Skin Antisepsis: First Line of Defense Set Skin Preparation in Motion Before the Incision

Molnlycke Health Care, 2611 Fallston Road, Fallston, MD 21047, USA

E-mail address: judith.seltzer@molnlycke.com

Abstract

There are multiple ways in which skin preparation can be accomplished. In addition, with the number of skin preparation agents approved for use, nurses sometimes find themselves asking which skin preparation agent will provide the best efficacy for skin disinfection. Adopting a standardized method for selecting and applying the surgical skin preparation may be the best way the surgical team can determine that all patients are receiving the same standard of care, thus promoting best outcomes in their fight against surgical-site infections.

Keywords

• Skin preparation agents • Manufacturer’s instructions • Surgical-site infection • Antiseptic agents

In 1992 the US Centers for Disease Control (CDC) revised its definition of wound infection, creating the definition surgical-site infection (SSI). SSIs are infections that occur at any site along the surgical tract.¹

Prevention of SSIs continues to be one of the greatest health care challenges in the world today. It is estimated that, in the United States alone, there are some 27 million annual surgical procedures resulting in 500,000 surgical-site infections.² These infections have proved to be a major cause of patient injury and mortality, as well as adding to ever-increasing health care costs. Overall, SSIs are associated with $7 billion to $10 billion annually. In health care expenditures in the United States:

• An estimated 2.6% of nearly 30 million operations are complicated by SSIs each year

• Infection rates of up to 11% are reported for certain types of operations

• Each infection is estimated to increase a hospital stay by an average of 7 days and add more than $3000 in charges (1992 data).³

The patient’s own indigenous flora is the most common form of pathogen transmission leading to an SSI.⁴ Therefore, once the surgical incision has been made, the patient’s skin is no longer intact and is at risk for an infection to occur. Therefore, preparing the patients skin before the incision is made can potentially the patient from developing a SSI. The CDC defines surgical skin preparation as a “procedure for cleansing the skin with an antiseptic before the surgical procedure.”¹ In the CDC Surgical-Site Infection Guidelines (1999), requiring patients to shower or bathe with an antiseptic agent on at least the night before the operative day is listed as a category IB recommendation (Box 1).¹ It is strongly recommended that all surgical patients receive preoperative skin cleansing before their procedure, regardless of surgery type.

According to the Association of periOperative Registered Nurses (AORN)

Rationale:

• Important factors to consider regarding surgical skin preparation outcomes include removal of pathogens while preserving skin integrity.

US Food and Drug Administration regulations of antiseptics

In the United States, drugs, pharmaceuticals, and cosmetics are regulated by the Food and Drug Administration (FDA). Thus antiseptics are under the jurisdiction of, and have parameters clearly defined by, the FDA. The health care facility should use FDA-approved agents that have immediate, cumulative, and persistent antimicrobial action ⁶:

• The skin preparation agents should have the following properties: fast-acting, persistent and cumulative, and nonirritating

• The surgical team members and infection prevention practitioner should be involved in the process of evaluating and selecting the skin preparation agents. In the United States, antiseptic agents are regulated by the FDA’s Division of Over-the-Counter Drug Products ⁵

• The evaluation should involve the review of the manufacturer’s information to confirm that the antiseptic agents were tested according to FDA requirements and to review the results of the testing to confirm efficacy of the product.

The involvement of the surgical personnel allows the evaluation of the properties of the antiseptic agents, including effects on the skin, and contributes to the final decision regarding the antiseptic agents that are the most effective antimicrobial solutions as well as least harmful to the skin.

When evaluating antiseptic agents, the following FDA standards should be taken into consideration. The agents should substantially reduce transient microorganisms; possess a broad spectrum of antimicrobial properties; be fast acting; have persistent, cumulative activity; and be nonirritating to the skin.⁵

Most frequently used skin preparation agents

Plastic, cosmetic, and reconstructive surgery refers to a variety of operations performed to repair or restore body parts to look normal, or to change a body part to look better. These types of surgery are highly specialized. They are characterized by careful preparation of the patient’s skin and tissues, by precise cutting and suturing techniques, and by care taken to minimize scarring.

The risks associated with plastic, cosmetic, and reconstructive surgery include the postoperative complications that can occur with any surgical procedure. However, these types of surgical procedures also carry specific risks for the patient:

• Formation of undesirable scar tissue

• Persistent pain, redness, or swelling in the area of the surgery

• Infection inside the body related to insertion of a prosthesis. These infections can result from contamination at the time of surgery or from bacteria migrating into the area around the prosthesis at a later time.

But when it comes to surgical skin preparation, plastic surgery is no different from other service lines. Patients must be protected from developing SSI’s. The 1999 CDC SSI guidelines require the “use of an appropriate agent for skin preparation.”¹ These guidelines discuss several skin preparation agents that are in use today. Currently, the 2 most common skin preparation agents used in plastic/reconstructive surgery are chlorhexidine gluconate (CHG), (with or without alcohol), and povidone-iodine (with or without alcohol) (Table 1).⁷

Table 1 Characteristics of CHG, povidone-iodine, and alcohol

According to the CDC, some comparisons of the 2 antiseptics when used as preoperative hand scrubs suggest that chlorhexidine gluconate achieved greater reductions in skin microflora than did povidone-iodine and also had greater residual activity after a single application.¹ When reviewing literature of skin preparation agents, more and more researchers/practitioners are concluding that CHG is superior to other products related to skin disinfection. In a study by Darouiche and colleagues,⁸ preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing SSI after clean contaminated surgery. In a separate study by Fletcher and colleagues,⁹chlorhexidine gluconate was found to be superior to povidone-iodine for preoperative antisepsis for both the patient and surgeon.

The major caveat to these and similar studies was that, although the best outcomes were achieved using CHG, the CHG was combined with alcohol. Alcohol is flammable product.

In an article by Prasad and colleagues,¹⁰ the use of alcohol-based products for hand hygiene and skin antisepsis could initiate even greater concerns regarding the hazards of operating room fires. In the case study reviewed in the article by Prasad and colleagues,¹⁰ the patient was scheduled for a tracheostomy.

The surgical site was prepared according to the facility protocol with a 1-step skin preparation agent with an alcohol solution covering the face, neck, shoulders, and upper chest. An oxygen-rich environment was ruled out as a possible cause of the surgical fire. The initial site of fire corresponded with the distribution of skin preparation agent used to prepare the surgical site. In addition, the short time between the preparation of the surgical site and the use of the electrosurgical unit (the ignition source) suggested that the solution in some areas of the surgical field was not yet entirely dry and that the amount of alcohol vapor was substantial. The distribution of the burned area on the patient corresponded with the distribution of the antiseptic solution. It was therefore confirmed in this particular case that the use of an alcohol-based antiseptic was the major contributing factor to the surgical fire.

One could therefore conclude that, based on the literature available today, CHG without the use of alcohol is a beneficial step to promoting the best surgical outcomes for our patients.