How can surgeons get away without using Ioban?

[Raygun77]

Hey guys, I have another question I've always wondered about-

At my hospital, the oldschool surgeons don't use Ioban or any sort of sterile sticky drape over the operative site.
They just lather the site with prep, set up the drapes (with a dance about getting the drapes just right so as not to touch 'non-prepped' skin then go back to touch the 'prepped' area, as you know), then have at it.

I'm raising this question after watching surgeons during say, inguinal lymph node excisions, touching and feeling around the scrotum (which was prepped yes, but is it sterile??), then putting their fingers back into the wound. I wasn't game enough to ask them whether this in fact introduced the potential for infection (i'd think so..) or why Ioban wasn't used...

Here for example is a fem-pop bypass video without the use of Ioban:
http://www.youtube.com/watch?v=JJzUsJxqmo0
Just trying to make the point of how the surgeon touches skin then the patients insides.

So my question is-
After prepping, is the site considered 'sterile'? I'd think its like a handwash (if even that)- gets rid of the excess bugs but commensals remain, which is why its important you don't touch the outside aspect of your gloves when gloving up.

Do you use Ioban or equivalent for some, or all surgeries?
Is there data to suggest Ioban or equivalent should be used for all surgeries?

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[Kuba]

Hey guys, I have another question I've always wondered about-

At my hospital, the oldschool surgeons don't use Ioban or any sort of sterile sticky drape over the operative site.
They just lather the site with prep, set up the drapes (with a dance about getting the drapes just right so as not to touch 'non-prepped' skin then go back to touch the 'prepped' area, as you know), then have at it.

I'm raising this question after watching surgeons during say, inguinal lymph node excisions, touching and feeling around the scrotum (which was prepped yes, but is it sterile??), then putting their fingers back into the wound. I wasn't game enough to ask them whether this in fact introduced the potential for infection (i'd think so..) or why Ioban wasn't used...

Here for example is a fem-pop bypass video without the use of Ioban:
http://www.youtube.com/watch?v=JJzUsJxqmo0
Just trying to make the point of how the surgeon touches skin then the patients insides.

So my question is-
After prepping, is the site considered 'sterile'? I'd think its like a handwash (if even that)- gets rid of the excess bugs but commensals remain, which is why its important you don't touch the outside aspect of your gloves when gloving up.

Do you use Ioban or equivalent for some, or all surgeries?
Is there data to suggest Ioban or equivalent should be used for all surgeries?

I think less than 50% of cases I observed in medical school used ioban..

 

[deuist]

1. Skin is never considered sterile, no mater what you clean it with.

2. Is there a reason to use ioban on every case? Do you have any research to support your implied claim that its use reduces infection rates?

 

[ESU_MD]

We never use ioban. It burns and blisters the skin, comes unattached at the edges, gets in the way and quite frankly wastes time.
There is a recent cochrane review that backs this up, at least for cardiac surgery

 

[Winged Scapula]

I haven't seen it used routinely in ages. Maybe since I was an intern or junior resident.

I roam around between my cases and visit my gen surg and surg subspecialty friends in other ORs and don't notice them using it either.

 

[Dr.LeoSpaceman]

I haven't seen it used routinely in ages. Maybe since I was an intern or junior resident.

I roam around between my cases and visit my gen surg and surg subspecialty friends in other ORs and don't notice them using it either.

The only people I've seen using them with any regularity around my hospitals are the vascular surgeons. Of course, some of them are beyond OCD when it comes to antiseptic voodoo (no one likes an infected goretex/dacron graft, though).

 

[dilated]

It's about time we got an answer folks. How are surgeons getting away without using voodoo priests to bless every incision before starting??

More seriously, anyone know of some actual good studies that show whether the bugs get in from the skin, OR environment post-prep or migrating in from the non-sterile skin postop? I've always wondered if the super-anal preps are even targeting the right problem.

 

[deuist]

... the vascular surgeons. Of course, some of them are beyond OCD when it comes to antiseptic voodoo

I do remember a vascular surgeon at my institute washing the patient in rubbing alcohol before prep. Every day during rounds he would then pour betadine again on the closed wound.

