Study of Blood Contact in Simulated Surgical Needlestick Injuries With Single or Double Latex

Gloving • 
Author(s): Andreas Wittmann, PhD; Nenad Kralj, MD, MScD; Jan Köver, BA; Klaus Gasthaus,
Dipl Phys; Friedrich Hofmann PhD, MD, MScD
Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 1 (January 2009), pp. 53-56
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology
of America
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 infection control and hospital epidemiology january 2009, vol. 30, no. 1

original article

Study of Blood Contact in Simulated Surgical Needlestick Injuries

With Single or Double Latex Gloving

Andreas Wittmann, PhD; Nenad Kralj, MD, MScD; Jan Köver, BA; Klaus Gasthaus, Dipl Phys;
Friedrich Hofmann PhD, MD, MScD

objective. Needlestick injuries are the most common injuries that occur among operation room personnel in the health care service.
The risk of infection after a needlestick injury during surgery greatly depends on the quantity of pathogenic germs transferred at the point
of injury. The aim of this study was to measure the quantity of blood transferred at the point of a percutaneous injury by using radioactively
labeled blood.
design. This study was conducted to evaluate the risk of infection through blood contact by simulating surgical needlestick injuries ex
vivo. The tests were conducted by puncturing single and double latex gloves with diverse sharp devices and objects that were contaminated
with Technetium solution–labeled blood.
results. A mean volume of 0.064 mL of blood was transferred in punctures with the an automatic lancet at a depth of 2.4 mm through
1 layer of latex. When the double-gloving indicator technique was used, a mean volume of only 0.011 mL of blood was transferred (median,
0.007 mL); thus, by wearing 2 pairs of gloves, the transferred volume of blood was reduced by a factor of 5.8.
conclusions. The results revealed that double gloving leads to a significant reduction in the quantity of blood transferred during
needlestick injury.
Infect Control Hosp Epidemiol 2009; 30:53-56

In a recent large survey, approximately 99% of all surgeons methods

said that they had experienced a needlestick injury over the
course of their professional lives. Among those surveyed, the
mean number of needlestick injuries over the previous 5 years
was 8; however, only approximately one-half of the surgeons
reported their injuries.1 Surgical glove punctures often go
unnoticed during surgery; in other words, undetected blood
contact and/or needlestick injuries can occur.2
The risk of infection after a needlestick injury that occurs
during surgery greatly depends on the quantity of pathogenic
germs transferred at the point of injury (resulting from the
quantitative blood contact) and on the probability that the
instrument was used for an infectious patient. The aim of
this study was to measure the quantity of blood transferred
at the point of a percutaneous injury by using radioactively
labeled blood. Surgical blades and automatic lancets were
used in this study. Because the literature regularly cites the
supposed protective effect of double gloving, the blood con-
tact volumes for needlestick injuries through a double layer
of latex were also determined, to assess the protective efficacy
of double gloving.
We chose an ex vivo model for conducting the tests. Circular
samples of fresh pork skin (thickness, approximately 19 mm)
were made with use of a stamping tube. Then, 2-mL samples
of fresh, human whole blood were obtained by using the
Sarstedt Monovette system, and sodium citrate was added to
the samples to prevent coagulation during the subsequent
tests. The blood sample for each test was obtained from the
same person performing the test to rule out any risk of
infection.
First, 1.5 mL of blood was pipetted from the available
sample and was mixed with approximately 1 mL of highly
radioactive (approximately 15 MBq/mL) Technetium solution
(99Tc). The activity in the 1.5-mL radioactive blood sample
was gauged by using an activimeter (Isomed 2000) and was
recorded.
To simulate the percutaneous injuries, the samples were
mounted in a holder, and a single finger from a medical glove
(Biogel; Mölnlycke) was stretched over the sample. The pat-
ented double-gloving technique with indicator (BiogelEclipse
Indicator; Mölnlycke) was used to test blood contact with

From the Department of Safety Engineering, University of Wuppertal (A.W., N.K., J.K., F.H.), and the Helios Klinikum Wuppertal, Klinik für Nuklearmedizin
(K.G.), Wuppertal, Germany.
Received July 3, 2008; accepted August 3, 2008; electronically published December 2, 2008.
䉷 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2009/3001-0010$15.00. DOI: 10.1086/593124

