Surgical Supply and PPE Alternatives for Animal Shelters
COVID-19

While the surgical load in many animal shelters and veterinary clinics has been reduced due to COVID-19, accessing adequate surgical supplies for current and future use is on the minds of many. What safe, evidence-based options exist for handmaking, reusing, or upcycling surgical supplies?

Guidance for Reuse and Conservation of Surgical Supplies for Animal Shelters

Gloves

Access to surgical gloves is a major concern for veterinarians during COVID-19. Surgical gloves must be sterile except in the cases of cat castration, puppy castration, and minor wound repair, all of which require clean gloves. Here are some options for surgical glove reuse and upcycling:

Re-autoclave Surgical Gloves

Originally, surgical gloves were not single use items: gloves were cleaned, reprocessed, and reused. While today’s surgical gloves are not designed for reuse, many currently practicing veterinarians remember a time when reprocessing was standard practice. In addition, surgical gloves are commonly reprocessed and reused in many underresourced and developing countries.

Two different techniques for cleaning and reprocessing have been described. The first, favored by most veterinarians in small practices with limited staff requires the surgeon to clean, powder, and repackage the gloves. The second, favored in healthcare settings with access to many staff, uses staff for glove cleaning, drying, repacking, and reprocessing.

Gloves may be reprocessed up to three times if no holes or punctures occur, but should be discarded after the third reprocessing.

Method 1: Surgeon repacks gloves

  • At the completion of a surgery while remaining gloved, the surgeon goes to a sink or basin and washes and rinses their gloved hands. If any glove perforation or damage is noted, the gloves should be discarded. The surgeon’s gloved hands are then dried on a huck towel or other lint-free towel.
  • Most surgeons choose to powder their gloves* to make donning easier, and powdering should occur while the gloves are still on the surgeon’s hands. Baby powder (talcum powder) or corn starch can be used for this purpose. Sprinkle a small amount of powder on (clean, dry) gloved hands and hands are rubbed together to distribute the powder. The surgeon then takes off the gloves, peeling from the cuff towards the fingertips so that the gloves are inside out, with the powder now on the inside of the gloves.
  • The cuffs are folded to assist in sterile donning, and the gloves are replaced in their original glove paper or an alternative wrapping (such as a lint free towel or wrapper). A piece of autoclave tape is applied to the packaging, and the gloves are autoclaved at 121C (250F) for 30 minutes and at a pressure of 106 kPa (15 lb/in2).

Click here for a video from Dr. Deborah Cottrell with more information on best practices for reusing gloves.

*caveat: glove powder, including talcum powder and corn starch, can cause granulomas or adhesions in the abdomen of veterinary patients

Method 2: Staff cleans and repacks gloves

  • In this technique, the surgeon removes the gloves after surgery and the responsibility for cleaning and repacking gloves is left to clinic staff. This technique is described in an appendix to the book Infection Prevention: Guidelines for Healthcare Facilities with Limited Resources, published by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO).
  • Using this technique, gloves are cleaned inside and out and then hung up to dry before repackaging. In this book’s description, the gloves are not powdered but instead a piece of gauze or paper is placed inside the glove opening prior to sterilization. After autoclaving at 121C (250F) for 30 minutes and at a pressure of 106 kPa (15 lb/in2), the gloves are allowed to rest for up to 48 hours to regain elasticity.
  • This document also describes high level disinfection of gloves for non-surgical or clean-surgical procedures (such as cat neutering) that can be used to reprocess exam gloves if supply disruptions occur.

Upcycling: Autoclave Exam Gloves

Another option for sterile surgical gloves is upcycling by sterilizing exam gloves. The process of packing and sterilizing the gloves is similar to that described above for reprocessing surgical gloves.

The following link contains a presentation based on this study and includes photos:

Nitrile or latex examination gloves can be autoclaved, although with the gloves in this study, the nitrile gloves were easier to don and latex were more likely to stick together after autoclaving. However, for the gloves that could be donned and were not stuck together, the latex gloves performed equally well.

