for hip and spine fracture but not for forearm fractures (hip fractures: RR = 1.39, 95% CI 1.23-1.58; spine fractures: RR = 1.76, 95% CI 1.10-2.82; forearm fractures: RR 0.86, 95% CI 0.46-1.60). Pooled risk estimates in current and previous smokers showed that the estimate for all types of fractures was higher in current versus previous smokers (P = 0.03).

Clinical implications. This study revealed that smoking is associated with an increased risk for hip and spine fractures, and cessation of smoking appears to be associated with a decrease in risk for all fractures. Perioperative nurses have many opportunities to provide patients with information on risk reduction strategies. The results of this study should be added to their armamentarium.

Antibiotic-impregnated shunt system

Journal of Neurosurgery November 2003

Hydrocephalus most often is treated with surgical placement of a shunt system that diverts the flow of cerebrospinal fluid from a site within the central nervous system to another area of the body where it can be absorbed as part of the circulatory process. Infection of the shunt with gram positive skin flora and Staphylococcus epidermidis is a serious complication that usually requires removal of the shunt, interim placement of an external ventricular drain, treatment with antibiotics, and placement of a new shunt after the infection has cleared. Consequently, prevention of shunt infection is a major concern for surgeons. The objective of this prospective, randomized blind study was to determine whether an antibiotic-impregnated shunt system is effective in reducing shunt infections). (3)

One hundred ten patients were randomly assigned to two groups. In group I (ie, the control group), 60 patients received a standard shunt system, and in group II, 50 patients received the antibiotic-impregnated shunt system. Follow-up evaluations for the development of infection were performed at one, two, and six months after shunt insertion and at six month intervals thereafter. Logistic regression analysis techniques were used to analyze the differences between the two groups.

Findings. Thirteen shunt infections occurred. Ten occurred in the control group (rate 16.7%) and three in the antibiotic-impregnated shunt group (rate 3%,) (P = 0.084). The relative risk of developing a shunt infection in the control group was 2.78 times that of the antibiotic-impregnated shunt group (95% CI 0.87-8.91). The overall shunt infection rate was 11.8% per patient (95% CI 5.8-17.8). Staphylococcus species accounted for the majority of shunt infections. Staphylococcus aureus was the most frequent pathogen recovered from eight of the 13 patients with shunt infections (62%), and Staphylococcus epidermidis was recovered from two (15%) of the 13 patients.

Clinical implications. The antibiotic-impregnated shunt system appears to be effective in reducing the risk for shunt infections. Perioperative managers and staff members should bring the results of this study to surgical staff members for consideration.

Thromboembolism in patients undergoing craniotomy

Journal of Neurosurgery October 2003

Patients undergoing neurosurgical procedures are at risk for venous thromboembolism (VTE) because of extended periods of venous stasis. As a result, prevention of VTE receives high priority. It generally is addressed by mechanical prophylaxis, most frequently with antiembolism stockings and an external pneumatic sequential compression device (SCD). Patients undergoing craniotomy involving motor mapping for gliomas of the contralateral lower extremity, however, should remain visible so that motor responses can be identified accurately. The objective of this retrospective study was to determine if the use of the SCD on only one extremity increases the risk for VTE in these patients. (4)

The charts and computer records of all patients 18 years of age and older who underwent craniotomy for tumor resection at the University of California, San Francisco, between December 1997 and June 2000 were reviewed. In addition to collecting general biographical information, cardiovascular risk factors, the results of preoperative neurosurgical examinations, and instances of VTEs within six weeks after surgery were determined. Venous thromboembolism was classified as deep vein thrombosis (DVT) or pulmonary embolism (PE) confirmed by Doppler ultrasonography, spiral computerized tomography scanning, or both. Common statistical techniques were used to analyze the data.

Findings. The records of 180 patients were reviewed. The intraoperative VTE prophylaxis of all patients consisted of ipsilateral lower extremity mechanical prophylaxis. Six of the 180 patients developed a VTE after surgery for an overall incidence of 3.3%. Of the six patients in whom VTE developed, three (1.7%) experienced a DVT in the lower extremity contralateral to the site of surgery and one (0.6%) experienced a DVT in the ipsilateral lower extremity. Two patients developed a PE with no detectable DVT. There was no significant difference between the incidence of DVT formation in the contralateral leg compared to the ipsilateral leg.

Clinical implications. This study indicated that there was no additional risk for VTE in patients who underwent craniotomy with motor mapping for gliomas in which only one extremity was subjected to mechanical prophylaxis. Perioperative nurses should know that unilateral intraoperative placement of mechanical prophylaxis (ie, antiembolism stockings, SCD) is a safe method for VTE prophylaxis for patients undergoing these types of procedures.

NOTES

(1.) L O Thanni, W Yinusa, "Incidence of glove failure during orthopedic operations and the protective effect of double gloves," Journal of the National Medical Association 95 (December 2003) 1184-1188.

(2.) P Vestergaard, L Mosekilde, "Fracture risk associated with smoking: A meta-analysis," Journal of Internal Medicine 254 (December 2003) 572-583.

(3.) S T Govender, N Nathoo, J R van Dellen, "Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus," Journal of Neurosurgery 99 (November 2003) 831-839.

(4.) K I Auguste et al, "Incidence of venous thromboembolism in patients undergoing craniotomy and motor mapping for glioma without intraoperative mechanical prophylaxis to the contralateral leg," Journal of Neurosurgery 99 (October 2003) 680-684

GEORGE ALLEN

RN, PHD, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

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