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All use subject to JSTOR Terms and Conditions
54 infection control and hospital epidemiology january 2009, vol. 30, no. 1
double-gloved hands. This double-gloving technique involves
use of a green inner glove that is an approximately half-size
larger than necessary and that is worn with a straw-colored
outer glove.
We only conducted tests with at least 1 layer of latex, be-
cause it is no longer common to perform operations without
sterile gloves. Each test configuration was repeated 40 times
under identical conditions.
To simulate punctures with surgical suturing needles, we
first applied 3 mL of blood with a dosing pipette (Brand
Transferpette 20 mL; accuracy, 0.02%) to the outside of each
test glove. Then, preloaded safety lancets (Owen Mumford
Unistik3 Normal, 21G; depth of puncture, 2.4 mm ) were
used to pierce the glove through the applied blood. By using
preloaded safety lancets, we were able to ensure that each
puncture took place under identical conditions (ie, the same
duration and depth of puncture). Injuries caused by sharp
objects such as bone fragments and scissor tips were also
simulated with an automatic lancet (Owen Mumford Unistik2
Neonatal, 18G; depth of puncture, 1.8 mm) equipped with
a blade-shaped needle (Figure 1). These tests were also con-
ducted by puncturing a glove with 3 mL of preapplied blood.
Punctures with scalpel blades (Otto Rüttgers KG Mini
Blades [used for microsurgery]; material thickness, 0.6 mm)
were made by using a specially constructed automated punc-
turing device (Figure 2). The scalpel blades were immersed
in blood at a depth of 10 mm for 30 seconds; then, the
puncturing device performed identical punctures (depth, 3
mm). We originally developed the puncturing device for mea-
suring blood volume transfers with cannule punctures. The
device reproducibly and constantly maintains the testing pa-
rameters, such as puncture depth, duration, and speed.
Each sample was then gauged by using a g well-counter
connected to a computer (Maestro MCB 129). The trans-
ferred blood volume was calculated according to the radio-
active decay determined 1 minute after blood contamination.
figure 1. The 2 automated lancets used in the study: Unistik
Normal (left) and Unistik Neonatal (right).
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figure 2. Automated puncturing device with which scalpel
blade injuries were simulated.
Before taking measurements, the gauge was calibrated daily
to the energy region of the Technetium activity with use of
2 different emitters (131I and 99Tc). The region of interest was
calibrated to 10 MeV greater than and 10 MeV less than the
mean b-decay energy (141 MeV) of the 99Tc isotope. The data
were analyzed using SPSS, version 14 (SPSS).
results
A mean volume of 0.064 mL of blood (median, 0.037 mL;
standard error of the mean [SEM], 0.012 mL) was transferred
in punctures with the Unistik3 Normal automatic lancet at
a depth of 2.4 mm through 1 layer of latex. With the double-
gloving indicator technique, a mean volume of only 0.011
mL of blood (median, 0.007 mL; SEM, 0.003 mL; P ! .05) was
transferred; thus, use of 2 pairs of gloves, the transferred
volume of blood was reduced by a factor of 5.8.
Punctures with the blade-shaped Unistik2 Neonatal lancet
through a single layer of latex transferred a mean volume
(ⳲSD) of 0.133 Ⳳ 0.069 mL of blood (median, 0.113 mL;
SEM, 0.011 mL), which was considerably more than the
amount transferred when punctures were made with the nee-
dle-shaped Unistik3 Normal lancet, even though the puncture
depth of the Unistik2 Neonatal lancet was only 1.8 mm. When
punctures were made through a double layer of latex, the
transferred mean volume (ⳲSD) decreased to 0.035 Ⳳ
0.033 mL (median, 0.027 mL; SEM, 0.005 mL; P ! .05), which
resulted in a factor of protection of 3.8.
Needlestick injuries through a single layer of latex simu-
lated with blood-contaminated mini-blades resulted in a
mean transferred volume of blood (ⳲSD) of 0.168 Ⳳ 0.102
mL (median, 0.141 mL; SEM, 0.016 mL); through a double
layer of latex, the mean transferred volume of blood (ⳲSD)
was 0.036 Ⳳ 0.031 mL (median, 0.028 mL; SEM, 0.005 mL;
P ! .05). Double gloving resulted in a factor of protection of
4.6 (Figure 3).
All punctures of the double layer of latex were clearly iden-
tifiable by the green coloring of the puncture site. This col-

