Pre-op Prep Should Safeguard Skin Integrity
By Kelly M. Pyrek
One preoperative ritual that generates a fair amount of controversy is patient skin preparation and its impact on reducing bacteria on the skin and preventing post-operative infections. A recent OR Manager survey revealed more than half of the respondents said surgeons at their hospitals are still using razors for preoperative hair removal, despite a growing body of research proving that it is unnecessary and perhaps even detrimental.1
The Guideline for Prevention of Surgical Site Infection, published in 1999 by the Centers for Disease Control and Prevention (CDC)2, advises that if hair is to be removed, it should be done so immediately before surgery and preferably with electric hair clippers. However, the OR Manager survey showed that only 27% of respondents stated their surgeons used clippers for hair removal.
The CDC's guidelines state: "Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SSI risk than either the use of depilatory agents or no hair removal." The guidelines point to a study in which SSI rates were 5.6% in patients who had their hair removed by razor shave compared to a 0.6% rate among those who had their hair removed by depilatory or who had no hair removed. Adds the CDC, "The increased SSI risk associated with shaving has been attributed to microscopic cuts in the skin that later serve as foci for bacterial multiplication. Shaving immediately before the operation compared to shaving within 24 hours preoperatively was associated with decreased SSI rates (3.1% vs. 7.1%); if shaving was performed greater than 24 hours prior to operation, the SSI rate exceeded 20%... Other studies showed that preoperative hair removal by any means was associated with increased SSI rates and suggested that no hair be removed."
A second important component to preoperative skin prepping is the application of an antiseptic to remove bacteria on the skin through the use of friction and antimicrobial agents. CDC guidelines state that a preoperative antiseptic shower or bath has proven to decrease microbial colony counts. In a study of more than 700 patients who received two preoperative antiseptic showers, chlorhexidine reduced bacterial colony counts ninefold, while povidone-iodine or triclocarban-medicated soap reduced colony counts by 1.3-fold and 1.9-fold, respectively.3 The CDC is quick to point out, however, that even though preoperative showers reduce the patient's microbial colony counts, they have not definitively been shown to reduce SSI rates.
The most common antiseptic agents used for preoperative skin preparation and surgical scrubs include alcohol, chlorhexidine, iodine/iodophors, and triclosan. Alcohol provides the most rapid microbial kill, acting to denature proteins and working well against both gram-negative and gram-positive bacteria, viruses, and fungi. Chlorhexidine has an intermediate rapidity of action, disrupting the cell membrane and working well against gram-positive bacteria, and to a lesser degree, against gram-negative bacteria. Iodine/iodophors also have an intermediate rapidity of action and are acceptable for use against a wide range of bacteria, fungi, and viruses. Triclosan disrupts the cell wall and has an acceptable kill rate against bacteria.
Overall, the CDC says no studies have adequately assessed the comparative effects of these kinds of preoperative skin antiseptics on SSI risk in well-controlled, operation-specific studies. The Association of periOperative Registered Nurses (AORN)'s recommended practices dictate that pre-op skin prep should employ an antimicrobial agent that has a broad range of germicidal action and is nontoxic.4
According to Dianne Rawson, RN, MA, technical services for 3M, the selection of antimicrobial agents should be based on a patient's history of hypersensitivity reactions, patient skin condition, and location of the surgical site. She explains that using an antimicrobial agent on a patient with sensitivity could result in an adverse patient outcome, as the antiseptics absorbed by the skin may be neurotoxic or ototoxic. Rawson adds that skin preparation techniques vary according to the condition of the skin at the surgical site. Burned, denuded, or traumatized skin should be prepared with normal saline irrigation. Mucous membrane areas may be prepared by applying an antimicrobial or antiseptic agent only.
Regardless of the kind of antiseptic agent used, before application the patient's skin should be free of gross contamination. The antiseptic should be applied to the skin in concentric circles, beginning in the area of the proposed incision. The prepared area should be large enough to extend the incision or create new incisions or drain sites if necessary. Rawson says that antimicrobial agents should be applied using sterile supplies and gloves, or by using the no-touch technique and proceeding from the incision site to the periphery. She adds that since wound infections can occur due to a high microbial count beginning at the incision site and reaching out to the periphery, the sponge should be discarded when the periphery is reached and a new sponge used as the skin preparation process continues.
The CDC acknowledges that modifications to this prescribed technique have developed, including:
- Removing or wiping off the skin preparation antiseptic agent after application
- Using an antiseptic-impregnated adhesive drape
- Merely painting the skin with an antiseptic in lieu of the standard skin preparation procedure, and
- Using a "clean," as opposed to a "sterile" surgical skin preparation5
The CDC says none of these modifications has been shown to pose a distinct advantage over standard preoperative skin preparation outlined above.
Drawing from CDC and AORN guidelines, Rawson emphasizes that skin preparation should be performed in a manner that preserves skin integrity and prevents injury. The following are important factors to consider regarding surgical skin preparation outcomes:
- Chemical burns may occur if the antimicrobial agent is allowed to pool beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads.
- An antimicrobial agent that is allowed to dry before sterile drapes are applied may have a longer duration of action.
- Sufficient time for the complete evaporation of a flammable antimicrobial agent must occur before electrosurgical devices or lasers are used, to reduce the possibility of fire.