To the Editor:—
The editorial “Gloved and Masked—Will Gowns Be Next?” by Hepner1is both interesting and disconcerting. The main reason surgeons resist neuraxial anesthesia is because “It takes too long!” For this reason, it is frightening to see the rubric “Will gowns be next?” Demanding that anesthesiologists wear gowns to perform neuraxial anesthesia will, in my opinion, be the death knell for spinal and epidural anesthesia. Locating and donning a gown for these procedures will obviously not make doing them less time-consuming. More importantly, is it even necessary?
Despite outcome data demonstrating a 1:10,000 to 1:50,000 risk of post–dural puncture meningitis, Dr. Hepner bases his recommendations for using gowns during neuraxial anesthesia on logic: “we must institute uniform sterile safety practices that have been proven, or seem by common logic to be prudent, and continue to study techniques used in other arenas [infection owing to central venous catheters (CVCs)] to determine their utility.”1That is, if gowns and full barriers are better for CVC insertions, it is logical that they are also good for neuraxial anesthesia.
In the study showing that full-barrier precautions (sterile gloves, long-sleeved sterile gown, mask, cap, and large sterile sheet drape) reduced the incidence of CVC-related bloodstream infection compared with standard precautions (sterile gloves and small drape), the incidences of infection were 4 of 176 patients (2.3%, full-barrier precautions) and 12 of 167 patients (7.2%, standard precautions).2The extrapolated CVC infection rate is 227:10,000 for full barrier and 718:10,000 for standard barrier.
If the neuraxial anesthesia infection rates were the same as for CVC insertions, no one would argue against the use of neuraxial full-barrier precautions. However, infections associated with neuraxial anesthesia (assuming 1:10,000 with standard precautions) are 718 times less than the infection rate for CVC placement. Why do we need to look to the CVC data, which clearly are irrelevant to neuraxial infections, and why do we need to depend on logic when we have valid neuraxial outcome data? If a 1:10,000 infection risk for lumbar puncture is unacceptable, what risk is acceptable? How much better can we do with full-barrier precautions and at what cost? How will we know whether full-barrier precautions are better? Based on the data, one could argue that full barriers for neuraxial anesthesia are an illogical solution to a nonproblem.
I have done many spinals and epidurals during 25 yr of practice. Fortunately, none have caused an infection. However, my numbers are not close to approaching 10,000. It is encouraging to learn from Baer's data3that the odds that I will have an infection are exceedingly low. I wear gloves and a cap when doing neuraxial anesthesia. Although I have not routinely done so, I will wash my hands before putting on sterile gloves because that will apparently easily and conveniently further lessen any risk. On the other hand, I am resisting the donning of a gown until there is more than “logic” to justify it. Doing so will only jeopardize neuraxial anesthesia by making it take longer than it already does.