Healthcare providers wear gloves not only to protect the patient, but to protect themselves from any potential bacteria or viruses that could be transmitted via the patient's blood and body fluids. Some glove manufacturers voluntarily test their gloves for viral barrier resistance per the American Society for Testing and Materials (ASTM) International standard test procedure.1 Surgical gloves passing this test should be the only ones considered for peri-operative use.
Surgical department managers must consider not only surgeon preferences, but barrier integrity, risk for allergic reactions, and cost when determining which gloves to include in the inventory.
Latex
Historically, natural rubber latex was the gold standard for surgical gloves. However, recent studies indicate that powdered, latex gloves have been linked to the increased number of people with latex sensitization.
Latex contains proteins, which are the main culprits in allergic reactions.2 Proteins in latex adhere to the cornstarch applied to gloves during processing. Once inhaled, these allergens can sensitize individuals as well as trigger allergic reactions in those already sensitized.2 Research has also indicated that the powder in powdered gloves contains more proteins than nonpowdered gloves, which may increase the incidence of sensitization.2
Glove powder is also a contributor to surgical wound infections and adhesion formation.3 Research-ers documented the development of an increased inflammatory response and increased bacterial growth when powdered latex gloves were used, which led to longer and more costly patient hospital stays.3
Considerations for glove selection
Typically, an ideal glove for surgeons and scrub personnel is strong, easy to don, resistant to puncture, comfortable, textured with a tacky surface to enhance gripping,4 and most importantly, barrier integrity, and nonallergenic. Sterile gloves are tested by manufacturers for comfort, feel, fit, and durability, and can be made from a variety of materials other than latex.5 Glove materials that meet ASTM International requirements for nonlatex surgical gloves include:
* chloroprene
* nitrile
* polymers or block polymers
* polyisoprene
* polyurethane.5
Deproteinized natural rubber latex (DPNRL), or low-protein latex gloves, are chemically treated to remove the proteins causing sensitization, which lead to allergies. One study comparing glove effectiveness concluded that DPNRL gloves provided tactile sensitivity and barrier integrity, yet significantly reduced the risk of sensitization to latex proteins.6 The cost of DPNRL gloves is still higher compared with natural rubber latex, yet less than other synthetic gloves. Researchers are still investigating low-protein alternatives, so they aren't yet recommended for patients or healthcare workers who have been diagnosed with a latex allergy.6
Barrier protection
The quest continues to find a synthetic alternative that provides the same level of barrier integrity as latex. Studies have been conducted to compare latex gloves with synthetic alternatives in categories that include barrier integrity, strength and flexibility, allergen content, puncture resistance, comfort, and cost. One such study concluded that as long as the gloves were intact, both latex and nonlatex gloves afforded adequate barrier protection; however, nonlatex gloves tended to have a higher perforation rate and a lower user satisfaction rate than latex gloves.7 The three variables that may affect barrier integrity in surgical gloves are material (latex or nonlatex), the type of surgery, and the length of time they are worn.7
Suture needles and scalpels are the top two surgical items responsible for glove penetration, followed by retractors, skin and bone hooks, and sharp electrode tips.8 A Cochrane study was conducted to determine which surgical specialty had the highest incidence of glove perforations. Orthopedic surgery, specifically open reduction of fractures with wiring, had the highest incidence of glove perforation, followed by gastrointestinal surgery.9 In obstetrics/gynecology, cesarean sections and tubal surgeries yielded higher perforation rates than vaginal procedures. Vascular, urology, and thoracic surgery had relatively low perforation rates.1 Nonlatex gloves were less durable in surgeries that required fine-motor movement, increased hand dexterity, or contact with hard surfaces or sharp bone.7
Length of surgery time and hand dominance also affected barrier integrity. Glove perforations have been noted 40 minutes into a surgical procedure, and for those lasting over an hour, glove perforations increased by 10%.8,9 Policies that allow for frequent glove changes during lengthy procedures may be helpful. A correlation between glove perforations and hand dominance was indicated; more glove perforations occurred on the nondominant hand, and than the thumb and the index finger sustained the most perforations.9
Many surgeons prefer to "double glove" to maintain asepsis during surgical procedures. The Cochrane study reviewed this practice as a means of perforation prevention and concluded that wearing two pairs of gloves during low-risk surgery offered more protection against perforation than single glove use.9 Double-gloving has been shown to decrease blood and body fluid exposure after perforation by as much as 87% if the inner glove remains intact.8
The Association of PeriOperative Registered Nurses (AORN) advocates double-gloving during invasive procedures, defined as, "the surgical entry into tissues, cavities, or organs or repair of major traumatic injuries." A review of clinical trials of gloving practices demonstrated that wearing double-gloves significantly reduced the number of perforations to the innermost glove, thereby decreasing the risk of exposure during invasive procedures.10
Glove perforation indicator systems use a colored pair of gloves (usually green) underneath a standard pair of gloves.9 Perforations can be readily detected when moisture from the operative field seeps between the layers of gloves, leading to earlier detection of glove perforation.9
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