Surgeon Personal Protection: An Underappreciated Benefit of Positive-pressure Exhaust Suits

Background Positive-pressure exhaust suits cost more than standard surgical gowns, and recent evidence suggests that they do not decrease infection risk. As a result, some hospitals and surgeons have abandoned positive-pressure exhaust suits in favor of less expensive alternatives. We propose that in addition to their original purpose of decreasing infection rates, positive-pressure exhaust suits may also improve personal protection for the surgeon and assistants, perhaps justifying their added costs. Questions/purposes (1) Do positive-pressure exhaust suits decrease exposure to particulate matter during TKA? (2) What areas covered by gowning systems are at risk of exposure to particulate matter? Methods Three surgical gowning systems were tested: (1) surgical gown, face mask, surgical skull cap, protective eyewear; (2) surgical gown, face mask, surgical protective hood, protective eyewear; and (3) positive-pressure exhaust suit. For each procedure, a cadaver knee was injected intraarticularly and intraosseously with a 5-mu m fluorescent powder mixed with water (1 g/10 mL). After gowning in the standard sterile fashion, the primary surgeon and two assistants performed two TKAs with each gowning system for a total of six TKAs. After each procedure, three independent observers graded skin exposure of each surgical participant under ultraviolet light using a standardized scale from 0 (no exposure) to 4 (gross exposure). Statistical analysis was performed using Friedman's and Nemenyi tests. The interrater reliability for the independent observers was also calculated. Results The positive-pressure exhaust suits had less surgeon and assistant exposure compared with other systems (p < 0.001). Themedian overall exposure grade for each gowning system was 4 for System 1 (range, 3-4), 2.5 for System 2 (range, 2-3), and 0 for System 3 (range, 0-0). In pairwise comparisons between gowning systems, the positive-pressure exhaust suits had less exposure than gowning System 1 (difference of medians: 4, p < 0.001) and gowning System 2 (difference of medians: 2.5, p = 0.038). There was no difference found in exposure between Systems 1 and 2 (difference of medians: 1.5, p = 0.330). When gowning Systems 1 and 2 were removed, particulate matter was found in places that were covered such as the surgeon's beard, lips, inside the nostrils, behind the protective eyewear around the surgeon's eye, and in both eyebrows and eyelashes. Conclusions The positive-pressure exhaust suits provided greater personal protection with each procedure than the other two gowning systems.