Optimal Approaches to Skin Preparation Prior to Neurosurgery
• povidone-iodine scrub-paint in combination with an alcohol paint; • 2% CHG and 70% isopropyl alcohol (Chloraprep); and • iodine povacrylex in isopropyl alcohol (DuraPrep).
The infection rates following these three treatments for each period were 6.4, 7.1, and 3.9%, respectively.25
These results suggest that
iodophor-based preparations may be superior to CHG preparations in the general surgery population.
Why Do Neurosurgical Procedures Pose Different Challenges for Skin-site Preparation? When deciding on the appropriate skin preparation for a neurosurgical procedure, e.g. a craniotomy, a number of different points must be taken into consideration that impact and limit the number of options available. Two such limitations are readily apparent:
• •
first, the head is covered with hair, which impacts what can be achieved in terms of skin preparation; and
second, chlorhexidine gluconate is considered less suitable for use in neurosurgery as in vivo evidence suggests that it is neurotoxic.
Since the head is largely covered in hair, traditional preparation for craniotomies and other intracranial procedures involves extensive shaving of the operation site. The rationale was that removing all hair as completely as possible from the scalp would reduce the risk for infection. However, the overall evidence in the literature over the past decade suggests that shaving does not decrease the risk for SSI and may even possibly increase it.
Two studies from the late 1990s in children26 and adults27 suggested a
Currently, many surgeons have moved towards minimal shaving of the incision site or to the use of clippers instead of shaving.
Winston et al. demonstrated similar findings in a study involving 638 patients undergoing craniotomies and cerebrospinal fluid shunts.28
similar level of infection control with or without shaving the scalp. A study reviewing 225 neurosurgical procedures performed in the US showed that shaved patients incurred a higher rate of SSIs—5.88% in the shaved population compared with 3.37% among non-shaved patients.27
Current Guidelines and Future Developments It is unfortunate that there are no clear current guidelines directing the choice of skin preparation in neurosurgery. Many institutions have developed their own body of recommendations based on literature reviews, but the choice of skin preparations largely remains a function of the individual neurosurgeon and what preparations are available at a particular institution. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America, Association of periOperative Registered Nurses, Centers for Disease Conrol and Prevention, and the Joint Commission National Patient Safety Goals 2010 all discourage the practice of shaving surgical sites. It is recommended that hair is either pinned out of the way or removed via the use of clippers. The use of alcohol-based preparations has also been discouraged in hairy areas by the American Society of Anesthesiologists due to the flammability risk.34
time is recommended for the solutions to dry.35
If such solutions must be used, one hour of It is also known that while
much in the literature recommends the use of chlorhexidine, this solution is worrisome for neurotoxicity. This limitation should be considered in neurosurgical cases. One thing is certain; the use of pre-operative antibiotics given 30–60 minutes prior to incision is recommended to decrease the risk for peri-operative infection.20
As greater attention is turned to the effects of various skin preparations in neurosurgery, one expects to see a number of developments. It is very likely that there will be greater use of iodine-based preparations (povidone/iodine antiseptic paints and scrubs, likely with alcohol) as opposed to chlorhexidine gluconate because of the associated neurotoxicity concerns. While it is unlikely that alcohol will be eliminated from the iodoform-based preparations that are used, the authors believe that more time will be given to allow these preparations to dry prior to the initiation of surgery to comply with US Food and Drug Administration (FDA) regulations and improve patient safety. It is anticipated that current guidelines from the general surgery literature will begin to emphasize these points for the neurosurgical subspecialty soon.
Despite having superior antiseptic properties to iodophor solutions, CHG is considered by many to be inappropriate for neurosurgery due to neurotoxicity. While this is not an issue for most general surgery cases, it becomes a major consideration for neurosurgical cases, wherein exposure of neural tissue to CHG could have long-lasting negative effects.
Reports in older studies from the 1970s suggested CHG as causing hearing loss following otosurgery and causing taste disturbance after oral surgery.29–33
this. A study by Henschen and Olsen33
Animal model investigations in later years confirmed in 1984 showed CHG to damage
autonomic nerve fibers in the eyes after exposure. This damage was still evident as long as 50 days after exposure. They also noted that the damage was most apparent in unprotected tissues.33
effectively limit the options available to neurosurgeons when choosing an appropriate skin preparation for surgery.
US NEUROLOGY These data
One also expects to see a complete elimination of shaving and extensive clipping of surgical sites as traditional methods are abandoned and evidence from microbiological studies are accepted. In its place, one would likely see an increased use of minimal clipping combined with antiseptic shampoos followed by an iodophor-based preparation at the surgical site. There is also likely to be an increased use of self-adhesive drapes containing iodine (i.e. Ioban). Neurosurgical studies are already beginning to show the effectiveness of this method in addition to the standard aqueous iodophor preparations.27
Conclusion
Changes in practice, the use of povidone or iodine-based skin preparations, the use of antibiotic-impregnated drapes, the elimination of shaving, and the reduced use of clipping should begin to decrease the overall risk for SSIs in neurosurgery. The combination of these with the standard use of pre-operative antibiotics and good sterile techniques should make neurosurgery less infection-prone. This will reduce patient morbidity, improve outcomes, and reduce costs for the healthcare system. n
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