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Denise M. Korniewsicz, DNSc, RN, FAAN, and Christopher D. Martin,BSN, RN
Theuse and demand for gloves used in clinical settings has increased dramaticallysince the implementation of Universal Precautions in 1987. Now glove use hasincreased from one billion pairs per year to 10 billion pairs.1 Theincreased use of gloves among healthcare workers (HCWs) has led to a variety ofcomplications such as: elevated costs, adverse events (latex allergy, contactdermatitis, occupational asthma), and issues related to waste disposal. As aresult, glove manufacturers have developed new gloves made of alternativematerials such as neoprene, nitrile, thermoplastic elastomers, natural rubber,latex, and vinyl. With the variety of glove choices available today, HCWs needto have an understanding not only of the newer synthetic gloves available but anunderstanding of the "donning" agents used to lubricate gloves. Often,the lubricants may be responsible for creating adverse reactions such as skindermatitis or inflammation at the site or as in the case of surgical gloves postoperative wound infections or surgical adhesions.
Reports on the adverse effects of powder in gloves have been documented inthe literature prior to 19502, and subsequent case studies have beenconducted throughout the years to evaluate the effect of cornstarch3,4,5on patients and HCWs. Current research has been targeted toward glove powdersand the adverse reactions observed after routine surgery, complicationsassociated with wound healing, and the ability of cornstarch to act as anairborne vector for latex proteins.6 Other important issues relatedto powder include proposed legislation to limit or eliminate the use of powderedlatex gloves in clinical practice settings. As for the newer non-latex,powder-free synthetic gloves, the issues of interest are primarily surroundedaround their performance and higher cost rather than the lubricants associatedwith donning.
Use of Cornstarch
Although gloves may contain a variety of other powders such as calciumcarbonate or lactose, one of the most common donning agents used has beenabsorbable USP powdered cornstarch. The use of cornstarch as a lubricant hasbeen to provide the user with the ease of donning the glove; however, cornstarchis difficult to absorb. Currently, the Food and Drug Administration (FDA) hasrecommended a reduction in the amount of powder a manufacturer is allowed touse,1 since cornstarch has been associated with occupational asthmaand latex allergenicity.7
Cornstarch is not completely absorbed when used as a donning agent forsurgical gloves, since the sterilization process effects the starch molecules.Irradiation, the current sterilization technique, causes starch molecules toremain intact, smooth and circular. In contrast, during the older autoclavingtechniques (steam and gas), the molecules were damaged leaving the entiremolecule uneven and pitted which allowed for easier tissue absorption andlimited the occurrence of infection or inflammation.8 Irradiationcauses the cornstarch to remain intact and less absorbable when in contact withtissue.
When cornstarch is in direct contact with a surgical site or open wound, itproduces a foreign-body reaction for the duration of its presence.5Depending on the surgical site involved, adhesions and granulomas have beenreported especially when introduced in the peritoneal cavity.5 As aresult, patients can develop surgical complications such as intestinalobstructions, increased peritoneal or abdominal pain or peritonitis. Althoughthe literature6,8,9 has been wrought with adverse events associatedwith cornstarch, and dangers associated with cornstarch in the healthcareenvironment, the FDA has not banned the use of cornstarch as a donning agent forgloves.10
Cornstarch has been used as a lubricant in latex gloves for three reasons: tohelp remove the glove from the manufacturer's mold during processing; to preventdecay while in storage; and to help when donning gloves. Although the first andsecond reasons are of no concern to the healthcare worker, the third (donning)is used as a marketing strategy. There has been some concern with latex poweredgloves vs. non-latex, powder-free synthetic gloves on the basis of donning,durability, and price. The manufacturing process used for producing syntheticgloves is similar to that of contact lenses, using a material known as a "hydrogelpolymer."8 The hydrogel polymer allows for trouble-free donningdue to its smooth inner surface and easy glide-on feel. The hydrogel polymer hasbeen readily accepted among HCWs and seems to be preferred.
