an evidence based protocol for preoperative skin preparation
TRANSCRIPT
8/20/2019 An Evidence Based Protocol for Preoperative Skin Preparation
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LITER TURE REVIEW
KEYWORDS Skin preparation / Skin antisepsis / Preoperative / Intraoperative / Surgical site infection / SSI
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication October 20 12 .
n evidence
based protocol for
preoperative skin
preparation
by Pe(dro Silva
Correspondence
address: Main Theatres Royai Free London NH S Foundation
Trust
Pond
Street
London NW3 2QG.
Emaii:
Surgical site infections (SSIs) represent a major source of morbidity and mortality a mo ng surgical
patients (Swenson et al 20 09 ). The most common source of SSIs is the patient's own skin flora
(Zinn et al 201 0). A literature review was performed on the impact of the d ifferent intraoperative
skin prepa ration solutions in reducing the risk of SSIs, concluding tha t 2 chlorhexidine in spirit
is the most e ffective.
Literature search
The literature search was performed
for peer reviewed studies and articles
published between 1980 and March
2012 ,
using the following databases and
resources; Medline, Cochrane, C inahl, NHS
Evidence, OVID nu rsingjourn als, Internurse.
The keywords used included; skin
preparation, skin antisepsis, preoperative,
intraoperative, surgical site infection, SSI,
povidone-iodine, chlorhexidine, clean
surgery, clean-contaminated surgery, plastic
surgery, orthopaedic surgery, isopropyl
alcohol.
Background
Surgical site Infections are the m ost
common form of hospital acquired infection
(Bagnall et a l 2009). They represent a major
source of morbidity and mortality among
surgical patients and increase t he length
of th e patient's hospitalisation, the number
of admissions to intensive care units
and, ultimately, the cost of the treatment
the count o f resident and transient
microorganisms in the patient's skin prior to
surgery will reduce the incidence of SSIs.
A diversity of options
In order to obtain the greatest reduction
of the microbe count from the surgical
patient's
skin,
several different disinfectant
solutions are available. It is desirable that
they have a broad spectrum of action
against both resident and transient
microorganisms, and that they ac t
quickly and at the same time prevent a
rapid re-growth and rebound of those
microorganisms (Zinn et ai 2010).
The preoperative skin preparation solutions
available in th e NHS involve different
combinations and conc entrations of a
limited group of substances; chlorhexidine,
povidone-iodine and their ethanolic
solutions (Veiga et al 2008). These
substances have a broad spectrum of
action against microorganisms and are,
However, in my area of practice, the
selection of the skin preparation solution
to be used at the beginning of a surgical
procedure Is made without reference to
defined criteria, and depends m ostly o n the
surgeon's preference.
Literature review
By reviewing the literature obtained from
the search, I was able to retrieve updated
and evidence-based information about
th e various preoperative skin preparation
solutions used, the process through which
each of them acts, their impact on the
incidence of SSI, and the benefits of t he
appropriate choice of a skin p reparation
solution in terms of the quality of healthcare
provided and the cost-benefit effectiveness.
Different skin preparation solutions and
tiie incidence of SSI
The major differences between skin
preparation solutions are in the s ubstance
on which they are based (povidone-iodine
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LITERATURE REVIEW
An evidence based protocol for preoperative skin preparation
ontinue
The studies obtained from th e literature
search showed the following difterences;
Povidone iodine versus ciiiorhexidine
Chlorhexidine is a powerful broad-spectrum
bactericidal agent, acting through disruption
of the cell membranes. It offers the
advantage of having a persistent eftect
in the
skin,
known as the residual eftect,
which delays the regrowth of microbes. On
the other hand, it is known for its toxicity to
the brain and neuronal structures (Zinn et
al 2010).
Povidone-iodine is also a broad-spectrum
agent, eftective against a wide range of
gram positive and gram negative bacteria,
the tubercle bacillus, fungi and viruses
(Edwards et al 2009). However, its rapidity
of action is only moderate, and its residual
effect is compromised when in contact with
organic substances such as blood or fat
tissue.
It can also cause local pain and skin
irritation (Zinn et al 2010 ).
Several studies seem to demonstrate
that chlorhexidine is more effective than
povidone-iodine in preventing SSis. A review
of randomised studies concluded that there
was a 36 reduction on the number of SSis
among patients who received preoperative
skin antisepsis with c hlorhexidine,
compared to those who received iodine (Lee
et al 2010).
Variations in the concentration of the
skin preparation solutions
There is a wide range of concentrations
of both chiorhexidine and povidone-iodine
available for preoperative skin preparation
solutions, in my area of practice,
chlorhexidine is available as 0.5 in spirit,
2 in spirit, and 4 as an aqueous solution.
