Chlorhexidine is safe for Spinal/Epidural use

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Reg Anesth Pain Med. 2012 Mar;37(2):139-44.
Neurologic complications after chlorhexidine antisepsis for spinal anesthesia.

Sviggum HP, Jacob AK, Arendt KW, Mauermann ML, Horlocker TT, Hebl JR.
Source

From the Departments of *Anesthesiology and †Neurology, Mayo Clinic, Rochester, MN.

Abstract

BACKGROUND AND OBJECTIVES:

Recent reports of infectious complications after neuraxial procedures highlight the importance of scrupulous aseptic technique. Although chlorhexidine gluconate (CHG) has several advantages over other antiseptic agents; including a more rapid onset of action, an extended duration of effect, and rare bacterial resistance, it is not approved by the US Food and Drug Administration for use before lumbar puncture because of absence of clinical safety evidence. The objective of this retrospective cohort study was to test the hypothesis that the incidence of neurologic complications associated with spinal anesthesia after CHG skin antisepsis is not different than the known incidence of neurologic complications associated with spinal anesthesia.
METHODS:

All patients 18 years or older who underwent spinal anesthesia at Mayo Clinic Rochester from 2006 to 2010 were identified. The primary outcome variable was the presence of any new or progressive neurologic deficit documented within 7 days of spinal anesthesia. The etiology of a patient's neurologic complication was independently categorized as possibly or unlikely related to the spinal anesthetic by 3 investigators. Consensus among all reviewers was required for final category assignment.
RESULTS:

A total of 11,095 patients received 12,465 spinal anesthetics during the study period. Overall, 57 cases (0.46%; 95% confidence interval, 0.34%-0.58%) met criteria for neurologic complication. Spinal anesthesia was felt to be the possible etiology of 5 neurologic complications (0.04%; 95% confidence interval, 0.00%-0.08%); all completely resolved within 30 days.
DISCUSSION:

The incidence of neurologic complications possibly associated with spinal anesthesia (0.04%) after CHG skin antisepsis is consistent with previous reports of neurologic complications after spinal anesthesia. These results support the hypothesis that CHG can be used for skin antisepsis before spinal placement without increasing the risk of neurologic complications attributed to the spinal anesthetic.

I use the small stick version

Originally Posted by BLADEMDA

Reg Anesth Pain Med. 2012 Mar;37(2):139-44.
Neurologic complications after chlorhexidine antisepsis for spinal anesthesia.

Sviggum HP, Jacob AK, Arendt KW, Mauermann ML, Horlocker TT, Hebl JR.
Source

From the Departments of *Anesthesiology and †Neurology, Mayo Clinic, Rochester, MN.

Abstract

BACKGROUND AND OBJECTIVES:

Recent reports of infectious complications after neuraxial procedures highlight the importance of scrupulous aseptic technique. Although chlorhexidine gluconate (CHG) has several advantages over other antiseptic agents; including a more rapid onset of action, an extended duration of effect, and rare bacterial resistance, it is not approved by the US Food and Drug Administration for use before lumbar puncture because of absence of clinical safety evidence. The objective of this retrospective cohort study was to test the hypothesis that the incidence of neurologic complications associated with spinal anesthesia after CHG skin antisepsis is not different than the known incidence of neurologic complications associated with spinal anesthesia.
METHODS:

All patients 18 years or older who underwent spinal anesthesia at Mayo Clinic Rochester from 2006 to 2010 were identified. The primary outcome variable was the presence of any new or progressive neurologic deficit documented within 7 days of spinal anesthesia. The etiology of a patient's neurologic complication was independently categorized as possibly or unlikely related to the spinal anesthetic by 3 investigators. Consensus among all reviewers was required for final category assignment.
RESULTS:

A total of 11,095 patients received 12,465 spinal anesthetics during the study period. Overall, 57 cases (0.46%; 95% confidence interval, 0.34%-0.58%) met criteria for neurologic complication. Spinal anesthesia was felt to be the possible etiology of 5 neurologic complications (0.04%; 95% confidence interval, 0.00%-0.08%); all completely resolved within 30 days.
DISCUSSION:

The incidence of neurologic complications possibly associated with spinal anesthesia (0.04%) after CHG skin antisepsis is consistent with previous reports of neurologic complications after spinal anesthesia. These results support the hypothesis that CHG can be used for skin antisepsis before spinal placement without increasing the risk of neurologic complications attributed to the spinal anesthetic.

anectodally we've all used this for our pain proecedures in the spine anyways. Now there's literature to back it up!

Sweet!

A nice piece of literature to shut up the ASC/hospital nurses/administrators when they try to give us flack about using chloraprep for pain procedures.

Nice to have some data for what a lot of people have been doing for years.

I always let it dry completely before placing needle to skin for fear of some sort of chemical meningitis... interesting that it was not mentioned in the methods section whether or not they let it dry.

