Aseptic patient prep - surgical spirit or not?

RE: Aseptic patient prep - surgical spirit or not?

Glen McIntosh — Wed, 23 Dec 2020 02:30:34 GMT

Our surgeons no longer routinely use surgical spirit as part of their surgical prep skin disinfection. Their reasoning is, in so far as I understand it, primarily because surgical spirit increases the likelihood and severity of the hypothermia associated with anaesthesia, due to evaporative cooling.

This would seem, from a common sense point of view, a logical reason not to use surgical spirit for skin prep. However there at least 2 recent studies in mice undergoing general anaesthesia that show that use of isopropyl alcohol (either alone or as a rinse following initial povidine iodine disinfection) has a protective effect against hypothermia in comparison to both providine iodine skin disinfection alone, or povidine iodine skin disinfection followed by either a room temperature or warmed saline rinse.

Hard to know if it is directly applicable to our patients.

RE: Aseptic patient prep - surgical spirit or not?

Evelyn Barbour-Hill — Fri, 11 Dec 2020 23:53:09 GMT

[quote userid="2249" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not/227195#227195"]Hi Evelyn. I think terminology, or its interpretation, may have changed.[/quote]

Unless by official agreement among experts (Cf. Nomina Anatomica Veterinaria) the only way that technical terminology can change is by misuse (something that our supposedly scientific profession is prone to).

Asepsis means a complete absence of microbes that are potential pathogens in a surgical wound (when the idea of asepsis was first formed, of course, no-one knew which were potentially pathogenic and which were not; in any case, I venture to suggest, very few bacteria or fungi or protozoans are not potentially pathogenic). Or it can perhaps,mean, by extension, the means employed to achieve such a state. Something called a-sepsis cannot mean just a reduction in something.

"Antiseptic" of course can mean the chemical used to kill or inactivate pathogenic microbes. But as a concept, as a technique of surgery, antisepsis means killing microbes as they swill around and land in the surgical site, or if possible before they actually land in it.

Lord Lister was the pioneer who recognised surgical sepsis (sepsis, now there's a word that has really been misused and abused in recent years!). Being a pragmatic chap, he invented antisepsis. While it must have been thoroughly unpleasant to work in a mist of carbolic acid, the technique worked and surgery became much less risky.

Asepsis as a surgical technique was, arguably, aspired to by Lister but developed by his followers and successors (to over-simplify a little). The name of Lawson Tait should be renowned, and probably even veterinary surgeons have heard vaguely of Halsted.

To achieve asepsis, you need sterility. Because contamination is inevitably mixed and unpredictable. You cannot say "Oh, I know that glove is not sterile, but it's aseptic all right because I know the only bacteria on it are non-pathogenic even in a wound". The great stumbling block is the skin. We all know that you cannot sterilise the skin (not in a living patient, anyway!) . So the skin has to be cleansed and disinfected as well as possible, and its surface may then well be sterile for a short while until more microbes come creeping up from deeper down, but true asepsis has then to be achieved by further measures such as draping technique.

I reckon it's fair to say that most veterinary surgery is not truly aseptic at all. But I also reckon it's fair to say that true asepsis is perhaps an aim, a target, an aspiration, rather than something that can be guaranteed.

RE: Aseptic patient prep - surgical spirit or not?

James Dunne — Fri, 11 Dec 2020 12:56:10 GMT

Hi Evelyn. I think terminology, or its interpretation, may have changed. It is certainly unclear. Asepsis seems now to relate to the reduction in potential pathogens that might cause a SSI to develop. Antiseptic is usually used to refer to the media that are used to render the operation site aseptic. Sterility is the removal of all organisms, pathogenic or not. There is, of course, an explanation that you won't hear mentioned too often on this forum, which is that I could be wrong.... agree that we should question how much all of this matters, since there is a dogmatic approach in the instruction of these techniques. However, the consensus from many published studies is that the use of spirit improves the reduction in bacterial counts on patient skin compared to other products, and does so rapidly. Since not that many practices carry out active surveillance for SSI, it begs the question of how do we know that we 'never had a problem with X, Y or Z'?? For example, if the best you could hope for is 2% postoperative SSI rate in clean surgery, would anyone notice a SSI rate of 3% or 4%, or 6%? Particularly when these are 'minor' infections or seromas? What is 'acceptable'? Is anyone okay with being twice as 'bad' as they should be? I'm kind of curious to know what would change people's minds as to what scrub materials or techniques they'd use, since it is not just based on figures! I'm guessing ease of application, cost, time and efficacy, but any other considerations would be welcome.

