No Skin Prep before SCS Implant

[hopefulgasman]

Thought this was interesting. This was posted on the Physician Community FB page. Bunch of mixed, indecisive answers in the replies. Obviously very few actual pain docs have chimed in.

Post:

Yesterday I was performing a lumbar spinal cord stimulator implant with percutaneous leads. The leads were placed at the T8-T10 levels within the epidural space. At that point the scrub nurse let me know she had failed to prep the patient's skin prior to the case. The prep we typically use is not tinted so nobody else had noticed this oversight. The case was aborted and the contaminated leads were removed. Skin was cleansed with betadine and the incision was closed.

My questions are regarding patient management.

1. Are prophylactic antibiotics warranted and for how long? Ancef 2 gm was given iv. prior to the surgery.

2. The patient is still very interested in having the stimulator implanted to help with his chronic pain. How long should we wait before it would be safe to perform the implant?

This is a situation I have never been faced with before and would appreciate any wisdom from this group. Thank you!

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[MitchLevi]

Saw this.

Do yall just walk into the room with the pt prepped and draped? How TF are you not there for the prep every single time? I would never trust anyone for this. Never.

 

[pmrmd]

Hmmmm.
I vote for wait and see without additional antibiotics but I wouldn’t argue with 10 days of a cephalosporin. I would have patient call with daily updates. Repeat SCS in 6 weeks.

Surgeon not involved in prep seems crazy to me.

 

[gaspasser127]

This is a good cautionary tale for everyone especially new grads. Don’t trust anyone in the OR to do the work for you - prepping, positioning etc.

If you don’t personally prep the patient that’s fine but also watch through the window while you’re scrubbing in or something if you can.

How to handle this:
1. Disclose error to patient and take accountability for the mistake
2. Contact hospital/ASC risk management team
3. Keflex for 10 days assuming pre op MRSA swab was negative (please tell me they got one). Low risk to give the abx
4. Maintain some sort of close follow up

I’d close with PDS or another unbraided suture to further mitigate risk of infection.

Patient will likely be fine but just gotta check all the boxes to make sure it was done

 

[TrailRun]

Antibiotics won’t hurt (they’re given for sniffles nowadays) but may not be necessary. But honestly I would thank the nurse for being honest with you and owning their mistake (so as to encourage that communication in the future); their silence could have been disastrous

 

[MitchLevi]

Pt should have gotten an IV dose of ABx and I’d give Keflex 7D. Wait 6-7W and do it again

 

[gaseous_clay]

I hope you copiously irrigated the wound before closing.

 

[gaseous_clay]

Also, second the part about you not being there and trusting someone else to use untinted prep…wtf?!

 

[RoloTomassi]

In my procedure suite, I trust my RT to prep. She's seen where the needle goes thousands of times.

In the OR I trust my scrub tech. If I trust her to sterilize instruments and setup the sterile table, skin is the easiest of her duties.

We always use orange Chloraprep

 

[PinchandBurn]

No way in private you can sit there and watch prep.

Only in academics.

You have to build a good team and trust.

I usually have my NP oversee

 

[MitchLevi]

No way in private you can sit there and watch prep.

Only in academics.

You have to build a good team and trust.

I usually have my NP oversee

I do it. What you mean?

 

[PinchandBurn]

I do it. What you mean?

I m usually seeing patients family , talking to the next patient, writing medz etc.. no way I can prep skin. The techs do the skin prep

 

[lobelsteve]

Ive never prepped an implant. The OR nurse wouldn’t let me. And she won’t let me drape until the 3 min timer goes off.

 

[MitchLevi]

I either do the prep or stand there while someone else does it. Either way, I’m directly visualizing the entire process.

 

[PinchandBurn]

I used to do tht in training. But do you have other things tht you have to do?

I mean that's the OR techs job. If she can't do it. Fire her

 

[GoBeers]

let other people prep, it's fine. trust the team. but it's on you if something goes wrong. it doesnt need to be this big philosophical academic debate.

that being said, personally i'd give ppx abx (more for peace of mind). it's fine to wait and see 2 weeks as well. no textbook answer here.

 

[ghost800]

let other people prep, it's fine. trust the team. but it's on you if something goes wrong. it doesnt need to be this big philosophical academic debate.

that being said, personally i'd give ppx abx (more for peace of mind). it's fine to wait and see 2 weeks as well. no textbook answer here.

Agreed. I’m in private practice and I trust the nurse or tech to prep the patient, but I will always drape afterwards so that I can clearly see the prep was done. We always use ORANGE chloraprep (unless allergic) so I look for clear delineations between the orange prepped and non-orange, non-prepped skin.

In those rare cases in which I have a
even a remote question as to whether the patient was properly prepped (such as when a patients skin tone does not allow me to clearly see the delineation, among others), I will simply re-prep the patient.

I probably have ‘wasted’ a lot of chloraprep over the years this way but we buy in bulk and I’d rather spend the extra $ than have lingering intrusive thoughts regarding proper prep.

 

[Agast]

Is orange chloraprep more expensive than clear? I can’t imagine why anyone would choose clear on purpose. I came across it a few times and it makes me nervous.

We got a green chloraprep sample to try, it gave the skin this weird clammy cadaver appearance that was really gross to look at so that was a no from me dawg 🤢

 

[Baron Samedi]

I absolutely agree with the recs others have stated.

I don't even let fellows prep or drape until they've done a few cases with me.

 

[lobelsteve]

Is orange chloraprep more expensive than clear? I can’t imagine why anyone would choose clear on purpose. I came across it a few times and it makes me nervous.

We got a green chloraprep sample to try, it gave the skin this weird clammy cadaver appearance that was really gross to look at so that was a no from me dawg 🤢

Clear for the face- gasserian rf.

 

[BobBarker]

The clear chloraprep is just a little cheaper. Not enough to matter.

 

[Orin]

There's some Steven Covey saying about being independent before becoming interdependent. I started out religiously scrubbing, but as you establish a system and a team, the goal is for everyone to be working in parallel to get the job done. As an academic doc, that means me telling folks where to prep or prepping myself if I need them for something else. The dyed prep helps a bit for sure.

In this case, the pre-op antibiotics will help, but I would give it at least 2 - 4 weeks before even considering anything. I would consider this a dirty wound that has been created, with a deep infection in a critical space, and treat it with IV antibiotics for a week or two if the markers are bumping up. Oral antibiotics are reasonable to start quickly but a deep dirty wound is generally IV is what ID folks tell me. I would trend ESR/CRP/Procalcitonin so you can document normal infectious markers prior to a repeat implant.

The good thing is the deep tissue may have been sterile-ish and if the needles didn't traverse the skin, the bacterial load introduced deep is likely relatively low.

Was there pre-operative CHG skin washing?

 

[gaspasser127]

Was there ioban used?

 

[CleanUp]

1. Chlorprep bath before
2. MRSA swab
3. Chlorhex x 3
4. Ioban
5. Pre-incision abx
6. Doors shut. No going in and out of room multiple times.
7. Post op ppx abx +/- SSI for DM