Infection Control Today - 01/2004: OR Topics

Skin Prep:
Preparing the Hypersensitive Patient

By Tina Brooks

Although anaphylaxis is rare, it is estimated that as many as 43 million people in the United States are at risk. The likelihood that one of these individuals will require a surgical procedure during their lifetime is a real possibility.

Anaphylaxis is a type I hypersensitivity reaction in which exposure of a sensitized individual to a specific antigen results in hives, itching, and swelling, followed by blood vessel collapse and shock and often accompanied by life-threatening respiratory distress.1 This condition may occur within seconds to minutes of exposure to the antigen. The quicker the reaction, the more severe it can be. In extreme cases, death may occur in 5 to 10 minutes after onset of the reaction.2

An anaphylactic reaction is considered a multisystem response, says Carolyn Twomey, RN, BSN, a clinical nurse consultant for Regent Medical. In addition to the typical allergic reactions such as hives, rhinitis, shortness of breath, and wheezing, one can have tachycardia, hypotension, laryngeal edema, cardiac arrest and even gastrointestinal symptoms.

Effective treatment is available as long as symptoms are quickly recognized and handled promptly. Pretreatment of known hypersensitive patients hasnt necessarily guaranteed that anaphylaxis will not occur.

A reaction can be triggered by exposure to an allergen through inhalation, injection, ingestion or skin contact. Common causes of anaphylaxis include foods, medications and insect stings. Products used during surgery, however, can cause anaphylaxis too, including those for skin preps.

Allergies in general have increased across the United States, says Wava Truscott, PhD, director of scientific affairs and clinical education at Kimberly-Clark Health Care. Many of the products that we use in healthcare contain some of the materials individuals are allergic to.

Skin Cleansing

The objective of a skin prep is to remove dirt, reduce microorganisms and prevent further microbial growth during a procedure. It is individualized to the clients needs, which are determined by health status and the type of procedure scheduled.

Whether using disposable trays or prepared sterile tables, the following items are usually required: towels, basins, sponges, gloves and an antiseptic agent.

Some disposable sterile skin prep trays include applicators and or containers of a pre-measured amount of antiseptic solution.3 Antiseptics are the most frequent cause of contact dermatitis in patients undergoing surgery.4

As with any topical, there will be a certain percentage of the population that cannot use it, says Steve Owens, marketing director at Healthpoint Ltd.

Antiseptic agents have been known to trigger anaphylaxis as well. Those that are frequently reported contain iodine and chlorhexidine. Initial exposure to these antiseptic agents may come from the use of every-day products such as hair dyes, gargles and toothpaste. A 64-year-old patient developed a life-threatening anaphylactic reaction caused by povidone-iodine during induction of anesthesia for elective coronary artery bypass graft surgery.5 There are a small but growing number of reports of anaphylaxis to chlorhexidine administered by a variety of routes, including intact skin, surgical wounds and immersion in a chlorhexidine bath.6

Occasionally, there may be individuals that are allergic to the soaps that theyre asked to bathe with prior to surgery, but a full anaphylactic reaction would be extremely rare, Truscott says.

Latex, which is a leading cause of anaphylaxis within the healthcare setting, may be present in gloves, applicators, and even adhesive tape. Allergic reactions to latex are often systemic responses to the proteins found in natural rubber latex (NRL). For the general public, the risk of becoming latex allergic is estimated to be less than 1 percent with higher occurrences among children with spina bifida or patients who have undergone multiple surgical procedures, reports the Food and Drug Administration (FDA). In one case, a woman with no past medical history of allergies to medications, food or latex was found to be latex-sensitive during surgery, however, her multiple surgical procedures could have suggested the potential for such an adverse event.7

When we talk about latex allergy or any other allergy, consideration must be given to those individuals who are atopic somebody who is genetically preprogrammed, Twomey says. Those people who are genetically preprogrammed have a greater propensity to develop allergies no matter what theyre exposed to.

Patients can be exposed preoperatively to this potential allergypromoting or skin-irritating substance used in connection with surgery.8 Remember that its not just their exposure in-house, but that exposure could happen in an outpatient surgery center, a podiatry office (if they have a procedure there) or even a dentist office, Twomey says. So, even if they dont come to a hospital frequently, if theyve had frequent procedures or exposure to certain products or scrubs, it would increase their potential to react to a product. Allergies occur because of exposure over time.

Patient Care

Avoidance of anaphylaxis requires an awareness of previous allergic reactions in individuals and identification of those people who are likely to experience a serious reaction to any of the items used in preparing the patient for surgery.9 Twomey suggests the use of an evaluation tool or decision tree, many of which are available in the practice arena, to evaluate patients reactions that theyve had historically.

