The role of surgical gowns, drapes, and masks in the generation of airborne particulates

AORN Journal, Oct, 2000 by Nathan L. Belkin

In reporting the results of their comprehensive study on airborne particulates, the researchers and authors of "Airborne particulates in the OR environment" (AORN Journal, June 1999) focused on two sources--one inanimate, the other human.(1) First was a qualitative comparison between two surgical gowns and drapes made of nonwoven materials--one was a combination of wood pulp and polyester, the other was 100% polypropylene. The second source focused primarily on the filtering capabilities of the surgical mask and its inability to effectively retain contamination expelled from the nose and mouth.

THE RESISTANCE OF NONWOVEN MATERIALS TO ABRASION

In commenting on the presence of wood pulp fibers that had been liberated from one material during its use, the researchers said "that the use of disposable gowns, scrubs, and surgical draping constructed of wood pulp/polyester was associated with significant linting compared to items made from polypropylene."(2) They further observed that even after 100% polypropylene fabrics had been used, they found lint in the air sampling devices composed of wood pulp fibers rather than polypropylene.

These results confirm a study performed in 1983 in which researchers reported that the construction of some nonwoven materials renders them conducive to abrading quite easily.(3) For example, a nonwoven cellulose laminate product was subjected to an abrasion test normally used for woven textiles and was found to produce approximately 632 times as much lint by weight as the woven material to which it was compared.

WOOD PULP FIBERS AND POSTSURGICAL COMPLICATIONS

As controversial as the role that airborne contamination may have on the outcome of a surgical procedure, the pathogenicity of wood pulp fibers has been identified in the literature on numerous occasions. Complications after surgery attributable to wood pulp fibers from nonwoven materials first was reported in the literature on several occasions more than 25 years ago.(4)

In 1979, wood pulp fibers again were cited as having caused complications in 22 out of 1,000 surgical procedures.(5) These complications included keloids, wound dehiscence, incisional hernias, and chronic abscesses at the wound site. Two patients suffered recurrent bouts of intestinal obstructions due to peritoneal adhesions. The, hospital's pathologist detected the presence of wood pulp fibers with polarized light and believed the failure to use this technique more than likely accounted for the lack of widespread recognition of wood pulp fibers' presence. Another less known report published in 1984 revealed that patients' reactions to wood pulp fibers were secondary to those attributable to cellulose lint fibers.(6)

MODE OF TRANSMISSION

These disclosures drew a response challenging the allegation that disposable gowns and drapes were the direct source of wood pulp fibers. The authors of a 1979 article titled "Wood fiber contamination of reusable cotton laparotomy pads" maintained that the fibers were released by reusable laparotomy pads that had not been properly cleaned or were mishandled.(7) When released, the fibers were said to have adhered to internal surfaces (eg, the intestine) and were thereby accountable for the complications. Interestingly enough, the authors did not dispute that the fibers were responsible for granulomas. As evidenced in this article, the wood pulp fibers' mode of transmission into the patients' viscera might have occurred via the airborne route. This, however, does not preclude the possibility of fibers being transmitted by direct contact via a number of other routes (eg, the surgeon's gloved hands, exposed [uncovered] instruments).

IDENTIFYING FIBER CONTENT

The federal government's Textile Fiber Products Identification Act of 1958 was enacted to ensure that consumers be provided with information regarding the fiber content of items identified as household textile articles. These articles were defined as "wearing apparel, costumes and accessories, draperies, floor coverings, furnishings, bedding, and other textile goods of a type customarily used in a household."(8) The government subsequently modified the law and currently requires manufacturers to include information as to how the items can be cleaned (eg, laundered and dried, dry cleaned).

There are several reasons why there is no reference to any product made out of a nonwoven material. First, at the time the law was enacted, nonwoven fabrics were not found in any of the items to which the law applied. In addition, the law was not intended to be applicable to items that were to be used once then thrown away.

It should be noted that in 1991, the nonwoven industry filed a petition requesting a reduction of tariffs on its surgical products. The document indicated that, with the exception of one particular brand, the range of wood pulp fiber content of the materials used for those products was an integral part of their construction, varying from 50% to 100%.(9)

Under the circumstances, and in light of what is recorded in the clinical literature, it appears to be reasonable that it is incumbent on the perioperative nurse to understand the products used in the OR. This would include requesting information about the fiber content of nonwoven surgical gowns and draping materials directly from the manufacturer.