Chloraprep vs betadine

[geauxg8rs]

I work in a hospital outpt setting and have been using chloraprep for all of our procedures both epidural and non spine. Numerous studies have shown its superiority over betadine.

The issue comes in with the package insert stating it is not for use where you might come into contact with meninges.

The real issue comes from hospital paper pushers stating they want to do away with chloraprep and just use betadine. I am more concerned with increased infection risk with betadine over the neurotoxicity of bolusing chloraprep directly into the intrathecal space.

Has anyone else won this argument with hospital paper pushers? At the very least I want something in writing stating that the hospital is aware of the increased infectious risk this poses to patients.

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Members don't see this ad.

 

[bedrock]

Show them this article and remind them who is the physician and who is the paper pusher!

Seriously though, don't increase expose your patients to an increased infection risk because of some douchebag bean counter-




Chlorhexidine is safe for Spinal/Epidural use
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.

 

[lobelsteve]

I work in a hospital outpt setting and have been using chloraprep for all of our procedures both epidural and non spine. Numerous studies have shown its superiority over betadine.

The issue comes in with the package insert stating it is not for use where you might come into contact with meninges.

The real issue comes from hospital paper pushers stating they want to do away with chloraprep and just use betadine. I am more concerned with increased infection risk with betadine over the neurotoxicity of bolusing chloraprep directly into the intrathecal space.

Has anyone else won this argument with hospital paper pushers? At the very least I want something in writing stating that the hospital is aware of the increased infectious risk this poses to patients.

You'd be happy to take all your cases to where they delivered standard of care infection control protocols. Using betadine at this point is proven not as effective as chloroprep.

 

[geauxg8rs]

Thanks for the link. I had missed that!

 

[SSdoc33]

most likely the real issue the paper pushers have is that chloaprep is more expensive than betadine.

 

[lobelsteve]

most likely the real issue the paper pushers have is that chloaprep is more expensive than betadine.

Buy a few gallons on 70% alcohol and a gallon of chlorhexidine.

I mix up a bottle of 40 oz alcohol and 3 oz chlorhex a few times per week.

 

[PMR 4 MSK]

Buy a few gallons on 70% alcohol and a gallon of chlorhexidine.

I mix up a bottle of 40 oz alcohol and 3 oz chlorhex a few times per week.

And you will only need one washrag, because you can also just keep it in the solution, as the alcohol and chlorhexadine will keep it clean!

 

[lobelsteve]

And you will only need one washrag, because you can also just keep it in the solution, as the alcohol and chlorhexadine will keep it clean!

I keep my comb in there as well. I just need some blue coloring to make it look right.

 

[emd123]

I keep my comb in there as well. I just need some blue coloring to make it look right.

I'm jealous that you still need a comb.

 

[painstop]

Tell them you will add 5 minutes to every case because you want to make sure the Betadine dries before starting the procedure...hopefully that will convince them otherwise. I use 70% isopropyl alcohol with no problems and no mess to clean up afterwards (HATED that with Betadine)...the clear Chlorhexidine was nice but the orange stuff was slightly annoying to clean.

 

[epidural man]

I work in a hospital outpt setting and have been using chloraprep for all of our procedures both epidural and non spine. Numerous studies have shown its superiority over betadine.

The issue comes in with the package insert stating it is not for use where you might come into contact with meninges.

The real issue comes from hospital paper pushers stating they want to do away with chloraprep and just use betadine. I am more concerned with increased infection risk with betadine over the neurotoxicity of bolusing chloraprep directly into the intrathecal space.

Has anyone else won this argument with hospital paper pushers? At the very least I want something in writing stating that the hospital is aware of the increased infectious risk this poses to patients.

People still use betadine?

Wow.....

 

[Jcm800]

People still use betadine?

Wow.....

I do

 

[ctts]

For those purchasing chloraprep and and alcohol and mixing it up...do you literally just apply it to the skin with a rag that is left in the solution?? I can understand that the rag would be kept disinfected from the solution...so I guess sterility is not an issue? If my MA is doing the prep, I guess they should apply it with sterile gloves? Or perhaps non sterile gloves are fine since the solution will kill off any germs on the gloves? I think the single use sticks are ideal since the whole delivery mechanism is sterile, but probably too expensive to use all the time in private office practice. Sorry for so many questions. Currently using betadine because that is what my partners have used for years, but thinking of making a change.

