Abstract
In Australia, sterile gowns are considered an essential component of aseptic technique for all neuraxial procedures. 1 However, guidelines from professional societies vary worldwide (Table 1), and the Australian and New Zealand College of Anaesthetists’ (ANZCA) guidelines are the oldest currently in use.1 –8 In the USA, Canada and Brazil, gowning is not considered to be a routine requirement when undertaking neuraxial anaesthesia.2 –4 Recent guidelines published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI; 2020) acknowledge the importance of aseptic technique in central neuraxial blocks, but no longer state that gowning is required (as did the previous version of the guidance).5,6 However, AAGBI guidelines do recommend gowning for neuraxial procedures involving immunocompromised patients. 5 The European and American Societies of Regional Anaesthesia (ESRA, ASRA) 2022 practice advisory guidelines recommend gowning for central neuraxial catheter placement in paediatric patients. 7 ASRA guidelines state that routine gowning is not required for adults, and ESRA does not have guidelines relevant to gowning for adult patients. 2,7 No explanation is given for this difference in recommendations. 7
Guidelines from professional bodies, regarding infection prevention in neuraxial procedures.
There is limited and conflicting evidence supporting the use of sterile gowns in neuraxial procedures to prevent associated infections. Notably, neither ANZCA nor the AAGBI guidelines cite any research evidence to support gown use in neuraxial procedures.1,5 In contrast, guidelines published by the American Society for Regional Anesthesia (ASRA) and the American Society of Anesthesiologists (ASA) cite a study by Siddiqui et al. as evidence for not recommending gowning.2,9 This randomised controlled trial (RCT) of 214 participants compared the bacterial colonisation rates of epidural catheters in participants randomised to epidural anaesthesia performed by gowned versus un-gowned anaesthetists. All anaesthetists wore sterile gloves, surgical mask and cap, and used sterile drapes. Cultures obtained from the epidural catheter tip showed no significant difference in colonisation rates for any microbial organism between the two groups. 9 No further RCTs investigating infectious outcomes of gowns for neuraxial anaesthesia appear to have been published.
Fayman et al. found that asepsis practices vary significantly among anaesthetists globally. 10 In their international survey of 151 heads of departments of anaesthesia across 13 countries, 48% of responders reported never wearing sterile gowns for neuraxial procedures, while 49% reported always wearing sterile gowns. 10 Furthermore, there is the accepted practice of “rapid sequence spinal anaesthesia” for emergent operative delivery in obstetrics, in which gowning is avoided to minimise procedural time. 11 Consequently, asepsis without gowning appears to be a common approach to neuraxial anaesthesia across many countries and is broadly considered in many countries to be a safe practice.
We recognise that maximal barrier precautions (including gowns) have been found to reduce the incidence of infection associated with central venous catheter (CVC) insertion. 12 However, the reduced infection rates demonstrated may not be attributed to sterile gowns alone, as these are used in combination with a package of other measures (large drapes, face masks and caps). Importantly, CVCs typically remain in-situ for a longer duration than epidural catheters and often take longer to insert, leading to a reportedly 700-fold greater incidence of infectious complications. 12
Neuraxial anaesthesia already has the potential to have lower environmental impacts than other modes of anaesthesia. 13 However, the various disposable and reusable items that are required to perform neuraxial blockade account for up to 70% of their associated total carbon emissions, of which sterile gowns are the largest contributing item. 12 Vozzola et al. found reusable gowns superior to disposable gowns in all major environmental outcomes. 13 Regardless, the life cycle of both gowns, from manufacturing through to disposal, causes significant energy consumption, greenhouse gas emissions, water consumption and solid-waste generation. 13 For every 1,000 disposable gowns used, 1,636 kg of CO2 equivalent emissions and 268 kg of solid waste is produced. 13 Furthermore, a single disposable or reusable gown costs approximately AUD$2–4. Decreasing the number of gowns used in neuraxial procedures would therefore result in both environmental and financial benefits.
In summary, current evidence does not appear to support the routine use of sterile gowns for neuraxial procedures. The only relevant RCT we could find reported no significant difference in infection rates post neuraxial anaesthesia when gowns were worn. 5 While there is arguably a need to investigate further the efficacy of sterile gowns in reducing infectious complications of neuraxial anaesthesia in an appropriately designed non-inferiority RCT, the very low rate of these complications would likely make such studies unfeasible. Anaesthesia societies from several other countries do not recommend routine gowning for neuraxial procedures. Additionally, there are readily quantifiable financial and environmental costs associated with gown use. Given these considerations, we feel that gown use during neuraxial anaesthesia is of no value in most cases. We feel that anaesthesia societies worldwide should strongly consider not recommending gowning for routine spinal or epidural anaesthesia, including catheter insertion, instead recommending this practice for specific high-risk populations only, such as immunocompromised patients.
