Antiseptic solution in Operating theatre

1. Antiseptic solution in Operating theatre Patricia Kan

2. Antiseptic solutions in operating theatre

3. Hospitalism: outcomes of pyaemia, septicaemia, erysipelas, hospital gangrene and tetanus One of the giants of infection control Laid down the principles of antisepsis in surgery In late 1800s, he started to use carbolic acid to clean the operation site before incision. Joseph Lister (1827-1912)

4. Topical antiseptic solution in OT • 1. Preoperative skin preparation • 2. Regional anaesthesia (epidural, spinal, etc) • 3. Central line insertion • 4. Hand hygiene

5. Topical antiseptic are antimicrobial agents that kill, inhibit or reduce the no. of microorganisms on the skin. • Human skin is colonized by a wide variety of microorganisms that may provide a protective mechanism to the host, but also a source of infection.

6. Normal skin flora • Transient: • contracted from the environment or from other people • thrive in the environment of sweat, dirt and oil • can be easily removed by soap and water. • Resident: • live in the skin pores and stratum corneum • continually work towards the skin surface • Difficult to remove and require antimicrobial agents with residual action to be effective

7. Topical antiseptic are active against both resident and transient flora by both mechanical and chemical action. • Apply enough pressure and friction to remove dirt, debris and microbes. (except superficial malignancy, areas of carotid plaque) • Common antiseptics: Alcohol, Iodine and iodophors, Chlorhexidine

8. Alcohol • Protein coagulation and denaturation • Alcohol-mediated disruption of cytoplasmic integrity, cell lysis and interference with cellular metabolism • 100% alcohol is not effective • it deprives bacterial cell walls of water • induce the formation of impermeable protein layers which prevent the alcohol from penetrating in to the cell

9. Alcohol is defined by FDA as having one of the following active ingredients: • Ethyl alcohol, 60-95% by volume in aqueous solution • Isopropyl alcohol, 50-91.3% by volume in aqueous solution • Most common concentration: 70% • Effective, less dessicating, less expensive

10. Advantages • Onset of action is most rapid, 10-15 sec • Broad antimicrobial spectrum: • Excellent bactericidal effect on G+, G- • Effective against tubercle bacillus, fungi and virus (certain enveloped viruses: HSV, HIV, influenza virus, RSV) • Not sporicidal, poor activity against certain nonenveloped viruses (e.g. poliovirus, enterovirus, HAV, rotavirus) • Alcohol antiseptic has been used since 1930s and there have been no reports of alcohol resistant bacterial strains

11. Disadvantages • No residual activity • Effectiveness is reduced by organic materials such as blood, mucus, excreta • Volatility and Flammability﹡ • Drying of skin, allergic contact dermatitis • Emollients, may enhance the antimicrobial activity • Toxic reactions have been reported in children after sponge bathing with isopropyl alcohol to reduce fever (1950-60s). The vapors may be absorbed through the lungs and cause acute poisoning.

12. Iodine and iodophors

13. Iodine and iodophors • Tincture of iodine was used as early as 1839 by French war surgeon who treated battle wound during the Civil War • Action: • Iodine molecules rapidly penetrate the cell wall of microorganisms • inactivate cell s by forming complex with amino acid and unsaturated fatty acids • Impaired protein synthesis, alteration of cell membrane • Most effective concentration is 1-2% • Cause stinging and irritation, discoloration • Must be removed with 70% alcohol after drying

14. Iodophors: solutions in which iodine is chemically bound to polymer carrier (complexing agents of high molecular weight) e.g. polyvinylpyrrolidone • Povidone-iodine = Betadine • Water soluble, less staining, less irritating to skin, eye and mucous membrane • Allows slow and continuous release of free iodine which determines the antimicrobial activity • 10% povidone-iodine contains 1% iodine

15. Onset: • iodophors require ~2 min of contact time to allow release of free iodine • after dried • Broad spectrum of bactericidal activity • Effective against G+, G-, tubercle bacillus , fungi, virus and certain spore forming bacteria (e.g. clostridia, Bacillus spp.) • Not sporicidal in concentration used in antiseptic

16. Rapidly neutralized in the presence of organic materials such as blood, mucus, sputum, urine, faeces, etc • Antimicrobial activity is affected by • pH (~6) • temperature (esp sporicidal activity is markedly temperature-dependent, ↑temp → ↑activity) • exposure time, conc of total available iodine, etc • Greater activity when the cpd is in dry state • Some residual effect • If washed away, 30-60 min (except 1 study: 6 hrs) • Bacteriostatic effect as long as on the skin

17. To dry or not to dry??? • Wipe the skin dry after apply the antiseptic agent to allow adherence of disposable adhesive drapes • Kutarski, Grundy. To dry or not to dry? An assessment of the possible degradation in efficiency of preoperative skin preparation caused by wiping skin dry. Annuals of the Royal College of Surgeons of England (1993) vol 75, 181-185. • Skin flora were obtained from subjects at 5, 30, 60 and 120 min • No significant difference in the reduction of baseline count of skin flora between wiping the agent off after 30 sec of application and leaving it to dry • Author suggested a longer period of application time may be worthwhile , particularly where infection would prove disastrous, e.g. implanting prostheses