 

[lobelsteve]

For those purchasing chloraprep and and alcohol and mixing it up...do you literally just apply it to the skin with a rag that is left in the solution?? I can understand that the rag would be kept disinfected from the solution...so I guess sterility is not an issue? If my MA is doing the prep, I guess they should apply it with sterile gloves? Or perhaps non sterile gloves are fine since the solution will kill off any germs on the gloves? I think the single use sticks are ideal since the whole delivery mechanism is sterile, but probably too expensive to use all the time in private office practice. Sorry for so many questions. Currently using betadine because that is what my partners have used for years, but thinking of making a change.

Yes, I use a rag that I just cleaned my rims with.

How about sterile solution and squirt it onto sterile 4x4's that have been dumped onto the tray or squirt them in the package. I use 10 pack of 4x4's for every case and just load them with 70% iso + chlorhex. My solution is about 5%.

 

[jettavr6]

Anyone using just 70% or 91% isopropyl alcohol for their cases in office? It was suggested to me by another pain specialist. Currently using betadine - chloraprep is $$$.

 

[pmrmd]

^^ I do. Over a decade of using simple 70% isopropyl alcohol on some cotton balls for just about everything with no infections. On the people that I question their hygiene I squirt a little chlorhexidine as well. I haven't used a sterile drape or a tray for an ESI in probably 5-6 years now either.

 

[lobelsteve]

Chloroprep superior to betadine. Can argue scip guidelines make a case that betadine below standard of care.

Above is erroneous, see following posts in this thread. No standard of care exists, other than not prepping.... 1/3/15

 

[pastafan]

Belt and suspender approach. I use chlorhexidine to scrub and then wipe with alcohol x 2 using one 10 pack 4x4's.

 

[ampaphb]

Chloroprep superior to betadine. Can argue scip guidelines make a case that betadine below standard of care.

Chloroprep is chlorhexidine plus alcohol.

There are no head to head studies between betadine and chlorhexidine.

There are also no head to head studies between alcohol & betadine vs chloroprep.

Study and resultant ISIS recommendation is based on an apples vs oranges comparison.

 

[emd123]

Chloroprep superior to betadine. Can argue scip guidelines make a case that betadine below standard of care.

Except a lot of the claims about chloraprep are based on:

"Off-label claims"

http://www.outpatientsurgery.net/su...raprep-whistleblower-case-for-40-1m--01-14-14

"Corrupting the standard-setting process through kickbacks ..."

http://www.justice.gov/opa/pr/caref...allegations-include-more-11-million-kickbacks


Wow. I'm surprised you aren't more aware that the so-called "standards of care" you quote as gospel, actually are so often very shaky with poor foundation. We have an epidemic of fraudulent, shaky and unreliable "standards" of care, through all of Medicine currently.

 

[pmrmd]

I remember reading something about the kickbacks for chlorhexidine. A lot of what we know will have to be studied again. My understanding is that alcohol is still the best antiseptic, however its duration is short. Chlorhexidine has a longer residual so that combination works well for longer procedures or surgeries.

 

[lobelsteve]

Except a lot of the claims about chloraprep are based on:

"Off-label claims"

http://www.outpatientsurgery.net/su...raprep-whistleblower-case-for-40-1m--01-14-14

"Corrupting the standard-setting process through kickbacks ..."

http://www.justice.gov/opa/pr/caref...allegations-include-more-11-million-kickbacks


Wow. I'm surprised you aren't more aware that the so-called "standards of care" you quote as gospel, actually are so often very shaky with poor foundation. We have an epidemic of fraudulent, shaky and unreliable "standards" of care, through all of Medicine currently.

I am surprised. I never reviewed the kickbacks or had heard of this before now. I didn't know the folks who wrote SCIP were ******.
http://apennedpoint.com/todays-evidence-based-guideline-may-be-tomorrows-malpractice/


And study showing near double rate of infection with Chloroprep compared to iodine based prep.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3371364/


Back to drawing board. Guess you cannot trust anyone regarding medical data, especially the government and admin.

But best data I could find on this rainy morning is as follows:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200194/

• Skin preparation:

Prior to incision, the surgical site is often prepared by sterilizing the skin. Most commonly, a commercial skin antiseptic solution is applied such as Chloraprep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodine and 74% isopropyl alcohol), or Betadine (0.75% iodine scrub, 1.0% iodine paint). Several studies have been conducted to compare the efficacy of these common preparation solutions. Ostrander et al. reported that ChloraPrep was superior to DuraPrep and Technicare in terms of eradicating bacteria from the skin, with decreased rates of positive cultures (30% vs. 65% vs. 95%, respectively, p < 0.0001) [63]. On the other hand, Savage et al. found no statistically significant difference in the rate of positive cultures between ChloraPrep and DuraPrep in a prospective study of 100 consecutive patients undergoing lumbar spinal surgery (0% vs 6%, p = 0.25) [64].