 

[Dr.LeoSpaceman]

I do remember a vascular surgeon at my institute washing the patient in rubbing alcohol before prep. Every day during rounds he would then poor betadine again on the closed wound.

Oh, the daily chloraprep cleanse of a groin incision before re-dressing (even on postop day 14) is pretty routine for some of our guys.

 

[SLUser11]

There's no evidence supporting the use of ioban for the reduction of SSI rates. While I typically hate Cochrane reviews, there is one addressing this. I believe there is even some evidence that Ioban increases infection rates in the longer cases....the theory is that you're sort of locking the bugs in...

 

[hanky1982]

Soon to be ortho intern here, but during my auditions at 5 different rotation spots, I saw Ioban used quite heavily for hip replacements. Not so much for trauma, scopes, etc. but definitely for joint replacements of the hip. Seemed like it was the rule and not the exception. Knee replacements often had Ioban, but not as consistent. Thinking back on it, I don't know if I can readily recall a time Ioban wasn't used for a hip. Maybe it is subspecialty specific?

I know that a post-op joint infection is a disaster, but I assume that any post-op infection can be a disaster (belly, thoracic, etc.). With that said, anyone have any thoughts on why it would be used so frequently for hips and other joint replacements and not nearly as prevalent in other fields of surgery?

 

[ESU_MD]

would also love to know what kind of evidence there is that compels the ortho guys to dress up in the space suits. they look pretty cool, but i bet they are a pain in the ass to wear.

you are right, is an infected hip that much worse than an infected vascular graft or valve? is it really prevented by wearing a space suit?

Soon to be ortho intern here, but during my auditions at 5 different rotation spots, I saw Ioban used quite heavily for hip replacements. Not so much for trauma, scopes, etc. but definitely for joint replacements of the hip. Seemed like it was the rule and not the exception. Knee replacements often had Ioban, but not as consistent. Thinking back on it, I don't know if I can readily recall a time Ioban wasn't used for a hip. Maybe it is subspecialty specific?

I know that a post-op joint infection is a disaster, but I assume that any post-op infection can be a disaster (belly, thoracic, etc.). With that said, anyone have any thoughts on why it would be used so frequently for hips and other joint replacements and not nearly as prevalent in other fields of surgery?

 

[hanky1982]

would also love to know what kind of evidence there is that compels the ortho guys to dress up in the space suits. they look pretty cool, but i bet they are a pain in the ass to wear.

you are right, is an infected hip that much worse than an infected vascular graft or valve? is it really prevented by wearing a space suit?

Agreed, would love to hear some people's thoughts on this. As for the space suits, they are actually quite comfortable. As for myself, they are a little more comfortable than the regular surgical attire... as you have a fan blowing cool air on you at all times. Also, you can work without masks and rub your face through the gown as necessary. They aren't nearly as uncomfortable as they might look.

 

[Buzz Me]

The old-school guys here use Ioban on cases when you're implanting a permanent prosthetic (Prolene mesh, PTFE graft, etc.). Not sure it makes a difference.

 

[Raygun77]

heh so it's the oldschool guys in the States who DO use Ioban!

I always thought it was used half as a convenient way to keep the drapes from sliding all over the place. But for pretty much every open ortho surgery I've seen, Ioban was used.

I was once in a hip case and asked the orthopod whether there was evidence for Ioban. His reply in true fashion was "cmon isn't it common sense?"

Also, please don't misinterpret my title- I didn't mean it to imply surgeons should be using Ioban or not, rather the mechanism they get away without causing infections!

For example, my surgeon checking the testes with a gloved hand before proceeding to chop out inguinal LNs...surely this could introduce infection?

 

[SocialistMD]

From what I've seen, it is a matter of prosthetic material being left behind.

 

[Winged Scapula]

For example, my surgeon checking the testes with a gloved hand before proceeding to chop out inguinal LNs...surely this could introduce infection?

You're assuming the scrotum is more rife with bacteria than any other area of the body. While that may be true in some, if the scrotum is properly prepped into the surgical field, then touching it is no different IMHO than touching the skin around the incision.

 

[VincentAdultman]

The spacesuit protects the surgeon as much as it protects the patient during a joint replacement, IMO.