18. Povidone-iodine related chemical burns • 24/F, R hand flexor tendon repair (2hrs) • Preparation ran down the patient’s arm and absorbed by the padding under the tourniquet cuff

19. 45 yrs old, epidural anaesthesia for femoro-popliteal bypass graft, gauze soaked in povidone-iodine antiseptic solution and was then covered with occlusive transparent waterproof dressing  blistered area in the shape of the gauze at the back

20. PI after closed and prolonged exposure can damage the skin • over bony prominence, pressure points, underneath an area constricted with a tourniquet dressing or bandage • Recommendations: • Skin must not be abraded excessively before the final skin preparation solution is applied • The agent should not be allowed to pool and become trapped under the tourniquet or the torso of the patient • The agent should be allowed to dry before the patient is draped.

21. Transcutaneous iodine absorption • Topical application of PI in burn patients • renal failure, metabolic acidosis, hypernatraemia, hyperosmolarity, hypothyroidism • Hypothyroidism in infants • Skin is very thin and permeable • High plasma iodine conc  transient inhibition of thyroid hormone production, ↓serum thyroxine level (Wolff-Chaikoff effect) • Usu lasts only 48hrs, even if the plasma iodine level remain high • Prolonged hypothyroidism esp in preterm infants • Recommendations: • Avoid iodine containing antiseptic in infants<3mths old • Iodine should be washed off with sterile saline solution

22. CHG 0.05% aqueous CHG 0.05% aqueous (25ml) Chlorhexidine gluconate CHG 0.015% + cetrimide 0.15%

23. Chlorhexidine gluconate (CHG/ Hibitane) • Cationic bisbiguanide • Action: • attachment, disruption of cytoplasmic membranes • precipitation of cellular contents • Broad antimicrobial spectrum • Good activity against G+ • Less activity against G-, fungi • Poor activity against tubercule bacilli • Not sporicidal • In vitro activity against enveloped virus (HSV, HIV, CMV, influenza, RSV) • Less activity towards non-enveloped virus (rotavirus, adenovirus, enterovirus)

24. Introduced to Europe in 1950s and US in 1970s • Bacterial resistance not common, limited to some resistant strains of Pseudomonas, Proteus, Staphylococcus aureus • Antimicrobial activity is not affected by the presence of organic material • ∵cationic ∴activity reduced by natural soaps, inorganic anions, nonionic surfactants, hand cream containing anionic emulsifying agents • pH dependent (5-8), if pH above 9  precipitation of active component

25. Onset: 3-5 min • Good residual activity • It binds to skin and mucous membrane and remain active for at least 6 hrs • Not absorbed through skin , low irritancy potential • Should not come into contact with eyes, meninges (neurotoxic), middle ear (ototoxicity)

26. Allergy/ Anaphylaxis to chlorhexidine • Most of the case reports from Japanese literature • Application to skin, mucous membrane, chlorhexidine-sulphadiazine-coated central venous catheter • (In our ICU, the antibiotic-coated central venous catheter is minocycline/ rifampicin coated)

27. Summary

28. Alcohol based antiseptic solution

29. Alcohol based antiseptic solution • low concentration (0.5-1%) CHG is added to alcohol (70%) • Combination of Alcohol and PI • Advantages: • Rapid action of alcohol • Persistent action of CHG • Decrease the drying time

30. Operating theatre fire and alcohol based antiseptics

31. Case reports • Barker S, Polson J. Fire in the operating room: a case report and laboratory study. Anesth. Analg. 2001; 93: 960-5 • Fong E, et al. Diathermay and alcohol skin preparations – potential disastrous mix. Burns 2000; 26: 673-5 • Chang BW, et al. Patient fire safety in the operation room. Plast. Reconstr. Surg. 1994; 93: 519-21 • Magruder G, et al. Fire prevention during surgery. Arch. Ophthalmol. 1970; 84: 237 • Briscoe C, et al. Infammable antiseptics and theatre fires. Br. J. Surg. 1976; 63: 981-3 • Nicholson M. Comments. Anesth. Analg 1972; 51: 646 • Waitemata Distric Health Board. Report into operating theatre fire accident, 17 Aug 2002. Witemata Distric Health Board Final Report. New Zealand; Waitemata Hospital, 2002. • Toother R, et al. Surgical fires and alcohol-based skin preparations. ANZ J Surg.2001: 74: 382-385 ………………………………..