Also, notably, this study found that using alcohol to disinfect exam gloves was ineffective in over half of cases, so alcohol disinfection of gloves should not be substituted for autoclaving.

Surgeon Apparel

The argument has been made that, since there is little evidence behind most of the traditional surgeon’s garb, perhaps surgeons should work naked. While this proposition presents operational and logistical problems in clinical settings, this body of evidence also suggests that changes can be made in the standard surgical garb without negative consequences in regards to patient safety and surgical site infection risk.

Surgeon’s Caps

  • Surgeon’s caps are worn to cover the hair and reduce the shedding of particles and bacteria into the room air and onto the surgery site. Studies show that wearing a cap reduces bacterial counts at the incision site,  but that cloth caps perform as well as or even better than disposable surgical caps at reducing microbial shedding.
  • Furthermore, there is no evidence of the need to cover the ears or all of hair with the surgical cap, making skull cap type caps an acceptable option for surgeons to wear.
  • As with other cloth surgeon’s garb, cloth surgical caps should be laundered at the end of each surgery day.

How to make cloth surgeon’s caps:

Many patterns to make different types of cloth scrub caps are available online. Here are a few free patterns:

Surgical Masks

In veterinary surgery, surgical masks are used to protect the patient from surgical site infections, and generally not to protect the surgeon from the patient (except in the case of dentistry—see the next section). The rationale for wearing a surgical mask is to prevent bacteria, skin cells, and other particles from the surgeon’s face from entering the surgical site. Indeed, there is an increase in bacterial shedding from the face when a person is speaking, and wearing a surgical mask reduced the amount of bacterial particles reaching the surgical wound. However, that bacterial dispersal does not seem to translate into an increased risk of surgical site infection; a recent review found no difference in the incidence of surgical site infections between surgeries where surgeons wore masks and surgeries done without masks.

We know from recent research that cloth surgical masks offer little protection against viral respiratory illness in human healthcare providers, but they do offer some filtering capability for larger particle sizes. The bioburden of cloth masks (number of bacterial colony forming units remaining on the mask after use) can be higher than that of disposable surgical masks, although some disposable masks performed nearly as poorly as cloth masks. For this reason, if cloth masks are worn, they should be laundered daily.

In summary, while wearing surgical masks for routine surgery is customary and may be required by clinic policy or practice guidelines, there is no evidence for their use as a means to reduce surgical site infections and so from an evidence-based standpoint their use should be considered optional. In times of shortage, cloth masks offer an alternative to disposable masks and if laundered daily should not present a hazard to the patient or the provider.

How to make cloth surgical masks

In this age of COVID-19, patterns for making cloth masks abound online.

  • Sew The Curve Flat is a network of volunteers whose goal is to organize and aggregate the grassroots efforts of Home Sewists and match them with hospitals and at risk communities in their area to provide supplemental PPE in a crisis capacity. The group strives to provide the most current best practices, most effective patterns as well as a material list. Sew The Curve Flat recommends the Deaconess and AB masks to be worn over N95 masks to increase the life of PPE. All patterns we recommend are found on our website here, where sewists can also sign up to volunteer.
  • This page has pdf patterns and video instructions for ear loop or tie back style surgical masks,
  • Several options are available in this link using ties or elastic.
  • This page has downloadable pdf patterns for masks made from surgical wrap (a similar mask could be made from fabric),
  • The CDC website (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html) offers more guidance on the use of DIY masks and other face coverings.

Face Shields and Protection During Dentistry

Pet dentistry is one of the areas of veterinary medicine where a mask is often worn as a way to protect the veterinarian or technician rather than as a way to protect the patient. Many veterinarians wear surgical masks during dentistry, but even standard surgical masks are unlikely to filter out all the aerosolized particles. An option for better protection may be to use a face shield, perhaps in combination with a cloth or other handmade surgical mask.