As for infection rates, a prospective cohort study that enrolled 3,209 patients found that DuraPrep was associated with the lowest rate compared with Betadine and ChloraPrep (3.9% vs. 6.4% vs. 7.1%, p = 0.002) [65]. Conversely, a multicenter prospective RCT reported ChloraPrep was associated with a lower rate of SSI than Betadine (9.5% vs. 16.1%, p = 0.004, risk ratio 0.59, 95% CI 0.41-0.85) [66].

As it stands, there is no clear evidence that one preparation solution is the better choice in effectively lowering rate of SSI.

 

[epidural man]

Wow. The whiste blower got 3.6 million. Does that also not set up a conflict of interest on that side as well?

I have done this a few times - It seems like a good and cheap way to lower infection risk/rate in our surgical procedures.

 

[bedrock]

Wow.
I feel like I can't trust any government body or any guidelines.

Scary how easily people are corrupted.

 

[emd123]

Wow.
I feel like I can't trust any government body or any guidelines.

Scary how easily people are corrupted.

And that's really the whole thing. Plus, when I hear of other doctors "reviewing" or criticizing other docs harshly, I just have to take pause and realize how shaky the foundations of much of our so called "standards" of care, which it's all based on, are. After all, a medico-legal review, though paid for, is still just an opinion. If fact, the pay-for-opinion nature of the whole process, calls that whole process itself, into question. Last decade's genius and forward thinker is this year's pariah. Some of today's pariahs, were those getting paid for their "expert" opinion a few years ago. Will today's paid "experts" be called into question tomorrow?

I makes me think of:


Glass Houses.....and Throwing Stones.

 

[Ducttape]

people can be corrupted, but the science should not be.

we need to find a way that takes drug companies (and insurance companies) out of the equation when it comes to quality evidence, and research should be used to allow physicians to decide on appropriate treatment, not mandated policy (by government or private entity such as insurance).

 

[101N]

I had a hunch about you sketchy Cloraprep users... Just say'n.

 

[Orin]

And study showing near double rate of infection with Chloroprep compared to iodine based prep.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3371364/

Their period of Chloroprep usage was July to December in a large academic center.

Weird things happen in July to December in academic centers.

 

[Ducttape]

not so wierd.

never have surgery July or August at an academic hospital... never...

 

[ctts]

How about sterile solution and squirt it onto sterile 4x4's that have been dumped onto the tray or squirt them in the package. I use 10 pack of 4x4's for every case and just load them with 70% iso + chlorhex. My solution is about 5%.

Resurrecting an old thread here... Steve, do you still make your own chlorhex/alcohol solution? Would you mind detailing which gallon chlorhexidine product you purchase? I see various products available, some are 2% and others are 4%.

 

[mid|ine]

Would love to know too. We have been trying to find an alternative procedure tray with chloraprep, but I would be open to making a chloraprep solution

 

[lobelsteve]

1 gallon Hibiclens. 70% isopropyl.

soak 4x4 in package. 1 squirt Hibiclens.
Only doing because chloroprep on back order

 

[ctts]

Thanks Steve! I was under the impression previously that making your own solution was your default. Did you change to chloraprep (I assume the big plastic applicator thing and not just the swabsticks?) for convenience? Not worth the cost savings?

 

[lobelsteve]

I work for a hospital. So whatever I want can be ordered. Chloroprep preferred.

 

[mid|ine]

I can't find any concentrated chlorohexidine to mix with isopropyl alcohol

 

[pmrmd]

Widely available through Henry Schein

 

[lobelsteve]

Gallon size.

 

[Orin]

Hibiclens Skin Cleanser (128 oz) 1 Gallon (Pack of 4) - Walmart.com

Buy Hibiclens Skin Cleanser (128 oz) 1 Gallon (Pack of 4) at Walmart.com

www.walmart.com

Well that's not unreasonable.

 

[lobelsteve]

Hibiclens Skin Cleanser (128 oz) 1 Gallon (Pack of 4) - Walmart.com

Buy Hibiclens Skin Cleanser (128 oz) 1 Gallon (Pack of 4) at Walmart.com

www.walmart.com

Well that's not unreasonable.

Walmart 4 gallon is $287.