The greatest concern about the use of non-latex, powder-free gloves is thecurrent market price. Currently, healthcare institutions are reluctant toallocate resources toward purchasing synthetic gloves, since the cost is greaterthan natural rubber latex gloves. To facilitate a changeover within a healthcareinstitution, all of the current gloves would have to be pulled, all clinicalareas would have to be cleaned thoroughly, and the entire setting would have tobe restocked with the new product. The average, cost of non-latex, powder-freegloves exceeds that of latex powdered gloves by $2.14 per box of 100 count or a32% increase for an entire fiscal year.6 Although these estimates aresizable, the benefits must be compared to the legal costs associated with HCWdisability and workman's compensation cases.
Latex Allergy and Cornstarch
Currently, between 7% and 17% of HCW suffer from Type I or Immediatehypersensitivity to natural rubber latex proteins11, while 7-10% mayhave delayed hypersensitivity11 to chemicals in gloves and over 50%may suffer from irritant dermatitis (Figure 1, a hand with glove powderreaction.)12 Experimental and clinical evidence indicates that theabsorbent cornstarch powder on latex medical gloves acts as an airborne carrierof natural latex allergens resulting in cutaneous, conjunctival, and/orrespiratory allergic reactions to latex.6 The clinical presentationof a latex allergy can range from a mild contact urticaria to fatal anaphylaxis.7Cornstarch powder has been reported on items such as sutures, instrument tips,and at the wound/incision sites even though not visually present.13Hermesch6 reported that after switching from powdered to powder-freegloves for an entire week, the levels of airborne powder was statisticallylower.
In the operating room environment, it has been common practice to wash thegloved hands of the surgeon and scrub personnel in a basin of sterile water,then wipe them dry with a lint-free towel.13 This glove washingpractice was recommended to remove the powder from the outside of the glove,thus eliminating any cornstarch-induced surgical complications. Stein13 foundthat even after the usual 1-to 2-minute rinse, powder still would appear on thegloves 10 to 30 minutes later due to the constant movement of the hands during asurgical procedure. As a result, the powder and latex protein can continue to bespread by the gloved hands of the surgeon or scrub person to instruments, trays,light fixtures, or other equipment.
There have been several legislative attempts to ban the use of glove powderin the states of Oregon, Nebraska, New York, Wisconsin, and Indiana; however,all of the attempts have been unsuccessful. There have also been attempts tolimit the high level of proteins in latex powdered gloves to eliminate or reducethe number latex allergic responses each year. It has been reported bymanufactures of non-latex, powder-free synthetic gloves that over 1,600 ofallergic reactions have occurred associated with latex allergy and 23 deathshave been reported to the FDA.14 Arguments against this type oflegislation, particularly among the manufactures of powdered latex gloves, hascentered on their position on the personal preferences of HCW ignoring theclaims that their products may be the cause of some of the adverse reactions.
The use of glove powder remains controversial however the future seems tolean toward alternate donning agents to irradicate the use of powder. Currently,research laboratories throughout the world, are developing alternative donningagents as well as synthetic polymers to replace natural rubber latex gloves. Themajority of the research has been directed toward duplicating natural rubberlatex gloves, since they provide adequate comfort, less hand fatigue, resealproperties and are popular among the HCW community. Future goals for medical andsurgical gloves are to create a barrier that provides complete protection forthe wearer and patient without the adverse reactions associated with latex orpowder when used. Although the solutions for the future are difficult, the gloveof the future must be cost effective and provide adequate barrier protection,safety, and comfort.
The future glove may depend on thinking "outside the box" andentertaining ideas such as the elimination of gloves altogether. Perhaps aprotective spray, like that for household furniture, could be applied directlyon the hands prior to a procedure or the use of a special soap that wouldproduce a protective skin coating. Other hand barrier protection may includedipping the hands into a solution that would adhere to the skin to provide a"natural coating" on the hands. Methods such as these may be in ourfuture and eventually universal products would be developed that addressestoday's concern about powder, comfort, fit and barrier effectiveness.
Dr. Denise M. Korniewicz is a professor at the University of Maryland,School of Nursing in Baltimore, Maryland. Christopher D. Martin is a graduateresearch assistant at the University of Maryland, School of Nursing.For a complete list of references click here