figure 3. Box plot showing the transferred blood volume in ex
vivo tests with 3 different automated puncture devices and with
single and double gloving. Grey boxes, interquartile range (IQR);
black lines within the boxes, median values; horizontal lines outside
boxes, range excluding outliers and extreme values; black circles, out-
liers (values 11.5 and !3 times the IQR from the 75th percentile);
stars, extreme values (values 13 times the IQR from either the 25th
or the 75th percentiles).
oring is the result of fluids entering the space between the
gloves through the puncture site, which causes the green inner
glove to show through the straw-colored outer glove.
discussion
A series of studies has been conducted worldwide on the risk
of surgical personnel being exposed to blood-borne patho-
gens.3 In those studies, blood contact and/or injury was usu-
ally detected by inspecting the latex gloves worn during sur-
gical procedures. The glove puncture rate was most frequently
determined by filling the gloves with water or by using elec-
trical measuring methods similar to those used for condom
testing.4 In every study, the glove puncture rate depended on
the type of surgical procedure (ie, there is an increased the
risk of blood contact during longer procedures5); operations
that required great effort and involved bones6,7or deep lo-
cations8 resulted in glove puncture rates of up to 70%. The
risk of blood contact during endoscopic procedures was sig-
nificantly lower, with a puncture rate of approximately 9%.9–
11
The lead surgeon and the assisting personnel have the high-
est risk of injury.12,13
Improved protection against infection can be achieved by
wearing 2 pairs of gloves. Many studies have proven the ben-
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surgical needlestick injuries 55
efits of double gloving in preventing blood contact. Studies
from the United States14,15 determined that double gloving
can reduce the risk of blood contact by a factor of 10. Two
other studies found that use of doubled surgical gloves re-
duced the rate of blood contamination among surgeons from
70% (in both studies) to 13% (in one study) and 2% (in the
other study).16,17 The rate of blood contamination was min-
imized despite a puncture in the outer glove, because the
inner glove remained intact in up to 82% of cases.18–20
Protection against infection can be increased even more
by double gloving with an indicator glove. This gloving tech-
nique includes a colored inner glove and an outer glove that
is neutral in color. If the outer glove is punctured during the
operation, the fluids present in all procedures will appear as
a clearly visible spot at the site of the puncture. Once such
a spot is noticed by any member of the surgical team, the
glove can be replaced, thus minimizing the risk of an infection
that results from continuing with the operation.
To date, the studies conducted on early detection of glove
punctures during surgical procedures have revealed that in-
dicator gloves are very effective. Compared with complicated
electronic indicator systems that often tend to sound the
alarm because of changes in the conductivity of the latex
gloves,21,22 indicator gloves enable the detection of up to 100%
of punctures immediately after they occur.23,24
A meta-analysis of the 18 studies conducted on glove safety
worldwide found that double gloving led to 3 times fewer
contacts with blood, compared with using a single pair of
gloves. No concentrations of punctures on the outer glove
were found that could indicate a reduction in hand sensitivity
or dexterity.3
Although the protective effect of double gloving is very
evident, it is not yet routine practice. This is mainly attrib-
utable to the alleged reduction in dexterity and sense of touch
through the double layer of latex. A study conducted at the
University of Wuppertal (Wuppertal, Germany), in which
participants underwent a standard neurological 2-point dis-
crimination test and a “dice test” (in which the blindfolded
participant had to determine the number of pips on dice of
various sizes), found no significant reductions in the sense
of touch in those wearing 2 pairs of gloves.25 A US study that
tested both sense of touch and dexterity found that 2 pairs
of gloves had an adverse effect only on the surgeons who
normally operated with a single pair of gloves; within a short
period, however, even these surgeons became accustomed to
using 2 pairs of gloves.26
Our tests prove that double gloving also has a positive effect
on the blood volumes transferred by surgical needlestick in-
juries. Use of 2 pairs of gloves led to a significant reduction
in transferred blood volume in all of the tests.
Therefore, it has been established that double gloving pro-
vides a significant reduction in the risk of blood exposure to
surgical personnel. Indicator systems have the added advan-
tage of preventing the infection of unnoticed injuries, which