 

[painfree23]

Widely available through Henry Schein

What do u do with this? Spray it on or pour it onto sterile gauze and use the gauze to spread it? If so, do u put sterile gloves on when prepping?

 

[lobelsteve]

What do u do with this? Spray it on or pour it onto sterile gauze and use the gauze to spread it? If so, do u put sterile gloves on when prepping?

Squirt 1-2 pumps on treadmill 4x4 pack of 10, pour on an oz of isopropyl. Dump pack on mayo. Glove up. Prep.

 

[deleted875186]

Place I started at uses beradine to prep everyone, they haven’t had any infections, been doing it forever.

is it worth having them use chlorhexidine for my patients or should I just go with it? I was initially all for chlorhexidine, but after reading this thread I’m not so sure.

 

[Tboned]

Place I started at uses beradine to prep everyone, they haven’t had any infections, been doing it forever.

is it worth having them use chlorhexidine for my patients or should I just go with it? I was initially all for chlorhexidine, but after reading this thread I’m not so sure.

I used betadine in fellowship and I just hate betadine…so sticky and brown/yellow. Patients needs a thorough cleaning afterwards. Used combo of chlorhexidine and isopropyl in residency…so much cleaner. Saves time in that you have to have a staff member clean off the betadine unless you’re a caveman and send them out with it all other the place

 

[RoloTomassi]

I think the drying time is the most annoying thing about betadine

 

[mid|ine]

If you want to get to a final concentration of 2% chlorhexidine and 70 % isopropyl alcohol, you need much more concentrated than 4%. You can get 91% isopropyl alcohol.

My my quick calculations, I would need at least 8.65% chlorhexidine to mix with 91% isopropyl alcohol to end up with the desired final concentrations.

 

[mid|ine]

I found this:

Chlorhexidine Gluconate Solution 20% w/v

Chlorhexidine Gluconate is a well-known additive in the medical field to provide or enhance antiseptic properties for an array of different products, including oral rinses, medical dressings, etc. WARNING: This product is NOT to be administered FULL strength. See the mixing guide for dilution...

www.maxill.com

but can't find anything in the USA

 

[Agast]

Expert Witness Case #23

What other physicians are saying about The Expert Witness Newsletter: "Reading your material has definitely shaped my documentation & my approach to the undifferentiated patient." - Dr. Emily Hamburg-Shields A 65-year-old man presented to a pain management clinic for low back pain. He was seen...

expertwitness.substack.com

“
A 65-year-old man presented to a pain management clinic for low back pain. He was seen by Dr. F, who is a board certified anesthesiologist and pain management physician. He underwent an uneventful lumbar epidural steroid injection. Four days later he developed fever, weakness and confusion. He was found to have a brain abscess and severe hydrocephalus. He was transferred to an academic medical center, where an EVD was placed with frank purulent discharge. He died several days later.

A lawsuit was filed alleging that the physician was negligent in his antiseptic technique. He had used Betadine, and the plaintiffs felt that Chlorhexidine should have been used instead.”

 

[lobelsteve]

Expert Witness Case #23

What other physicians are saying about The Expert Witness Newsletter: "Reading your material has definitely shaped my documentation & my approach to the undifferentiated patient." - Dr. Emily Hamburg-Shields A 65-year-old man presented to a pain management clinic for low back pain. He was seen...

expertwitness.substack.com

“
A 65-year-old man presented to a pain management clinic for low back pain. He was seen by Dr. F, who is a board certified anesthesiologist and pain management physician. He underwent an uneventful lumbar epidural steroid injection. Four days later he developed fever, weakness and confusion. He was found to have a brain abscess and severe hydrocephalus. He was transferred to an academic medical center, where an EVD was placed with frank purulent discharge. He died several days later.

A lawsuit was filed alleging that the physician was negligent in his antiseptic technique. He had used Betadine, and the plaintiffs felt that Chlorhexidine should have been used instead.”

Excellent link.
Despite following policy and falling within accepted standards of care…….

if complications happen you can still get sued and get a settlement as cheaper than risk of court room award.

can argue tort reform but that will never happen. Can only minimize risk and potential damages from complications.

 

[RoloTomassi]

Do you all alcohol swab single dose vials? There's a SIS fact finder that recommends with weak evidence, but never did in training and not routine at several facilities I've been to.

 

[DOctorJay]

Do you all alcohol swab single dose vials? There's a SIS fact finder that recommends with weak evidence, but never did in training and not routine at several facilities I've been to.

we do