32. 32/F, R axillary abscess for I&D under GA Diathermy is used Upon removal of surgical drapes, the underlying incontinence pad was on fire, curling up at the edges (alcohol burns with an invisible flame) large area of full thickness burn involving mainly the dependent sites where the solution had pooled soaking the incontinence pad

33. 17/F, LSCS under epidural anaesthesia • 0.5% CHG with 70% alcohol was used to prepare the abdomen • Diathermy was used • “woomph” noise was heard • Patient complained of heat and the anaesthetist felt the heat and saw a flame/shimmer • Fire was put out with fire and CS completed with birth of a healthy baby • The mother suffered 12-16% full thickness burns to her inner thighs and both flanks • due to pooling of alcohol-based skin antiseptic underneath the adhesive surgical drapes which produced alcohol vapour which was ignited by a spark from diathermy • No oxygen supplement is given

35. Recommendations • Alcohol-based solutions are not recommended for skin preparation in the presence of ignition source ( electrocautery unit, laser) • Any alcohol based solution should be clearly labelled • Run-off and pooling of alcohol based antiseptic should be avoided by • Using minimum amount necessary • Allowing solution to dry completely prior to draping • Preparation that contains dye are recommended because they make it easier to see what skin has been painted  less likely to use excessive amt and pooling • Temporary absorptive sheets around the surgical site while using alcohol based solution and removed after use

36. The drying time for skin preparation might need to be longer than the manufacturer’s recommendation (usu 2-3 min), 5 min might be preferable • Electrosurgical instruments should be used on the lowest power setting to minimize the risk of sparking and excessive temperatures • Don’t put diathermy and laser foot pedals side by side • Don’t leave diathermy in the quiver each time after use • The creation of oxygen rich atmosphere should be avoided • Not to create O2 tents by placing drapes over nasal cannula or oxygen mask • In event of fire , oxygen and nitrous oxide supply should be ceased immediately

37. Alcohol vs non-alcohol based antiseptics ??

38. An audit of pre-operative skin preparative methods practised by the surgeons in Northern Ireland in 2005 1. Surgical site infection (SSI)

39. CDC guideline for prevention of surgical site infection, 1999 • Use an appropriate antiseptic agent for skin preparation. Category IB (Strongly recommended for implementation and supported by some experimental, clinical or epidemiological studies and strong theoretical rationale) • ….The iodophors, alcohol-containing products and chlorhexidine gluconate are most commonly used agents…. • ….No studies have adequately assessed the comparative effects of these preoperative antiseptics on SSI risk in well-controlled, operation specific studies….

40. The Cochrane Database of Systematic Reviews Preoperative skin antiseptic for preventing surgical wound infections after clean surgery (2004) • There is insufficient evidence from randomised trials to support or refute the use of antiseptic preparation of skin at operative sites, or of one antiseptic over another. • Only one RCT (Berry 1982) demonstrated a significant difference in infection rates between two different antiseptics (in favour of CHG over iodine)

41. Berry A, et al. A comparison of the use of povidone-iodine and chlorhexidine in the prophylaxis. J. of Hospital infection 1982; 3 (1): 55-63. • 371 clean operations • Results: • Gp1. povidone-iodine 10% in alcohol • 28/176 , 15.9% • Gp2. chlorhexidine 0.5% in spirit • 8/195, 4.1% • Limitation: • Lack of extensive FU, underestimate the infection rates

42. Hibbard, et al. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: A Review. J. of infusion nursing 2005, 28 (3): 194-207. • CHG+IPA provided the best immediate, persistent, cumulative antimicrobial activity • Ostrander, et al. Efficacy of surgical preparation solutions in foot and ankle surgery. J. Bone joint Surg Am 87: 980-985, 2005. • ChloraPrep ( 2% chlorhexidine and 70% IPA) was most effective for eliminating bacteria from the forefoot prior to surgery, when compared with DuraPrep (0.7% iodine + 74% IPA) or 3% chloroxylenol • Bibbo C, et al. Chlorhexidine provided superior skin decontamination in foot and ankle surgery. Clinical orthopaedics and related research 438: 204-208, 2005.

43. A survey of fellows of ANZCA with a special interest in obstetric practice, about their beliefs regarding aseptic precautions for insertion of epidural catheter in labour ward in 2002 2. Epidural catheter insertion

44. Mechanisms of epidural infection: • Skin flora introduced either at the time of puncture or bacterial migration along a catheter or needle tract (soiling of the back by amniotic fluid, urine and feces during labour and delivery  ↑catheter contamination) • Contamination of drug or material • Haematogenous spread from another site of infection • Catheter colonization arising from clinicians’ and nurses’handling of syringes and solutions, via catheter hub

45. Clevenot D, et al. Critical review of the literature concerning the comparative use of two antiseptic soultions before intravascular or epidural catheterization. Ann Fr Anesth Reanium 2003 Nov; 22(9): 787-97 • Chlorhexidine in alcoholic solution seems more efficient than povidone iodine in aqueous solution in the clinical setting. • The place of povidone iodine in alcoholic solution, whose performances on the healthy skin are similar to those of alcoholic chlorhexidine, is being in evaluation.

46. Birnbach, et al. Comparison of povidone iodine and DuraPrep (iodophor in IPA) for skin disinfection prior to epidural catheter insertion in parturients. Anesthesiology 2003; 98(1): 164-9.

48. Explanation: • Alcohol provides rapid antisepsis • Long lasting effect: • Duraprep, when placed on skin, produces a film of disinfectant • This film resists being washed away by fluids and blood

49. Kinironsm et al. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children. Anesthesiology 2001; 94: 239-44. • Alcoholic solution of 0.5% chlorhexidine vs aqueous solution of 10% povidone iodine