ISSUE 8
THE
CLINICAL ISSUE
FOREIGN DEBRIS IN POSTSURGICAL COMPLICATIONS
QUESTION: What happens when lint, powder or other
foreign debris contaminating your surgical instruments,
devices, or implants is deposited into your patient?
TABLE OF CONTENTS:
Introduction..................................1
Blood Clots...................................3
Amplified Inflammation.............4
Poor Wound Healing..................4
Granulomas..................................5
Adhesions......................................5
Summary and Actions................6
References.....................................7
Wava Truscott, PhD. MBA
Director Medical Sciences & Clinical
Education, Halyard Health
One of the most important attributes of living organisms
is the capacity to self-repair. This ability is expected and
observed every time a patient undergoes a major or
minor invasive procedure. Needless to say, lack of this
healing ability would render surgery useless and every
injury, whether large or small, would be a potential death
sentence. Instead, a surgeon removes an appendix,
sets a fracture, or performs brain surgery expecting
normal wound healing, without infection or other
complications within a fairly predictable period of time.
Simplistically, to keep microbial contamination of the
site to a minimum, all which is necessary is to make the
necessary repairs, keep the tissues moist, and properly
align the wound margins. Although the auto-pilot repair
process initiates to some degree in any individual, the
quality of the healing can vary substantially depending
on many factors. These include the patient’s general
health, degree of trauma sustained, level of microbial
contamination, and the presence or absence of foreign
bodies in the wound.
FOREIGN DEBRIS IN POST-SURGICAL COMPLICATIONS
FOREIGN DEBRIS IN POSTSURGICAL COMPLICATIONS
Unfortunately, the important role that these
foreign particles can play in post-surgical
complications does not receive enough
attention. Lint is composed of fine fibers
that separate from the surface of fabrics
including gowns, drapes, sterilization wrap,
and huck towels. Fibers also abrade off
paper fenestrations and drapes, cardboard
and poorly laminated or embrittled sterilization
pouches. In practice, such debris is generally
referred to as lint. Associated pathologies
depend upon the composition, size, and
number of fibers, as well as the tissues in
which they are deposited. Lint and fiber
associated complications include:
• Increased incidence/severity of infections
• Blood clots
• Amplified inflammation
• Poor quality wound healing
• Granulomas
• Adhesions
Lint and debris in the surgical wound increase
the risk of infection both as a transport for
microorganisms and as an immune distraction.
Transporter: Lint and debris can be carried on
air currents throughout the operating room
(OR). They can fall on any surface, including
floors, exposed skin of surgical staff, and
monitor screens, where bacteria can cling to
them. As staff move and equipment pieces are
repositioned, the now contaminated debris
can be airborne again, potentially landing on
surgical instruments, drapes, gloves, or directly
into the open surgical wound. (AORN)
2
A study conducted by Verkkala demonstrated that
reducing lint reduces surgical site contamination and
that cellulose containing fabrics generate significant
amounts of lint. In a series of 66 coronary artery bypass
surgeries performed by the same team in the same OR,
he found that replacing cellulose (cotton and paper)
containing gowns and drapes with those made of 100
percent polypropylene reduced airborne lint and fibers
from 850 particles/m3 to 50 particles/m3. Sternal wound
bacterial contamination was reduced by 46 percent and
those at the vessel harvest site in the leg by over 90
percent. Immune distraction: When lint or fibers are
present with bacteria in the same surgical area, the
immune system perceives them as a much larger threat
to the body than tiny bacteria. Thus, while the immune
cells are working to wall off the lint or fibers, they ignore
the bacteria. The few bacteria that contaminate any
surgical wound can then multiply unimpeded; gaining a
strong presence that is difficult for the immune system
to overcome. An example of the effectiveness of the
mechanism of “immune distraction” is a study performed
by Elek, where he was able to demonstrate that the
presence of a suture fiber reduced the number of
bacteria needed to cause an infection by 100,000 times.
BLOOD CLOTS
Lint- or fiber-associated thrombogenesis is initiated
when platelets trigger the clotting cascade to wall off
the debris introduced into the bloodstream. Fibrin is
deposited, forming a net to trap the foreign threat.