A randomised study showed that a solution
of 4 aqueous chlorhexidine was more
eftective in reducing the count of microbes
than a 2 aqueous chlorhexidine solution
(Edminston Jr et al 2007 ). A difterent study,
comparing a 2 chlorhexidine in spirit
solution with three other chlorhexidine-
based solutions, conciuded that enhanced
Povidone-iodine is also available in several
difterent c oncentrations. However, the
most commonly used for preoperative skin
prepara tion are 7.5 and 10 , in aqueous
or alcoholic solutions.
Ferguson et al (2003) concluded that
solutions with higher concentrations of
povidone-iodine seem to be more effective
than more diluted ones. This study is
directed specifically to the conjunctival
bacterial flora, and the concentrations
compared are 1 against 5 povidone-
iodine, which makes itdifticultto generalise
any conclusions for other types of surgery.
The impact of an ethanoiic com ponent
Alcohol alone is recognized as having an
excellent activity against gram positive
and gram negative bacteria, the tubercle
bacillus and many fungi and viruses
(Edwards et al 20 09). It acts by denaturing
proteins, and has an extremely rapid action.
However, alcoholic solutions alone present
no residual activity, allowing microbes
to re-grow shortly after application (Zinn
et ai 2010 ). One other disadvantage of
alcoholic solutions is the increased risk of
intraoperative fires or chemical burns.
The literature search did not present any
studies comparing the impact of the same
product with and without an alcoholic
component in the reduction of SSIs.
However, Swenson et al (2009) stated
that the combination of 2 chlorhexidine
and alcohol had a better imm ediate
eftect than 4 chlorhexidine alone, and
also demonstrated a better residual
antimicrobial activity than 4 chlorhexidine
alone or isopropyl alcohol alone.
Given all the differences between skin
preparation solutions, the possibility of
establishing an ideal skin preparation
solution that would bring about the best
possible results in terms of reduction of
SSis seems to arise.
Choosing the appropriate skin
preparation solution
The difterences established above seem
• Alcoholic solution s seem to be more
eftective than non-alcoholic (Swenso
et al 2009).
Several other studies also supported thes
conclusions;
• Darouiche et al (2010) compared the
impac t of 2 chlorhexidine in spirit
with 10 aqueous povidone-iodine o
SSIs for clean-contaminated surgery.
They concluded that the application
of chlorhexidine-alcohol reduced the
risk of surgicai site infection by 4 1
as compared with the most common
practice in the United States of using
aqueous povidone-iodine.
• Cstrander et al (2005 ) and Saltzman
al (2009) concluded that chlorhexidin
was more eftective than povidone-
iodine for foot and shoulder surgery,
respectively.
» Berry et al (1982) compared 0.5
alcoholic chlorhexidine w ith a 10
alcoholic povidone-iodine solution in
elective surgery, concluding that th e
number of SSIs was significantly lowe
in the group of patients prepped with
chlorhexidine.
• Levin et al (2011 ) observed that
antisepsis with chlorhexidine and
alcohol was associated with a signific
reduction in the rate of SSIs compare
to povidone-iodine antisepsis in patie
undergoing elective gynaecological
laparotomies (Levin et al 2011 ).
• The Depa rtmen t of Health published
a high impact intervention stating tha
2 chlorhexidine gluconate in 70
isopropyl alcohol should be used for
intraoperative skin preparation (DH
2011).
The evidence presented seems to su ppor
the suggestion made by the D epartment o
Health. However, chiorhexidine Is proven
to be toxic for neuronal structures, and
alcoholic solutions can also be damaging
when in contact with internal bodily
structures, these being contraindications
their use.
The following special considerations also
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LITERATURE REVIEW
The main goal of preoperative skin preparation
is the reduction of the risk of SS to a minimum
solution in order to m inimise the risk of
SSIs. However, there are situations in which
it should not be used:
s If the patient has an allergy to
chlorhexidine. In this case, povidone-
iodine should be used (Ostrander et al
2005)
«i Chlorhexidine should not be used in
direct contact with brain or spinal
tissue, due to its neurotoxicity. Also,
alcoholic solutions can be damaging
for these tissues. 10 aqueous
povldone-lodine should be used in these
situations (Ferguson et al 20 03)
: Alcohol should not be in direct contact
with m ucosa; an aqueous chlorhexidine
solution should be used. However, a
study published by the Kuwait Medical
Journal suggests that, for perineal
skin preparation, better results are
obtained when the area is painted
with aqueous povidone-iodine followed
by a chiorhexidine-cetrimide solution
(Kehinde etal 2009)
;i Chlorhexidine has been shown to be
toxic to the cornea (Hamill et al 1984)
and so are alcoholic solutions. In 200 3,
Ferguson et al's study supported the
use 5 povidone-iodine in decrea sing
the conjunctival bacterial flora in ocular
surgery
Once these exceptions for the use of 2
chlorhex idine in 70 isopropyl have been
established, and the best solution for each
of them identified, it becomes possible
to define a protocol for preoperative skin
preparation that minimises SSIs.