 

[thedrjojo]

the body is quite good at fighting off infection. Look at cases where you enter the bowel and spill some stool (10^10 per gram of bacteria if i remember correctly) into the field (regardless of how careful you get). Those wounds only have like a 40% infection rate (clean-contaminated). Meaning that half the time the body can fight off the infection (with the help of perioperative antibiotics. Most prep stuff is voodoo (like masks, not actually proven to provide any protection.

 

[cpants]

I've never heard of anyone Iobanning a scrotum either.

 

[kirurg]

the body is quite good at fighting off infection. Look at cases where you enter the bowel and spill some stool (10^10 per gram of bacteria if i remember correctly) into the field (regardless of how careful you get). Those wounds only have like a 40% infection rate (clean-contaminated). Meaning that half the time the body can fight off the infection (with the help of perioperative antibiotics. Most prep stuff is voodoo (like masks, not actually proven to provide any protection.

If there's gross spillage, the wound is classified as contaminated (not clean-contaminated). For spillage of bowel contents, I believe the recommendation is to continue antibiotics. Does anyone just give perioperative abx in these situations?

 

[SLUser11]

For spillage of bowel contents, I believe the recommendation is to continue antibiotics. Does anyone just give perioperative abx in these situations?

Absolutely. I very rarely give more than 24 hours of antibiotics for gross spillage. The literature is pretty clear on this for trauma situations, but it's not as well studied for general surgery.

Now, if the person is septic or shows signs of advanced peritonitis, I will absolutely continue antibiotics postoperatively....but spillage in itself does not scare me very much.

A side question: If you're keeping all patients with gross spillage on antibiotics, when do you decide to stop antibiotics?




Here's a link to the classic J Trauma article I remember....here's the guidelines, although I can't read that one from home so I actually don't know what the guidelines say...will look tomorrow at work....

 

[45408]

Soon to be ortho intern here, but during my auditions at 5 different rotation spots, I saw Ioban used quite heavily for hip replacements. Not so much for trauma, scopes, etc. but definitely for joint replacements of the hip. Seemed like it was the rule and not the exception. Knee replacements often had Ioban, but not as consistent. Thinking back on it, I don't know if I can readily recall a time Ioban wasn't used for a hip. Maybe it is subspecialty specific?

Our ortho guys use it a lot for joint replacements (all of them), but not the rest of their cases. Our neurosurgeons use it pretty often, as do our cardiac surgeons. Our vascular guys do NOT use it much, nor do our general/colorectal surgeons.

would also love to know what kind of evidence there is that compels the ortho guys to dress up in the space suits. they look pretty cool, but i bet they are a pain in the ass to wear.

No, it's not bad. The fan keeps you cool, but the extra weight on your head really throws off your balance. I feel tipsy when I turn my head while wearing one. It's also nice because then your head/face are all sterile, and for when the bone saw spews chunks everywhere.

You're assuming the scrotum is more rife with bacteria than any other area of the body. While that may be true in some, if the scrotum is properly prepped into the surgical field, then touching it is no different IMHO than touching the skin around the incision.

Bad experience?

 

[Winged Scapula]

Bad experience?

Hey, let 's keep my social life outta this discussion. 😉

 

[45408]

I didn't even say anything about your social life. 😱 Now it really sounds like story time...

 

[europeman]

I use iobane in situations where i'm trying to keep things absolutely as sterile as possible and I will be placing implanted material into the body and that material may touch skin.

For example, during a lap hernia, if you use the technique of putting the mesh literally over the skin in order to approximate before/during taking measurements, then if you have iobane, you avoid having mesh touch skin.

Of course, you could just not do that, and simply stick the mesh into the port, however, you are still contaminating yourself a bit more because your gloves are touching skin, which touch mesh, etc.

The other nice thing about iobane (or even tegaderms) is keeping your drapes in place. I hate people that stable the heck out of poor people's skin as the alternative! how mean! 🙂 This is particularly helpful in weird body positions, like a VATS or open thoracotomy whereby the drape really just wants to come off the whole time!