Blood cells are ensnared and trapped in the net forming
a clot. This cycle continues, essentially “snowballing” in
size until the clot (lint emboli) becomes large enough
to block narrowing blood vessels. An important
distinguishing feature of a lint or fiber-initiated blood
clot is the failure of the entire embolus to dissolve when
anti-thrombolytic treatments are used. Lint fibers are
attracted to guidewires, pacemaker leads, and catheters
by static cling.
Bookstein conducted a study to understand the
formation of clots during angiography after an increase
in cases of thromboembolic complications, including
strokes and two deaths. With magnification, he was
able to see the smooth clean surface of guidewires
immediately removed from the package become
contaminated with lint from sterile drapes, and powder
from gloves, either during preparation or the procedure
itself. The clinging debris (sterile or nonsterile) can
then be deposited directly into the bloodstream or into
the inside of the catheter, soon to be injected into the
bloodstream. The investigator determined that foreign
debris on the guidewire or within the catheter may
influence hypercoagulance and amplify the thrombosis
impact of high velocity injections. He concluded that
coagulant complications resulting from angiography are
probably, in large part, preventable.
Particulate embolization, usually initiated
by cotton fibers, was present in as
many as 25 percent of the resected
arteriovenous malformations.
Shannon conducted a 5-year retrospective study
of the postmortem cases of postangiographic
neurologic complications, performing histologic
examination on all associated clot formations.
Particulate embolization, usually initiated by
cotton fibers, was present in as many as 25 percent
of the resected arteriovenous malformations. The
author concluded that unintentional foreign body
emboli remain common in modern angiographic
practice and are probably underappreciated
clinically. When postangiographic ischemia or
infarction occurs, lint, or other foreign debris
should be included in the differential diagnosis.
Chapot reported that thromboembolic
events are the most frequent complications
of endovascular treatment of intracranial
aneurysms. The author reported a case where
he was able to ensnare a non-dissolvable clot
from the middle cerebral artery and identify the
fibers at the center of the clot as coming from
unsealed gauze in the vascular set used during
the procedure.
3
FOREIGN DEBRIS IN POST-SURGICAL COMPLICATIONS
Whelan had similar findings when lint from drapes and
powder debris from gloves were attracted to intravascular
stents during preparation and found to be responsible
for thrombogenic events in the coronary artery and an
unsuspected contributor to restenosis. He reduced the
complication by addressing the sources of contamination.
AMPLIFIED INFLAMMATION
When particles are deposited in tissues at the surgical
site, cell injury is initiated due to direct cellular
damage from physical abrasion, collateral damage
from neutrophilic enzymes and oxidative radicals, and
from chemicals sometimes leached from lint, fibers
and particles over time. Each of these contributors is
associated with inflammation that can spread beyond
direct contact as the body tries to protect itself from
the foreign “invasion.” For example, neutrophils (PMN)
are energetic white blood cells representing one of the
body’s first lines of defense when something enters the
tissues. As soon as they arrive, they expel destructive
enzymes and oxidative radicals in efforts to “kill” the
foreign invader. They spray the area much like shotgun
pellets directed at a target hit items in the periphery.
In doing so, the enzymes and oxygen radicals harm
healthy tissues in the vicinity of the lint and particles.
The injured tissues signal an inflammatory response in
an expanding area that, depending on the nature of the
foreign debris, may continue for an extended period.
4
POOR WOUND HEALING
After uncomplicated surgery, normal healing
commences almost immediately and proceeds in very
well-orchestrated interdependent sequential events.
However, the presence and persistence of amplified
inflammation caused by foreign debris sends mixed
signals such that areas farther away from the debris
may heal rapidly and well, while others lag behind or
only partially complete the sequential phases. It may
take longer for new blood vessels to be constructed
in the swollen, inflamed area. This means less oxygen
delivered, signaling that impacted areas are not yet ready
for collagen, thus delaying healing. The delay in healing
can potentially result in a regional mosaic of weak and
strong areas with mixed levels of optimal alignment and
contracture. Complications have included increased
scar volume possessing decreased center strength,
toughness, resilience, and flexibility of the repaired
tissues, delayed healing, an increased risk of dehiscence,
and reduced functionality.
GRANULOMAS
A granuloma is a very small “pearl” formed when the
body tries to walloff foreign debris. This foreign body
reaction starts with white blood cells (macrophages)
surrounding the perceived invader. Unable to dissolve
it, the white cell encapsulated fibers are then encased
by more white cells including T-lymphocytes and with
more fibrin. Tinker reported 45 consecutive cases of
cellulose fiber granulomatous disease with mild to severe
consequences. Analysis of specimens suggested that
cellulose foreign body granulomas may be a significant
cause of intestinal obstruction as adhesions strangling
the intestines often had cellulose-granulomas as
probable initiators. His conclusion was that new drapes
containing paper were the source of the cellulose fibers.