Proposal of a preoperative skin
preparation protocoi
The following protocol (Figure 1) is based on
the above review of the literature search.
Putting this protocol into practice could
have an impact in terms of costs for the
healthcare institution which , in the actuai
financial climate , also needs to be taken
into consideration.
Costs for thie lieaitiicare institution
Lee et al (2010) suggested in their study
Exception
Allergy to chlorhexidine
Direct contact with neuronal tissue
Ocular surgery
Perineal surgery
Open wounds/mucosa
CHG - chlorhexidine giuconate
PI - povidone-iodine
Skin preparation solution
Alcoholic PI
10 aqueous PI
5 aqueous PI
10 aqueous PI plus ch lorhexidine/cetrimide
Aqueous CHG
Figure 1 Pre-operative skin preparation solution: 2 CHG in 70 IPA is recom men ded,
with the identified exceptions
rate of SSIs, which carry more expenses
for the healthcare institution than the
utilisation of a more expensive, but also
more effective 2 chlorhexidine in spirit.
Summary
The main goal of preoperative skin
preparation is the reduction of the risk
of SSI to a minim um. Several studies
demons trate that chlorhexidine is more
effective than povidone-iodine for this
purpose , highlighting 2 chlorhexidine
giuconate in 70 isopropyl alcohol as
the best skin preparation solution, if no
contraindications are found for its use. It
may require an initial financial effort, but
that will quickly lead to a reduction in the
number of SSIs, and will ultimately save
financial resources and take a step closer
to the patient's right to an 'infection-proof
perioperative journey.
References
Adams D, Quayum M, Worthington T et al 2005
Evaluation of a 2 chlorhexidine giuconate in 70
isopropyl alcohol skin disinfectant
Journal
o f
Hospital Infection 61 287-90
Berry
A
Watt B, Goldacre
M
et al 1982 A comparison
of the use of povidone-iodine and chlorhexidine in
the prophylaxis of postoperative wound infection
Journal of Hospital Infection
3(1 ) 55-63
Bagnall N, Vig S, Trivedi
P
2009 Surgical-site
infection
Surgery
27 (10) 426-30
Department of Health 20 11 High impact
intervention: Care bundle to prevent surgical
infection Available from : hcai.dh.gov.uk/
files/2011 /O3/2011
-03-14-HII-Prevent-Surgical-Site-
infection-FINAL.pdf [Accessed November 2012j
Edminston Jr C, Seabrook G, Johnson
C
et al
2007 Comparative of a new and innovative 2
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chlorhexidine giuconate as topical antiseptic for
preparation of the skin prior to surgery merican
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Infection Control
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Edwards P, Lipp A , Holmes
A
2009 Preoperative skin
antisepsis for preventing surgical wound infections
after clean surgery (Review)
The Cochrane Library,
Oxford, John Wiley & Sons Ltd
Ferguson AW, Scott JA, McGavigan J et al 2003
Comparison of
5
povidone-iodine solution against
1
povidone-iodine solution in preoperative cataract
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with use of iodine for preoperative skin antisepsis to
prevent surgical site infection Infection ontrol
ft
Hospital Epidemiology 3^
(12) 1219-29
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LITERATURE REVIEW
An evidence based protocol for preoperative skin preparation
Continued
Ostrander R, Botte M, Brage M 2005 Efficacy of
surgical preparation solutions in foot and ankle
surgery
Journal of one St Joint Surgery 87 5)
980-5
Saltzma n M, Nuber G, Gryz lo S et al 2009 Ef f icacy
o f surg ica l p repara t ion so lu t ions in shou lder surgery
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Bone St
Joint
Surgery 9 1 8) 1949-53
Segal C, Anderson J 2002 Preoperative skin
preparation of cardiac patients
ORN Journal
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(5)821-8
Stinner D, Krueger C, M asini B, Wenke J 2011 Time-
dependent effect of chloriiexidine skin prep
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of
Hospital Infection
79 313-6
Swenson B, Hedrick T, Metzger
R
et al 2009 Effects
of preoperative skin preparation on postoperative
wound infection rates: A prospective study of 3 skin
preparation protocols Infection Control tHospital
Epidemiology
30 (10) 964-71
Veiga D, Damasceno C, Veiga-Filiio J e t a l
2008 Povidone iodine versus chlorhexidine in
skin antisepsis before elective plastic surgery
procedures: A randomized con trolled tria l
Plastic Et
Reconstructive Surgery 122 5) 170-1
Zinn J, Jenkins J, Swofford V, Harrelson M, McCarter
S
2010 Intraoperative patient skin prep agents: Is
tiiere a difference?
ORN Journal
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About the author
Pedro Silva
Honours Degree in Nursing
-
Portugal
Registered Nurse, Main Theatres, Royai Free Lond
NHS Foundation Trust
No
cpmpe ting Interests dec lared
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