Suture needle
Evaluation of Blunt Suture Needles in Preventing Percutaneous
Injuries Among Health-Care Workers
Evaluation of Blunt Suture Needles in Preventing Percutaneous
Injuries Among Health-Care Workers During Gynecologic Surgical
Procedures -- New York City, March 1993-June 1994
Infections with bloodborne pathogens resulting from exposures
to blood through percutaneous injuries (PIs) (e.g., needlestick
injuries and cuts with sharp objects) are an occupational hazard
for health-care workers (HCWs) (1). PIs have been reported during
1%-15% of surgical procedures, mostly associated with suturing
(1,2). Most suturing is done using curved suture needles, although
straight needles are used by some surgeons for suturing skin.
Blunt suture needles (curved suture needles that have a relatively
blunt tip) may be less likely to cause PIs because they do not
easily penetrate skin. Based on small studies and anecdotal experience,
blunt suture needles appear able to replace conventional curved
suture needles for suturing many tissues, although they may require
more pressure to penetrate the tissues (three teaching hospitals
in 3,4,5,6). This report summarizes results of a study in which
CDC collaborated with New York City during 1993-1994 to evaluate
a safety device (a blunt suture needle) in gynecologic surgery.
The findings indicate that use of blunt needles was associated
with statistically significant reductions in PI rates, minimal
clinically apparent adverse effects on patient care, and general
acceptance by gynecologic surgeons in these hospitals.*
Blunt suture needles (Ethiguard™, Ethicon, Inc., Somerville, New
Jersey)** were evaluated as a potential replacement for conventional
curved needles in gynecologic surgery, a specialty in which high
PI rates have been reported (2). From March 1993 through June
1994, trained nurse observers at the three hospitals systematically
recorded information about the nature and frequency of all PIs
and the number and type of suture needles used during gynecologic
surgical procedures (laparoscopy and dilation and curettage procedures
were excluded from the study). PIs observed or reported during
surgery were confirmed by inspection of HCWs' hands before they
left the operating room. Beginning in February 1994, hospital
investigators replaced conventional curved suture needles with
blunt needles on all gynecologic surgical instrument trays; however,
surgeons retained the option of requesting conventional needles.
During March 1993-June 1994, a total of 1464 gynecologic surgery
procedures were observed; of these, 1062 (73%) were performed
using only conventional curved needles, 55 (4%) using only blunt
needles, and 347 (24%) using both. Straight needles were used
in addition to curved needles in 104 procedures. Overall, 87 PIs
occurred during 84 (6%) of the 1464 procedures; of these, 61 (70%)
involved suture needles, and 26 (30%) involved other surgical
devices. Of the 61 injuries involving suture needles, 56 (92%)
were associated with conventional curved needles, none with blunt
needles, and five (8%) with straight needles.
The mean number of curved suture needles used per procedure (24
needles) was constant throughout the study period. The percentage
of blunt needles used during a calendar quarter increased, from
<1% to 55% during the study; during April-June 1994, at least
one blunt suture needle was used in 243 (81%) of 299 procedures.
The increase in use of blunt suture needles was temporally associated
with a decrease in PIs from curved suture needles, from 5.9 PIs
per 100 procedures (49 PIs among 835 procedures) in 1993 to 1.1
PIs per 100 procedures (seven PIs among 629 procedures) in 1994
(p<0.01). Rates of PIs with devices other than curved suture
needles remained constant (2.1 PIs per 100 procedures). The rates
of PIs associated with use of curved suture needles were 1.9 per
1000 conventional curved suture needles used (56 PIs among 28,880
conventional curved suture needles used) and zero per 1000 blunt
suture needles used (0 PIs among 6139 blunt suture needles used)
(p<0.01; relative risk=0.0; 95% confidence interval [CI]=0-0.03).
For straight suture needles, the PI rate was 14.2 PIs per 1000
needles used (five PIs among 351 needles used).
