An Evidence Based Protocol for Preoperative Skin Preparation

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:

[email protected]

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



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



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

chlorhexidine gluconate-impregnated c loth w ith 4

chlorhexidine giuconate as topical antiseptic for

preparation of the skin prior to surgery merican

Journal

o f

Infection Control

35 (2) 89-96

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

surgery antisepsis: a prospective randomised double

blind study

British Journal

o f

Ophthalmology

87

163-7

Hamill B, Osato M, Wilhelmus

K

1984 Experimental

evaluation of chlorhexidine giuconate for ocular

antisepsis

Antimicrobial Agents t

hemotherapy

26 (6) 793-6

Hopper W, Moss

R

2010 Common breaks in sterile

technique: Clinical perspectives and perioperative

implications/ÍORNJournaí

91

(3) 350-64

Kehinde E, Jamal W, Ali

Y

et al 2009 Comparative

efficacy of two methods of skin preparation of the

perineal and genital skin of male urological patients

Kuwait

Medical Journal

4 2) 103-7

Lee I, Agarwal R, Lee B et al 2010 Systematic review

and cost analysis comparing use of c hlorhexidine

with use of iodine for preoperative skin antisepsis to

prevent surgical site infection Infection ontrol

ft

Hospital Epidemiology 3^

(12) 1219-29



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

Journal of

Bone St

Joint

Surgery 9 1 8) 1949-53

Segal C, Anderson J 2002 Preoperative skin

preparation of cardiac patients

ORN Journal

76

(5)821-8

Stinner D, Krueger C, M asini B, Wenke J 2011 Time-

dependent effect of chloriiexidine skin prep

Journal

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

92 (6) 662-74

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

Members can search ali issues of the BJPN/JPP

pubi ished s ince 1998 and download art ic ies f ree o

charge at

www.afpp.org.uk.

Access is also avaiiabie to non-members who pay a

smali fee for each art ic le download.

I WARMING

I UPDATE

W hat did the experts say about patient w arming?

It is widely k nown that h ypothermia can result from temp erature drops that occur during s urgical proced ures, which can lead to potentially

health consequences. Molnlycke

i ealth

Care hosted a Wa rming Update webin ar on No ve mb er8 , 2012, to illustrate how adopting a critica l

activity (patient warming) can result in cost savings and reduced risk of complications.

Featuring Dr Dan Sessier from the Cleveland Clinic and Dr Johan Raeder from Oslo University Hospital, renowned experts in this

f ield,

the

aimed to instruct participants on how and why they need to improve patient warming.

Watch the patient warm ing we binar at vww/.molnlycke.com or contact: [email protected] for more inform ation.



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An Evidence Based Protocol for Preoperative Skin Preparation