chlorhexidine for neuraxial

[thegasman]

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My group is currently looking at switching from betadine to chlorhexidine prep for neuraxial placement. Literature appears to confirm this is a superior prep and asra as declared chg prep of choice. ASA practice guideline also recommends it in advisory statement due to literature although in discussion states there was no consensus. Concern is package warning regarding not for use for lp or contact with meninges. What is everybody else doing?

 

[jennyboo]

My group is currently looking at switching from betadine to chlorhexidine prep for neuraxial placement. Literature appears to confirm this is a superior prep and asra as declared chg prep of choice. ASA practice guideline also recommends it in advisory statement due to literature although in discussion states there was no consensus. Concern is package warning regarding not for use for lp or contact with meninges. What is everybody else doing?

I switched to chlorhexidine, although our kits still come with the betadine which I now throw out. Haven't had a problem with it, and don't have to think about it for those "iodine allergy" patients.

Chloraprepped backs hold tegaderms better than betadined backs, assuming you don't wash it off. If you wash off the betadine, then I can't say for sure.

 

[Dejavu]

We have totally abandoned betadine preps in favor of chlorohexidine for all lines and all blocks of any kind throughout our entire institution.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/20054046

New England Journal of Medicine


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.) 2010 Massachusetts Medical Society

 

[BLADEMDA]

Technique is something we often take for granted when performing neuraxial techniques. An interesting study of videos taken of CA-2 anesthesia residents over 6 months found a strong correlation between increasing experience and manual skills.22 However, there was almost no correlation between the aseptic technique checklist score and number of epidurals performed. Most of the time residents did not recognize breaches in sterile technique and therefore did not correct them. Clearly this is an area we could teach more effectively.
• A troubling conflict in recommended technique for neuraxial anesthesia is the use of chlorhexidine prep. The ASRA guidelines state it is the antiseptic of choice for regional techniques23, but the package of the Chloraprep applicator states that the solution should not be used when working in proximity to meningeal structures. An article in the Anesthesia Patient Safety Foundation (APSF) newsletter notes that the FDA has no prospective evaluation of chlorhexidine in the setting of epidural and spinal anesthesia that would support a change their labeling.24 The expense for the manufacturer to seek a label change is prohibitive. No resolution of that problem is in sight.

 

[Idiopathic]

needs to dry, just like betadine...

 

[pgg]

needs to dry, just like betadine...

At the risk of sounding ******ed, can someone explain why betadine needs to dry?

This is something I've heard for years, and it's accepted as gospel (even though nobody ever waits for it to dry). It makes no sense to me and smells like dogma.

IIRC betadine solutions kill bacteria via two mechanisms
- a dessicant action in which an osmotic gradient sucks water out of cells
- release of free iodine resulting in oxidation/halogenation of proteins

How exactly is either mechanism dependent on "drying" of the solution? Even the dessicant action shouldn't need the solution to dry since it's the intracellular-extracellular gradient that dehydrates the cells.

Should surgeons using iodine-based scrubs stand there and let their hands air dry completely? Are bacteria safe as long as they can swim in covered liquid iodine solutions?

Or is "dry" just a convenient surrogate for "wait long enough for it to work"?

 

[rsgillmd]

At the risk of sounding ******ed, can someone explain why betadine needs to dry?.....

Or is "dry" just a convenient surrogate for "wait long enough for it to work"?

I've wondered the same thing. I think your last statement is probably the most accurate.

Chlroraprep has some alcohol mixed with it, so I think most surgeons wait for it to dry for that reason -- reduce risk of fire and all that stuff.

After a series of post-op wound infections in L&D the scrub nurses started wiping the bellies with alcohol and waiting for it to dry, and then using Chloraprep. It was hilarious watching this when it wasn't the middle of the night. They wouldn't listen to me when I said they are wasting time and that Chloraprep alone is enough. They finally listened when an obstetrician with an ID background told them the same thing.

I was taught to prep the back for epidurals and "let it dry" while I prepared the rest of my equipment. When I'm ready I wipe off what hasn't dried. I was taught to wipe off this excess out of concern of inadvertently translocating liquid betadine to the epidural or intrathecal space --> chemical meningitis.

Duraprep, which is betadine and alcohol, dries very quickly.

So in summary, I think your last statement is probably the most accurate for most situations.

 

[rsgillmd]

When we were looking at new epidural trays the reps refused to put chlorhexidine in them because of the product labeling. If that isn't proof enough that lawyers rule the world, I don't know what is.

 

[Doc13]

I think if it's safe enough for spine surgeons to prep the back with chlorhexadine we're okay too. They are a bit more likely to come in contact with the meninges.

 

[Idiopathic]

Im under the impression that the iodine-containing solutions are stable when in solution and dont release free iodine until drying, which is what kills the cells, and this can take a minute or two. i know chlorhexidine has a different mechanism that probably isnt time sensitive,

regarding either prep, you shouldnt introduce any into the epidural space or CSF so I say let it dry or wipe it off after prepping, i think most people agree.

 

[lobelsteve]

THoughts on technique:

1. Iodine based- 3 circles starting at center and working outward with little to no overlap of prior wipe.

2. CHG/Alc/Duraprep- scrub the area like you are washing a wall, ok to cross over the area and no circles. I start in the middle and work outward, but not 3 circles form center-out.

 

[epidural man]

At the risk of sounding ******ed, can someone explain why betadine needs to dry?

This is something I've heard for years, and it's accepted as gospel (even though nobody ever waits for it to dry). It makes no sense to me and smells like dogma.

IIRC betadine solutions kill bacteria via two mechanisms
- a dessicant action in which an osmotic gradient sucks water out of cells
- release of free iodine resulting in oxidation/halogenation of proteins

How exactly is either mechanism dependent on "drying" of the solution? Even the dessicant action shouldn't need the solution to dry since it's the intracellular-extracellular gradient that dehydrates the cells.

Should surgeons using iodine-based scrubs stand there and let their hands air dry completely? Are bacteria safe as long as they can swim in covered liquid iodine solutions?

Or is "dry" just a convenient surrogate for "wait long enough for it to work"?

It doesn't have to dry. This is a myth created to force you to wait for the killing action of betadine. It takes time for the chemical to do its thing.

Also, betadine is just as toxic to nerves, etc as chlorohexadine....just a thought.