Janoff reported 24 cases of foreign body reactions
secondary to cellulose lint fibers that occurred in
three local hospitals over a five year period. Ten of
these patients acquired extraperitoneal granuloma and
fourteen with intraperitoneal granuloma. Six patients
with intraperitoneal reactions developed severe acute
granulomatous peritonitis. One these patients died of the
complication. Twenty-two patients required re-surgery
as a direct result of the complications brought on by the
reactions to the cellulose lint fibers. It was estimated that
400 days of additional hospitalization were required.
Precautionary measures including replacement of the
offending cellulose containing drapes and gowns with
polypropylene gowns prevented the complications.
ADHESIONS
Adhesions can be potentially devastating complications.
Fibrin strands are deposited by the body to stop
movement of invading debris. The fibrin strands anchor
themselves around nearby structures. Because lint and
other fibers do not dissolve, the fibrin strands persist,
and they become thicker and more permanent. They
may contract, causing mild to severe pain, impeding
optimal function of organs to which they are attached.
Cases include impaired ovaries, fallopian tubes, kidneys
and intestines. It is estimated that 50 percent of postsurgical abdominal pain is due to adhesions. In 1997,
Duron performed an extensive study in which he excised
chronic adhesions from 107 patients and performed
histopathology on the masses. He found 80 percent
contained lint and fibers.
ISOLATED FROM CHRONIC ADHESIONS
JJ DURON 1997
Lint / Fibers
Cornstarch Glove Powder
Sutures
80%
3%
2%
5
FOREIGN DEBRIS IN POST-SURGICAL COMPLICATIONS
ACTIONS: Make certain that complications
associated with lint and fibers do not adversely
impact post-surgical recovery.
• Ensure that drapes (including fenestration
area), gowns, sterilization wrap, and other
materials present in the area are low-linting
and noncellulose containing
• Circulators, Anesthesia providers, Technicians,
etc. in ORs and Cath Labs cover linting
clothing as they walk in and out of critical
areas
• Newspapers (cellulose with dyes and ink) are
banned from Surgery Suites, Cath Labs and
other areas of open invasive procedures
SUMMARY AND ACTIONS
GENERAL: Lint and fibers come from natural and
synthetic sources. Belkin’s studies have emphasized
that material containing paper or cotton are cellulose
based (from plants and trees) and are generally the
higher linting and bio-reactive materials. Whether
natural or synthetic, source materials may contain
dyes, glues/ adhesives, and fire-resistant treatments
that can be leached into the wound. The fibers
themselves do not dissolve. For example, cotton
fabrics are washed in washing machines and do
not dissolve. Similarly, paper will eventually degrade
and fall apart in water, but the fibers are still there.
In tissues, most lint and fibers remain and are
associated with many different preventable postsurgical complications.
6
• Devices are dried and assembled in lowlinting, Sterile Processing areas, free of
cellulose towels and rags
• All items in custom packs are low-linting and
gloves powder-free to prevent contamination
of other items
• Cleaning is performed with low-linting
materials
• Air filtration units are adequate and
performing optimally
REFERENCES
•A
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Thread of Lint by Transesophageal Echocardiography
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•T
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•A
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•V
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•A
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Perioperative Standards and Recommended Practices 2014
•B
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•B
ookstein JJ, Arun K. Experimental investigation of
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•C
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•W
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•Y
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•Z
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•E
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•E
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•G
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KNOWLEDGE NETWORK* Accredited Education
•S
hannon P, Billbao JM, Marotta T, Terbrugge K. Inadvertent
foreign body embolization in diagnostic and therapeutic
cerebral angiography. AJNR. Am J Neuroradiol.
2006;27(2):278-282.
Tools & Best Practices
•T
inker MA, Burdman D, Deysine M, et al. Granulomatous
peritonitis due to cellulose fibers from disposable surgical
fabrics: Laboratory investigation and clinical implications.
Annals of Surgery 1974;180(6):831-835.
•T
inker MA,Teicher I, Burdman D. Cellulose granulomas
and their relationship to intestinal obstruction. Am J Surg
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