I dunno.. had a patient die of a hernia mesh infection (long story) and now I'm starting to slowly become one of those psycho ocd vascular guys 😉

 

[Mr. Freeze]

We pretty much just use Ioban for joints. The space suits are very comfortable, can hide your closed eyes from attendings, and allow you to actually see what someone is saying when they talk to you. However, we read an article from across the pond earlier this year that said wearing the caps that have the sideburn covers actually has a lower infection rate than spacesuits.

Does the use of laminar flow and space suits
reduce early deep infection after total hip and
knee replacement? JBJS Br, Jan 2011

 

[kirurg]

Absolutely. I very rarely give more than 24 hours of antibiotics for gross spillage. The literature is pretty clear on this for trauma situations, but it's not as well studied for general surgery.

Now, if the person is septic or shows signs of advanced peritonitis, I will absolutely continue antibiotics postoperatively....but spillage in itself does not scare me very much.

A side question: If you're keeping all patients with gross spillage on antibiotics, when do you decide to stop antibiotics?




Here's a link to the classic J Trauma article I remember....here's the guidelines, although I can't read that one from home so I actually don't know what the guidelines say...will look tomorrow at work....

Thanks for the info! I guess the cases I was thinking about were the bowel obstructions with massively dilated small bowel or colon. Usually there's some signs of peritonitis. We keep these patients on abx until they're stable, afebrile, normalizing white count. For planned bowel resections with small amount of spillage, we just do periop as well.

 

[4EvrNBluGreens]

The skin ain't never sterile! The rumor on Iobans are that they supposedly "glue" the resident bugs that survive the skin prep "in place" so they don't "travel" to the incision site...other "perk" is if your patient position is one of those precarious type positions where you know there's no way just towels or drapes are going to stay where you placed them (gaping everywhere), the Ioban does serve the function of keeping your drapes where you want them...and reduces risk of wound contamination, if for no other believable reason. Largely a matter of convenience for most...so they say

 

[McGillGrad]

I didn't see ioban used at all during my surgery rotations. Might be region-specific.

 

[thedrjojo]

If there's gross spillage, the wound is classified as contaminated (not clean-contaminated). For spillage of bowel contents, I believe the recommendation is to continue antibiotics. Does anyone just give perioperative abx in these situations?

I may be wrong, and will go back and look at it again, but if you started the case clean (say, an elective hemicolectomy), and then entered the bowel and got spillage, that case is considered clean-contaminated.... if you have, for say a trauma situation where a bullet injured the bowel and when you enter there is already spillage, or an injury where the wound is dirty already, then that is a contaminated case, no?

 

[SouthernSurgeon]

I may be wrong, and will go back and look at it again, but if you started the case clean (say, an elective hemicolectomy), and then entered the bowel and got spillage, that case is considered clean-contaminated....

Anytime you have gross spillage of significant amount of bowel contents it is a contaminated case...it doesn't matter where the case starts (i.e. an elective hemi should in theory be a clean-contaminated case), it matters where you finish (i.e. an elective hemi where you get into the bowel by mistake and spill stool all over the abomen is a contaminated case).

 

[SLUser11]

Anytime you have gross spillage of significant amount of bowel contents it is a contaminated case...it doesn't matter where the case starts (i.e. an elective hemi should in theory be a clean-contaminated case), it matters where you finish (i.e. an elective hemi where you get into the bowel by mistake and spill stool all over the abomen is a contaminated case).

Agreed...where you start the case is sort of irrelevant.

Still, 24 hours of antibiotics is enough.

 

[lura]

I had a few transplant surgeons as a resident who would use it fairly routinely. I don't use it much myself except as a ghetto-VAC contraption. However, I do recall some literature in the not so recent past that suggested that it is helpful in reducing infection/SSI but only for short cases. If I remember correctly, cases longer than 2 or so hours tend to have higher infection rates cause moisture and whatnot can accumulate under the barrier.

 

[thedrjojo]

Anytime you have gross spillage of significant amount of bowel contents it is a contaminated case...it doesn't matter where the case starts (i.e. an elective hemi should in theory be a clean-contaminated case), it matters where you finish (i.e. an elective hemi where you get into the bowel by mistake and spill stool all over the abomen is a contaminated case).

After relooking it up, i agree, gross spillage is contaminated regardless... thanks for the refresher.