Safer Use
Safer Use of Hoods and Togas in Total Joint Arthroplasty
Introduction
Surgical spacesuits, or togas, have become an integral part of operating room protocols, especially in hip, knee and shoulder arthroplasty. Many arthroplasty surgeons view these specialized surgical gowns as essential for reducing infection risks for patients, while also protecting themselves and the surgical team from potentially infectious fluids, bone fragments, and other airborne particles. However, recent data has called into question whether modern positive-pressure surgical hoods and togas, commonly used in operating rooms today, offer a clear protective benefit for patients or inadvertently increase the risk of periprosthetic infection.
The Charnley toga, developed over 50 years ago, was a negative-pressure body exhaust suit designed to draw air from within the suit and vent it outside the operating room through hoses attached to the toga. Although less comfortable than today’s positive-pressure togas, this design significantly reduced infection risk by preventing air from inside the toga from escaping into the sterile surgical field. In contrast, modern positive-pressure togas, with their integrated fans, enhance the comfort and mobility of the surgeon and staff, making them much more wearable. However, it remains uncertain whether these modern togas improve patient safety in joint replacement surgeries.
Research has shown that contamination can occur at the wrist area with positive-pressure togas, and this contamination risk increases with the duration of surgery. There is also potential for leakage of body exhaust air from the unsealed backs of of surgeons when using hoods with a standard surgical gown, a risk that may be mitigated but not eliminated by surgical vests. Although various strategies are in place to reduce infection risks surrounding joint replacement surgeries, there has been insufficient focus on the fact that positive-pressure togas, with their fans, increase local air circulation and potentially elevate the movement of airborne particles near the operative field.
Recommendations for Safe Hood and Toga Use
To help mitigate these risks, orthopedic surgeons may consider implementing the following safety practices when using hoods and togas during joint arthroplasty:
1. Test the Helmet and Fan Before Entry into the OR
Before entering the operating room, test the helmet and fan by turning them on, and then turn off the fan or unplug the battery. This ensures that the equipment is functional but avoids introducing additional air circulation in the OR before donning the toga.
2. Keep the Fan Off During Donning
Maintain the fan in the off position until the toga and gloves are on. This helps prevent unfiltered air from passing by the surgeon’s head and hair onto the sterile field while the sterile attire is put in place.
3. Avoid Zippers on Togas
Choose a toga without a zipper when possible, as this reduces the risk of an unsterile circulating nurse accidentally contaminating the back of the toga through improper handling.
4. Watch for Face Shield Contamination
If wearing only a hood or a two-piece toga, monitor that the surgical technician avoids touching the face shield after it has contacted the helmet, as this can lead to contamination.
5. Careful Waist Tie Management
The surgical technician should grab the waist tie and ensure that the toga is pulled down carefully to avoid contact of the waist tie with unsterile areas.
7. Tie the Waist Loosely
Keeping the toga waist tied loosely allows positive pressure air to escape at the lower edge of the toga near the feet, reducing pressure at the glove-gown interface and subsequently decreasing contamination risk at the wrists.
8. Prevent contamination of the wrist during glove application
This can be performed by keeping the surgeon’s fingertips inside the cuff of the toga sleeve during inner glove application.
9. Seal Wrist Areas
Securely fasten the wrists of the inner gloves to the gown interface using Ioban to prevent air leakage and reduce contamination at this critical junction.
10. Use Low Fan Settings
Keep the fan at the lowest comfortable setting to minimize internal positive pressure, which helps reduce the risk of airborne particle leakage near the surgical field.
11. Avoid Mask Adjustment After Gloves Are On
If mask adjustment is necessary, perform it before donning the outer gloves. Thin material around the neck area increases infection risk, so avoid nose scratching or other unnecessary adjustments during the procedure.
12. Consider the Crown of the Hood Non-Sterile
Do not assume sterility of the hood’s crown, as this area may be more permeable and thinner than other parts of the helmet, increasing contamination potential.
13. Turn Off the Fan Before Doffing
To minimize airborne particle spread in the OR, turn off or unplug the fan before removing the toga, and perform this step either outside the operating room or as far from the sterile field as possible.
Conclusion
These recommended guidelines are intended to help reduce contamination risks associated with the use of positive-pressure togas and hoods in total joint arthroplasty. By adopting these practices, surgeons and staff can continue using these products for their protective benefits while enhancing the safety of patients undergoing joint replacement procedures.
If you have any additions or suggestions about how to make hood and toga use safer, please email me at cchri@bluegrassortho.com. If you would like a FREE POSTER detailing the 13 rules for your OR staff, please email joe.putnam@stubmed.com.