Sterile gowns for spinal anaesthesia – environmental cost without clinical gain: a reply

Abstract

The letter by Waite et al. highlights the need for sterile gowns in spinal anaesthesia [1]. Our local survey of 202 anaesthetists found that 178 (88%) would consider omitting a sterile gown if guidelines allowed. Currently, a number of anaesthetists reported that they do not use sterile gowns for elective and emergency obstetric spinal anaesthetics (20 (10%) and 63 (31%), respectively). The ‘rapid sequence spinal’ method described in 2010 promoting gown omission in emergencies, may explain this [2]. Guidelines from the USA, Canada and Germany do not mandate sterile gowns for spinal anaesthesia [3]. In a 2018 survey across 151 institutions in 13 countries, approximately 48% of respondents did not use sterile gowns routinely for epidural placement [4].

Barrier precautions for neuraxial procedures differ across specialities and our discussions with local colleagues support these findings. Notably, during the administration of intrathecal chemotherapy to immunosuppressed patients, haematologists do not typically wear sterile gowns.

A 2008 review suggested that infectious complications from spinal anaesthesia often arise from poor aseptic practices or contaminated equipment [5]. The importance of proper facemask use and oropharyngeal sources of common meningitis-causing organisms was stressed. This was supported by a 2018 review, which found that not using a mask was the most frequent risk factor in cases of septic meningitis, with Streptococcus salivarius being the most isolated organism [6].

Our survey showed 95% (192/202) face mask compliance in elective settings and 87% (176/202) in emergencies. Considering the infectious complications reported, perhaps it is also important to question whether assistants preparing spinal anaesthesia equipment should wear face masks. Our data indicated this is not common practice (12%, 24/202).

The infrequency of rare, but potentially devastating, infectious complications effectively precludes a randomised controlled trial, and there will likely never be definitive evidence to either support or reject sterile gown usage. Nonetheless, it is feasible to make a practical decision by weighing the practices of our international peers alongside the environmental impact of sterile gown usage. For instance, the carbon dioxide emissions produced yearly from sterile gown use for spinal procedures at one centre in Severn (UK) were 4000 kg of carbon dioxide equivalent (over 2500 spinal procedures annually) [3]. Reducing consumables from sterile gowns is an immediately actionable intervention to help deliver the more environmentally sustainable surgery outlined by Ledda et al. [7].

Our findings indicate many anaesthetists are forgoing sterile gowns, especially in emergency obstetric anaesthesia, mirroring results from NHS Tayside [1]. This suggests a general acceptance of changing practices among anaesthetists nationwide. If guidelines are revised, the importance of face mask use should be stressed and possibly extended to include assistants.