RE: Aseptic patient prep - surgical spirit or not?

Evelyn Barbour-Hill — Fri, 11 Dec 2020 01:11:37 GMT

I can't resist pointing out ( ) that none of these techniques is aseptic skin preparation, they are all antiseptic skin preparation. There's nothing wrong with that, of course; in fact I'm not sure I can see any practical way of rendering the skin aseptic.

RE: Aseptic patient prep - surgical spirit or not?

Michael Woodhouse — Fri, 11 Dec 2020 00:42:15 GMT

[quote userid="6407" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not/227189#227189"]Invictus can do lunch and learns regarding proper techniques. [/quote]

They claim "evidence based". On their website they cryptically link 4 papers. The first paper shows that skin bacteria cause surgical site infections! The second is a series of experiments done in human patients that showed generally chlorhex and alcohol was better than either on their own - but in some cases it failed to kill enough bacteria! The third and forth are not listed on Pubmed, one of them only being conference proceedings.

None of the published evidence I can find is done in veterinary patients. Human paper looking at infection rates with cardiac and spinal surgery found Chloraprep performed a bit worse than iodine in alcohol! I like this study where they found a lot more areas not cleaned using Chloraprep compared to conventional scrubbing (https://www.ncbi.nlm.nih.gov/pubmed/27083319)! When they start claiming that a spray is a fire hazard I feel they are scraping the barrel (as I stand next to a pressurised oxygen cylinder, fag in mouth, with a few scented candles for ambience.....)

Edit: It gets better. There's a helpful document with 2 more human references called "technical update, surgical". We see that the product is mildly more effective in 1 out of 5 cases when tested in a lab and not with real patients. The other claim that "single use applicators should be used" is based on an OPINION article and that opinion is not supported by any evidence. I'm keeping my multi use bottle of Hibitane in alcohol!!!!!!!!!

To be clear I am not knocking the product, but I want some good evidence that it works in our veterinary patients to reduce post operative infection rates over and above what is happening now in the typical first opinion practice. Until then I'm not going to waste my lunch listening to them.

Lets not leap on the 'gold standard' bandwagon.

RE: Aseptic patient prep - surgical spirit or not?

nick shackleton — Thu, 10 Dec 2020 22:02:48 GMT

We use 2% Chlorahexadine and water. Mixed in sterile kidney dish with sterile swabs. We use non-woven swabs, as less abrasive to skin and are lint free. We use Chloroprep Wanda in theatre for final prep (2% Chlorahexadine gluconate and 70% IPA alcohol). Invictus can do lunch and learns regarding proper techniques.

RE: Aseptic patient prep - surgical spirit or not?

David Mills — Thu, 10 Dec 2020 20:01:10 GMT

It comes around this debate.

There is some quite strong evidence that flushing the skin with saline (like a wound) is more effective than chlorhexidine it iodine. Also the time from clip to cut is a big factor. Clip as close as possible to cut because the damage to the skin surface is significant and allows rapid colonisation. The BSAVA manual on surgical principles is a good resource.

Spirit? I wouldn't miss it at all but it's become almost religious in its use in nurse training (a bit like "surgical rate" fluids a few years ago)

RE: Aseptic patient prep - surgical spirit or not?

James Dunne — Wed, 09 Dec 2020 20:13:25 GMT

Hi Anthony

There is quite a bit of literature on this. Some of it is controversial.

Specifically re patient preparation: alcohol-based chlorhexidine scrub at the correct concentration [according to manufacturer's recommendations] then spirit is what seems to be the consensus. Surgical spirit causes a rapid kill of bacteria on the prepared skin. Iodine has a broader spectrum but takes much longer to be effective. Bottles should be deep cleaned regularly; unless you are using active surveillance, you may not be seeing a problem - many of the problems are 'minor' and the difference between a normal and 'bad' surgical site infection [SSI] level is small enough. If you are looking for studies, the WHO guidelines are a good place to start. I'd also have a look at pubmed. Contact time and gentle application are likely as important as the actual product used. The disposable Chloroprep-type devices are very useful, but whether they'd just add to the cost of routine surgery without an observable benefit is a good question!

RE: Aseptic patient prep - surgical spirit or not?