Of special importance is the way in which questions are asked during the evaluation, says Milt Hinsch, technical director at Regent Medical. For example, if you ask somebody, Are you latex allergic? they may say a flat no. But if you ask, When you were a kid and blowing up balloons, did your lips ever swell up? or When you wear rubber gloves and do the dishes, what happens? Those kinds of things suddenly take it from a no to Oh, yeah. I have had some reactions to latex products and things.

John Calhoun, product manger at Sempermed USA, recommends, Find out if the patient has observed sensitivities to chemical accelerators or chemical residuals in gloves in addition to latex.

Twomey adds that she once had a patient that wasnt aware of having any allergies. Yet, upon further questioning as to why the patient avoided certain foods, it was discovered that the patient had an allergy to bananas. A lot of times people dont get diagnosed. They simply practice good avoidance. So, you have to be a good sleuth and get that information.

Another critical component is communication between the surgeons office and the surgical posting for a hospital. Surgeons should be very communicative about issues, questions or things theyve found when theyve asked their patients or taking their histories, says Twomey.

They should pass that information along so that you dont find yourself in trouble in the OR. You can be proactive. But, that link is always a challenge.

Product Selection

Twenty to 30 years ago, we didnt have nearly the myriad of selections of products in the medical device field that we have today, Hinsch says. Today, somebody can easily go and find an alternative if there is a question of irritation or allergic reaction to a particular material or product. There are many options.

Experts agree that the key to proper selection of items used for a skin prep involves product education. You have to be very discerning and knowledgeable about the equipment you use, and if we are talking about scrubs or preps, you have to know the information about the active ingredients to understand the product, Twomey says.

Owens suggests that clinicians seek prep alternatives that may not include some of the known allergens such as iodine or CHG (chlorhexidine gluconate).

With regard to gloves, One of the biggest things is to understand latex and these different materials used in gloves. People really dont understand the nature of the materials. That is the first part of educating themselves on what these materials are and how they could affect the patient, Calhoun says.

It is important not to inadvertently introduce new complications with selected gloves, says Truscott. Could substances penetrate the glove, causing health concerns for the wearer? Would it break down during use?

Tito Aldape, vice president of regulatory and scientific affairs at MicroFlex Corp., says, The one-glove-fits-all notion is a big misconception. There are many different types of medical gloves and glove needs in the marketplace. Clinicians, for example, have specific hand protection needs the glove selection process must consider the application for which the glove is intended to be used. The risk manager has to consider employee health and safety, again taking the specific work function, task, and medical glove application into consideration before recommending a particular medical glove. The quality of the medical glove is very important and needs to be considered heavily. Not all medical gloves are created equal and can vary significantly in overall quality. Clinicians should also request that their medical glove supplier provide them with documentation that the medical gloves they are purchasing meet current regulatory requirements and current performance standards. One such document that should be requested is a certificate of compliance.

Owens emphasizes, In general, the one thing that clinicians want to make sure of is that they can maximize or provide the highest levels of efficacy in conjunction with providing a product that offers the lowest sensitivities/allergic properties or irritation opportunities.

Did You Know...

The Internet offers a wealth of information on anaphylaxis. Here is a list of Web sites to investigate for more information:

  • American Academy of Allergy, Asthma & Immunology Provides the general public and professionals with the latest information for a variety of allergic conditions, including anaphylaxis.
  • American Society of Anesthesiologists Offers a number of articles discussing latex allergy, anaphylaxis and the role of the anesthesiologist.
  • Annals of Internal Medicine Provides patients a summary of delayed drug hypersensitivity reactions for educational purposes only. The journal also allows access to previously published articles.
  • eMedicine Provides clinical knowledgebased articles on anaphylaxis for physicians and health professionals.
  • Food Allergy and Anaphylaxis Alliance Presents facts about food allergy and related issues from the perspective of various countries: Australia, Canada, New Zealand, Netherlands, United Kingdom and United States.
  • Food Allergy and Anaphylaxis Alliance Provides information and resources to the general public and professionals about various issues surrounding anaphylaxis.
  • Food and Nutrition Information Center Provides several links to other Web sites offering information about allergies and food sensitivities.
  • National Institute of Infectious Diseases Presents anaphylaxis and allergy statistics in the United States. Reference sources are provided.
  • PubMed Lists several citations for biomedical articles from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources.  
  • U.S. Food and Drug Administration Offers several articles about anaphylaxis, latex allergy, drugs and related issues.

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