Anesthesia & Analgesia | 2021
Reply to letter to editor.
Abstract
In Response We would like to thank Sahni et al 1 for commenting on the use of nonsterile examination gloves during the coronavirus disease 2019 (COVID-19) pandemic. We agree that gloving can be a controversial issue and that more high-quality research is needed to fully understand what should be the best practices for gloving during patient care. In thinking about gloving, it is important to understand when gloving is used to protect the health care worker and when it is used to protect the patient. The popularity of wearing nonsterile examination gloves originated with the human immunodeficiency virus (HIV) epidemic, and was part of “universal precautions,”2 later known as “standard precautions.”3 These consist of gloves, gowns, and eye protection when needed to prevent contact between the health care worker and the bodily fluids of patients. In the presence of blood borne pathogens, the main reason for wearing gloves is to protect the health care worker from contact with pathogens that could infect them through breaks in the skin of their hands. Obviously, this is still a concern today; despite our current focus on COVID-19, bloodborne diseases such as HIV are of enormous importance. Whether gloving protects the patient is difficult to know, and the equivocal results of the meta-analysis of Chang et al4 examining the effect of “universal gloving” on hospital-acquired infection reflects this ambiguity. Arguably, if a health care worker touches a patient with clean hands that have been properly washed with soap and water or gelled with an alcohol-based gel, there may be no more risk to the patient than if the health care worker is wearing nonsterile gloves. The recommendation to wear double gloves during airway management and discard the outer layer of gloves following intubation or supraglottic airway placement is based primarily on simulation laboratory studies by Birnbach et al.5,6 These studies demonstrated that a fluorescent dye in the mouth of a mannequin was widely spread around the anesthesia workspace following simulated airway management, but the spread was reduced if double gloving was utilized. This recommendation was included in the expert guidance for infection prevention during anesthesia of the Society for Hospital Epidemiology of America (SHEA)7 and in our recent article concerning COVID-19.8 While the evidence for this practice is not strong, double gloving is easily performed and could be valuable. Applying alcohol-based hand gel to gloves, rather than removing soiled gloves and applying the alcohol-based hand gel directly to the hands, is a controversial approach to hand hygiene. The presence of bodily fluids on hands is an indication for worn gloves will affect the incidence of HAI in operating rooms and ICU, both COVID and non-COVID. The other concern is that multiple applications of ABHR on gloves may alter their physical properties. Gao et al5 observed ABHRs affected the tensile strength of the tested nitrile more than latex gloves. In addition, ethanol-containing ABHR led to minimal changes in tensile strength of gloves compared to isopropanol containing ABHR.5 Birnbach et al,6 however, showed that the application of ABHR on widely available nitrile examination gloves does not hamper glove integrity and allows safe performance of anesthesia practices. The possible changes in glove properties with multiple applications of ABHR need to be addressed. This is especially significant in the context of safety of HCW working in COVID areas. In the current COVID-19 scenario, when HCW are advised to perform patient care along with self-care, these concerns need to be explored to understand the impact of universal gloving and application of ABHR over worn gloves on incidence of HAI while maintaining safety of HCW.