Julian Earl — Wed, 25 Nov 2020 13:13:30 GMT

Lucy, and everyone else,Have you seen my post in the Chlorhexidine thread above? I said this:

here are a lot of papers on Entrez PubMed about chlorhexidine and canine pyoderma. Such as this one: Topical therapy for drug-resistant pyoderma in small animals - PubMed (nih.gov)

But a lot of links to other papers , clinical trials and others. I searched chlorhexidine and pyoderma and they all came up. I have not read them all I'm afraid so you will have to fid the conclusions yourself. Sorry!

PubMed is a fabulous resource for answering these sorts of questions.. HTH?

RE: Aseptic patient prep - surgical spirit or not?

Lucy Fleming — Wed, 25 Nov 2020 12:09:34 GMT

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not"]therefore creating 'a pathogen soup' [/quote]

How many bacterial species can survive /reproduce in surgical spirit? And if they can, will they also be able to survive in the very different conditions of a mammalian wound?

RE: Aseptic patient prep - surgical spirit or not?

Julian Earl — Wed, 25 Nov 2020 12:01:30 GMT

Does spirit not take several minutes to be effective? Iodine and chlorhexidine work much faster IIRC?

TIA...

RE: Aseptic patient prep - surgical spirit or not?

Rob Loxley — Wed, 25 Nov 2020 08:45:10 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not/226980#226980"]followed by Hibitane with spirit, but its discontinued. Plan on going back to spirit[/quote]

Vetasept spray an option?

RE: Aseptic patient prep - surgical spirit or not?

Beats — Tue, 24 Nov 2020 21:08:38 GMT

Hi Anthony,

I do 2% chlorhexidine scrub in prep room (so that's hibiscrub diluted half in half with (tap)water in a clean-but-not-sterilised kidney dish and using clean cotton wool that no-one has been grabbing at to clean ears with).

I follow that up with either:

a) a squirt from a squirty-bottle of ?%-chlorhexidine/70%-alcohol mix [most basic stuff]

b) Chloraprep orange-dyed alcohol-chlrohexidine sterile pre-filled scrubbers [eg a cruciate or significant procedure where infection a potential concern]

I think approach can vary with what procedure doing.

Cat castrate - I've never seen an infection - I give a cursory clean with soapy hibiscrub and then squirt some alcohol out of a bottle in prep room.

Cat spay - I only remember ever seeing 2 x infections in my career to-date, both done by students or inexperienced vets with longer operating times and big amounts of thick catgut in larg-ish wound - I give these a quick clean with hibiscrub much like a cat castrate, then probably usually squirt on some alcohol.

Foot surgery - in a glove with 4% chlorhexidine for 10 minutes after an intial clip and clean.

Dog castration - I think attention to detail in clipping [I think often less is more...] is probably most critical thing to avoid post-op problems.

Thyroidectomy - never seen an infection, only get quick cursory clean.

As a clinic, we do have issues with post-op infections in my opinion, but trying to get that quantified is difficult [I started a recording system a number of years back, but it will need resurrected in 2021 from a death in 2020, and numbers have never been very exact or helpful]. A lot of years back I trawled through cruciate cases to find that 15% of extracapsular repairs had post-op infections to some degree, while 0% of MMP's had post-op infections - I think a big part of this was the level attention to detail in patient preparation rather than a difference in surgical procedure per se.

RE: Aseptic patient prep - surgical spirit or not?

Michael Woodhouse — Tue, 24 Nov 2020 19:29:06 GMT

There is sod all out there in the literature, but some fiercely held opinions. If you posted this on the nurse forum half would tell you it's vital you use it, half would tell you you're going to hell for using it and someone would suggest Avacta do a lunch and learn (and they have bugger all to claim any superiority their very wasteful product but some nurses seem to love it).

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not"]not deep cleaned regularly[/quote]

How is cleaning different to deep cleaning? No one has ever really given me a good answer. Why is it OK in the 5l bottle under the sink but becomes a bacterial soup once put in a trigger sprayer/wash bottle? Mental images of Krypton factor style bacteria trying to make their way up the nozzle.

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29520/aseptic-patient-prep---surgical-spirit-or-not"]However with our clinical governance we aren't really seeing this.[/quote]

Then carry on. We currently scrub with dilute Hibi* followed by Hibitane with spirit, but its discontinued. Plan on going back to spirit.

* Hibiscrub concentration another contentious issue. We always squirt a bit in some water in a kidney dish and use that to scrub - mild pink. The vet wound people say to use neat (!) and dilution means vastly longer contact time. Never use a more than 10% solution, and also no issues with post op infections. Don't even time the scrub.

How are my patients still alive? Don't stock ACP, maybe that's it.