A logistic regression model was developed to identify and control
for potential risk factors for PI during a procedure, including
type and duration of the procedure, selected aspects of surgical
technique (e.g., using fingers to hold tissue being sutured),
estimated patient blood loss, number and type of curved suture
needles used, status of the primary surgeon (attending or resident),
and whether the primary surgeon had participated in a training
program on PI prevention. The model indicated that the use of
blunt needles was protective: for each percentage point increase
in blunt needles used during a procedure, the adjusted odds ratio
for risk of curved suture needle in-jury was 0.96 (95% CI=0.92-0.98;
p<0.01). For example, if the percentage of blunt needles used
increased from 30% to 40%, the odds of a PI with a curved suture
needle were reduced by 34% (i.e., 100 X [1-0.9610]). According
to the model, the estimated odds of a PI with a curved suture
needle were reduced by 87% when 50% of the suture needles used
during a procedure were blunt.
In 25 (6%) of the 402 procedures during which blunt needles were
used, surgeons reported technical difficulties with the blunt
needles, including problems penetrating tissue (18), tearing of
tissue (three), needle slippage (three), and bleeding when the
needle entered the tissue (one). However, none of these were reported
to be clinically important; for procedures performed with and
without blunt needles, mean blood loss was similar (328 cc and
351 cc, respectively; p=0.29), and mean operative time was similar
(102 min and 106 min, respectively; p=0.24). Long-term complications
(e.g., surgical site infections) were not assessed.
Reported by: M Mendelson, MD, R Sperling, MD, M Brodman, MD,
P Dottino, MD, J Morrow, MD, J Solomon, MPH, Mt. Sinai Medical
Center; B Raucher, MD, J Stein, MD, N Roche, MD, A Jacobs, MD,
Beth Israel Medical Center; P Nicholas, MD, I Karmin, MD, B Brown,
MD, Elmhurst Hospital, New York, New York. Hospital Infections
Program, National Center for Infectious Diseases, CDC.
Editorial Note: The findings in this investigation indicate that
in the three participating hospitals, use of blunt suture needles
effectively reduced suture-related PIs during gynecologic surgical
procedures. Smaller studies in other surgical specialties also
concluded that use of blunt suture needles was not associated
with PIs (3-6). Although some tissues cannot tolerate the increased
force required to use a blunt needle, a blunt needle probably
could be substituted for a conventional curved needle in a variety
of procedures (3-6). Blunt suture needles may be particularly
useful in preventing PIs during suturing in a poorly visualized
anatomic space--a situation associated with increased risks for
PI for surgeons and with transmission of hepatitis B virus from
surgeons to patients (7). Blunt needles recently have become available
in a variety of sizes and suture materials; the effectiveness
of blunt needles in reducing PIs suggests that they should be
considered for more widespread use in surgical procedures.
In this study, the PI rate for straight suture needles was more
than seven times the rate associated with conventional curved
needles. Straight needles are used by some surgeons to close the
skin; however, because safer alternatives (e.g., staplers, conventional
curved needles, and possibly blunt needles [6]) are available,
indications and techniques for using straight suture needles should
be reevaluated. Safety devices designed to reduce the risk for
PI to HCWs should not adversely affect patients. In this study,
no clinically important patient-care complications attributable
to blunt needles were reported by surgeons or suggested based
on objective clinical parameters. One limitation of this assessment
was the lack of systematic long-term follow-up of patients to
assess possible delayed complications of surgery (e.g., surgical-site
infections); however, a previously published report on a small
number of patients did not document infections in association
with use of blunt needles (6). Safety devices must be acceptable
to the HCWs who use them. In this and previous reports, blunt
needles were acceptable to surgeons as replacement for some or
all conventional curved needles in a variety of procedures (3-5).
Although specific uses and limitations of blunt needles require
further delineation, the findings of this report support the use
of blunt needles as an effective component of a PI-prevention
program in gynecologic surgery and possibly for other surgical
specialties. The Public Health Service is continuing to evaluate
the implications of these findings, data from a companion report
on safety devices for phlebotomy (8), and other information to
assess the need for further guidance on selection, implementation,
and evaluation of safety devices in health-care settings.
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