56 infection control and hospital epidemiology january 2009, vol. 30, no. 1
can occur with glove punctures that are difficult to detect.
The aforementioned double-gloving techniques already exist,
and their benefits, compared with single gloving, are known
in the field of surgery. In conclusion, double gloving should
be recommended for all surgical procedures and should be
required for procedures for patients with known infections
or for patients who have not yet been tested for infections.
acknowledgments
Financial support. Regent Medical Overseas, Mölnlycke Healthcare.
Potential conflicts of interest. All authors report no conflicts of interest
relevant to this article.
Address reprint requests to Andreas Wittmann, PhD, University of Wup-
pertal, Dept. of Safety Engineering, Gauss Str. 20, D-42097 Wuppertal, Ger-
many (andwitt@uni-wuppertal.de).
references
1. Makary MA, Al-Attar A, Holzmueller ChG, et al. Needlestick injuries
among surgeons in training. N Engl J Med 2007; 356:2693-2699.
2. Kralj N, Beie M, Hofmann F. Surgical gloves–how well do the protect
against infections? [in German]. Gesundheitswesen 1999; 61:398-403.
3. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection.
Cochrane Database Syst Rev 2006;(3):CD003087.
4. Kralj N. Handschuhe—infektionsschutz für beschäftigte und patienten.
In: Hofmann F, Reschauer G, Stößel U. Arbeitsmedizin im Gesundheits-
dienst XIV. Freiburg: FFAS; 2001:100-105.
5. Zimmermann CH, Junghanns K. Die verwendung eines neuen perfor-
ationsindikatorsystems in der chirurgischen routine. Hyg Med 1996; 21:
486-492.
6. Eckersley JR, Williamson DM. Glove punctures in an orthopaedic trauma
unit. Injury 1990; 21:177-178.
7. Wright KU, Moran CG, Briggs PJ. Glove perforation during hip arthro-
plasty: a randomised prospective study of a new taperpoint needle. J
Bone Joint Surg 1993;75:918-920.
8. Hollaus PH, Lax F, Janakiev D, Wurnig PN, Pridu NS. Glove perforation
rate in open lung surgery. Eur J Cardiothorac Surg 1999; 15:461-464.
9. Eklund AM, Ojajärvi J, Laitinen K, Valtonen M, Werkkala KA. Glove
punctures and postoperative skin flora of hands in cardiac surgery. Ann
Thorac Surg 2002; 74:149-153.
10. Beie M, Kralj N, Hofmann F. Gefährdungsanalysen in krankenhäusern.
This content downloaded from 194.29.185.154 on Thu, 15 May 2014 14:17:35 PM
All use subject to JSTOR Terms and Conditions
In: Hofmann F, Reschauer G, Stößel U. Arbeitsmedizin im Gesundheits-
dienst XII. Freiburg: FFAS; 1999:347-364.
11. Popejoy SL, Fry DE. Blood contact and exposure in the operating room.
Surg Gynec Obstet 1991; 172:480-483.
12. Rieger MA, Hasselhorn HM, Beie M, Kralj N, Vetter HD, Hofmann F.
Personnel-to-patient transmission of hepatitis C virus: underestimation
of exposure. Arch Int Med 2000; 161:2313-2316.
13. Heeg P. Sicherheitsaspekte bei operationshandschuhen. Operat Orthop
Traumatol 1993; 5:291-293.
14. Bennett B, Duff P. The effect of double gloving on frequency of glove
perforations. Obstet Gynecol 1991; 78:1019-1022.
15. Bebbington MW, Treissman MJ. The use of a surgical assist device to
reduce glove perforation in post vaginal repair: a randomised control
trial. Am J Obst Gynecol 1996; 175:862-866.
16. Greco RJ, Garza JR. Use of double gloves to protect the surgeon from
blood contact during aesthetic procedures. Aesthetic Plast Surg 1995; 19:
265-267.
17. Naver LPS, Gottrup F. Incidence of glove perforations in gastrointestinal
surgery and the protective effect of double gloves: a prospective, ran-
domised controlled study. Europ J Surg 2003; 166:293-295.
18. Cole RP, Gault CT. Glove perforation during plastic surgery. Br J Plast
Surg 1989; 42:481-483.
19. Thomas S, Agarwal M, Mehta G. Intraoperative glove perforation—single
versus double gloving in protection against skin contamination. Postgrad
Med J 2001; 77:458-60.
20. König M, Bruha M, Hirsch HA. Perforation of surgical gloves in gy-
necologic operations and abdominal Cesarean section [In German]. Ge-
burtsh Frauenheilk 1992; 52:109-112.
21. Caillot JL, Cote C, Abidi H, Fabry J. Electronic evaluation of the value
of double gloving. Br J Surg 1999; 86:1387-1390.
22. Fisher MD, Reddy VR, Williams VM, Lin KY, Thacker JG, Redlich RF.
Biomechanical performance of latex and non-latex double-glove systems.
J Biomed Mater Res 1999; 48:797-806.
23. Manson TT, Bromberg WG, Thacker JG, McGregor W, Morgan RF,
Redlich RF. A new glove puncture detection system. J Emerg Med
1995; 13:357-364.
24. Duron JJ, Keilani K, Elian NG. Efficacy of double gloving with coloured
inner pair for immediate detection of operative glove perforations. Eur
J Surg 1996; 162:941-944.
25. Beie M, Kralj N, Sieker S, Hofmann F. Infektionsschutz im arbeitsleben-
studien zum tastsinn bei einfacher bzw. doppelter behandschuhung. In
Schäcke G, Lüth P. Dokumentationsband über 40. Jahrestagung der
DGAUM. Rindt Druck: Fulda; 2000:310-312.
26. Novak CB, Patterson MM, Mackinnon SE. Evaluation of hand sensibility
with single and double latex gloves. Plast Reconstr Surg 1999; 1:128-131.