Originally Posted by Frank Rizzo

Nice to have some data for what a lot of people have been doing for years.

I always let it dry completely before placing needle to skin for fear of some sort of chemical meningitis... interesting that it was not mentioned in the methods section whether or not they let it dry.

Do you think 3+ inches of tissue is going to wipe off the chloroprep on its way in?

Hint: it will.

Originally Posted by lobelsteve

Do you think 3+ inches of tissue is going to wipe off the chloroprep on its way in?

Hint: it will.

I have no idea. Maybe 3+ inches of tissue will wipe away the bacteria/viruses and we're just wasting our f@ucking time?!? Give me a break.

We recently had an OB lecture and our attending sited an articles which showed that chloroperp was actually superior to betadine in preventing catheter colonization when doing an epidural. And wants us to now use chloroprep almost exclusively. With the possibility of a wet tap I thought a study like the one mentioned by Blade would have been done before doing studies on infection rates, and thus Blades article shouldn't be big news.

As for letting the chloroperp air dry before inserting the needle, the manufacturer has always recommended letting it air dry for best results so that also shouldn't be anything new.


I don't remember if this is the article my attending quoted but here's one I found.

Anesthesiology. 2001 Feb;94(2):239-44.
Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial.
Kinirons B, Mimoz O, Lafendi L, Naas T, Meunier J, Nordmann P.
Source

Department of Anesthesia and Intensive Care, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France.
Abstract
BACKGROUND:

Chlorhexidine is better than povidone iodine for skin preparation before intravascular device insertion or blood culture collection, but it is not known whether chlorhexidine is superior in reducing colonization of continuous epidural catheters.
METHODS:

Children requiring an epidural catheter for postoperative analgesia longer than 24 h were randomly assigned to receive skin preparation with an alcoholic solution of 0.5% chlorhexidine or an aqueous solution of 10% povidone iodine before catheter insertion. Using surgical aseptic techniques, catheters were inserted into either the lumbar or the thoracic epidural space based on the preferences of the anesthesia team, on clinical indication, or both. Immediately before epidural catheter removal, their insertion site and hub were qualitatively cultures. After their removal, the catheter tips were quantitatively cultured. Catheters were classified as colonized when their tips yielded 1,000 or more colony-forming units/ml in cultures.
RESULTS:

Of 100 randomly assigned patients, 96 were evaluable. The clinical characteristics of the patients and the risk factors for infection were similar in the two groups. Catheters were kept in place for a median (range) duration of 50 (range, 21-100) h. Catheters inserted after skin preparation with chlorhexidine were one sixth as likely and less quickly to be colonized as catheters inserted after skin preparation with povidone iodine (1 of 52 catheters [0.9 per 100 catheter days] vs. 5 of 44 catheters [5.6 per 100 catheter days]; relative risk, 0.2 [95% confidence interval, 0.1-1.0]; P = 0.02). Coagulase-negative staphylococci were the only colonizing microorganisms recovered, and the skin surrounding the catheter insertion site was the origin of all the colonizing microorganisms.
CONCLUSIONS:

Compared with aqueous povidone iodine, the use of alcoholic chlorhexidine for cutaneous antisepsis before epidural catheter insertion reduces the risk of catheter colonization in children.

N Engl J Med. 2010 Jan 7;362(1):18-26.
Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis.

Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH.
Source

Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX 77030, USA. rdarouiche@aol.com

Abstract

BACKGROUND:

Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine-alcohol is more protective against infection than is povidone-iodine.
METHODS:

We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections.
RESULTS:

A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups.
CONCLUSIONS:

Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

http://cid.oxfordjournals.org/content/46/2/274.full.pdf


Betadine is inferior. Go with the Chloraprep!

J Med Assoc Thai. 2011 Jul;94(7):807-12.
Alcohol-based chlorhexidine vs. povidone iodine in reducing skin colonization prior to regional anesthesia procedures.

Krobbuaban B, Diregpoke S, Prasan S, Thanomsat M, Kumkeaw S.
Source

Department of Anesthesiology, Chaiyaphum Hospital, Chaiyaphum, Thailand. Albkb@diamond.mahidol.ac.th

Abstract

BACKGROUND:

Povidone-iodine is a commonly used antiseptic for preparing the skin for regional anesthesia. However chlorhexidine solution has been demonstrated superior for skin preparation before insertion of intravascular devices, taking of blood cultures and before epidural insertion in children. The information regarding the initial efficacy of these disinfectants has not yet been defined The purpose of the present study was to investigate the initial efficacy ofan alcohol-based chlorhexidine and povidone iodine solution as the antiseptic of choice for all regional techniques.
MATERIAL AND METHOD:

One hundred patients requesting regional anesthesia were randomly assigned to receive skin preparation with either single-use povidone iodine or alcohol-based chlorhexidine solution. Two quantitative skin cultures were obtained from the insertion site: one obtained just prior to skin disinfection and the other immediately following antisepsis after allowing it to air-dry.
RESULTS:

Complete data were available for 98 patients. Bacteriological examination revealed mainly coagulase negative Staphylococci (78.6%; 77/98). The proportion of subjects with a positive skin culture immediately after skin disinfection differed significantly between the povidone iodine and alcohol-based chlorhexidine groups (35% vs. 10%, respectively; p = 0.003). The incidence of positive skin culture was lower in the chlorhexidine group, with an absolute risk reduction (ARR) of 0.25, a relative risk reduction (RRR) of 71% and a number need to treat (NNT) of 4.
CONCLUSION:

For skin disinfection prior to the neuraxial blockade procedure, the use of alcohol-based chlorhexidine compared with the use of povidone iodine lowered the incidence of insertion-site-colonization

I've got another good study whiich needs to be done:

Duraprep vs. Chloraprep. Perhaps, Duraprep is better and safer?

Anesthesiology. 2003 Jan;98(1):164-9.
Comparison of povidone iodine and DuraPrep, an iodophor-in-isopropyl alcohol solution, for skin disinfection prior to epidural catheter insertion in parturients.

Birnbach DJ, Meadows W, Stein DJ, Murray O, Thys DM, Sordillo EM.
Source

Departments of Anesthesiology and Obstetrics and Gynecology, University of Miami School of Medicine, Florida 33136, USA. dbirnbach@med.miami.edu

Abstract

BACKGROUND:

Although rare, infectious sequelae of epidural analgesia can occur. A recently marketed antiseptic solution (DuraPrep) which contains an iodophor in isopropyl alcohol, may provide enhanced and longer-lasting antimicrobial activity and thus be useful in the obstetric setting. The purpose of this study was to evaluate the antisepsis achieved with DuraPrep compared with povidone iodine (PI).
METHODS:

Sixty women in active labor who requested epidural analgesia were randomly assigned to receive skin preparation with either PI or DuraPrep solution. A total of three cultures were obtained from each subject. The first was obtained just prior to skin disinfection, the second was obtained immediately following antisepsis, and the third was obtained just before removal of the catheter. In addition, the distal tip of the catheter was also submitted for culture.
RESULTS:

The clinical characteristics and the risk factors for infection were similar in the two groups. The proportion of subjects with positive skin cultures immediately after skin disinfection differed significantly between the PI and DuraPrep groups (30 3%, respectively, P = 0.01). The number of subjects with any positive skin cultures at the time of catheter removal was greater in the PI group as compared to the DuraPrep group (97 50%, respectively, P = 0.0001), as was the number of organisms cultured from skin (log CFU 1.93 +/- 0.40 0.90 +/- 0.23, respectively, P = 0.03). Six catheters, all from the PI group, yielded positive cultures by the roll-plate technique.
CONCLUSION:

As compared to PI, DuraPrep solution was found to provide a greater decrease in the number of positive skin cultures immediately after disinfection, as well as in bacterial regrowth and colonization of the epidural catheters.

I've been using chloraprep for 7 years. Most of the literature for disinfecting anything suggests chloraprep is superior to betadine. And there is good literature showing betadine is neurotoxic. So I don't care if the FDA never approves it, chloraprep is better.

Originally Posted by Mman

I've been using chloraprep for 7 years. Most of the literature for disinfecting anything suggests chloraprep is superior to betadine. And there is good literature showing betadine is neurotoxic. So I don't care if the FDA never approves it, chloraprep is better.

New Data Show ChloraPrep(R) Significantly More Effective Than DuraPrep(TM) and Povidone-Iodine in Eliminating Bacteria From Skin Prior to Shoulder Surgery






SAN DIEGO, Aug. 25 /PRNewswire-FirstCall/ -- Data published in The Journal of Bone and Joint Surgery demonstrates that use of the preoperative skin preparation ChloraPrep((R) )from CareFusion is significantly more effective than both DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region. After antisepsis with ChloraPrep (2 percent chlorhexidine gluconate and 70 percent isopropyl alcohol), only seven percent of skin cultures tested positive for bacteria compared to 19 percent (p<0.01) for DuraPrep (0.7 percent iodophor and 74 percent isopropyl alcohol) and 31 percent (p<0.0001) for povidone-iodine (0.75 percent iodine scrub and 1 percent paint).(1)

I was pretty sure I recently read an ASA document that stated CHG was their preferred agent. As I search the website right now, I can't find it.

I think Betadine has a prettier color!

Originally Posted by Planktonmd

I think Betadine has a prettier color!

Where have you been?

Originally Posted by BLADEMDA

Where have you been?

Hi Blade, Glad to see you ...
I am still here, a little busy but I do check this forum sometimes.