Surgical Gowns

In routine spay neuter surgery, the use of a surgical gown is not required and is at the discretion of the surgeon. For surgeries in which gowns are required, commercial options include reusable cloth gowns or disposable gowns.

Cloth surgical gowns can be as effective as disposable gowns at protecting the patient from bacterial contamination and surgical site infection during soft tissue surgery.

The degree of impermeability required for a surgical gown varies with the surgery. In surgical cases with minimal expected fluid exposure during surgery, a gown with minimal barrier capabilities would be sufficient, whereas for wetter surgeries a fluid-resistant fabric would be required.  A moderate degree of fluid repellency can be achieved with 175- to 280- thread-count*, tightly woven cotton or polyester-and-cotton blended fabric. Higher degrees of repellency require chemical treatment of the fabric or special water-repellent fabrics or disposable barrier gowns.

While commercially made cloth gowns are available, shortages may occur. If a clinic chooses to manufacture their own surgical gowns, the fabric should be lint free, flame-resistant, and easily sterilized in an autoclave. Modern surgical gown sewing patterns are not readily available, but someone skilled in sewing may be able to create a pattern for a reusable gown using the template from an existing disposable surgical gown. If barrier requirements are minimal, the isolation gowns described in the PPE section of this website may be adequate for surgical gowns with only minor modifications.

* Thread count is determined by adding the number of horizontal and vertical threads per inch. A fabric with 80 horizontal and 80 vertical threads per inch would have a 160 thread count.

Surgical Drapes

As with surgical gowns, surgical drapes are available commercially as reusable cloth drapes or single use disposable drapes.  As with gowns, cloth surgical drapes can be as effective as disposable drapes at protecting the patient from bacterial contamination and surgical site infection during soft tissue surgery.

The degree of impermeability required for a surgical drape varies with the surgery. In surgical cases with minimal expected fluid exposure during surgery, a drape with moderate barrier capabilities would be sufficient, whereas for wetter surgeries a fluid-resistant or impervious fabric would be required.

Standards for different levels of barrier capabilities are summarized in ANSI/AAMI PB 70:12 Classification of Barrier Performance.

  • Level 1 material has minimal resistance to water and is therefore less effective as a drape when moisture from blood or lavage solutions is expected.
  • Level 2 material has low water resistance under constant contact with increasing pressure, although has some resistance to water spray.
  • Level 3 material has moderate water resistance, even with some constant contact and pressure.
  • Level 4 material is resistant to blood and viral penetration.

Cloth Drapes

Commercially made fenestrated cloth drapes are available, but it is also possible to sew surgical drapes. As with surgical gowns, materials for surgical drapes should be free of punctures and tears, resistant to fluid penetration (to the degree required by the anticipated procedure), lint-free, flame-resistant, and easily sterilized

Cloth barrier drapes (level 3 or 4) require a thread count* of 270 or more, but for many surgeries in veterinary practice this level of fluid barrier may not be necessary and a level 1 or 2 barrier fabric with lower thread count and a looser weave may be adequate.

* Thread count is determined by adding the number of horizontal and vertical threads per inch. A fabric with 80 horizontal and 80 vertical threads per inch would have a 160 thread count.

How to make cloth drapes:

The choice of fabric for surgical drapes will depend on the degree of fluid barrier that is required. Cotton or cotton-polyester blend fabrics may be used. Two layer cloth drapes are preferred. Both layers may be made of the same fabric, or a tighter-weave, less permeable fabric may be used for the area near the fenestration.

Reuse disposable drapes

Some veterinary clinics re-use disposable drapes if they are in good condition after surgery. In these cases, the drapes are rinsed in water to remove any blood, tissue, and fat that remains on the drapes after surgery. The drapes are then hung up to dry, are refolded, packaged, and re-autoclaved.

Surgical Hand Hygiene

Learn more with our guide to surgical hand hygiene alternatives for animal shelters.

Other Surgical Savers:

Sharpen re-usable surgical needles with a fish hook sharpener with this video.