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Dear Colleagues,
The event(s) that led to cautionary measures concerning skin antisepsis for neuraxial blockade were the so-called “epidural tragedy” or “epidural tragedies” after applying chlorhexidine-alcohol (CHX-ALC) antiseptics. There were several cases of severe persistent neurological damage following the application of CHX-ALC skin antiseptics.
I have commented on the Infexion Connexion List before about this, so I will keep it short and refer to my previous post.
For one (or a few, can’t remember how many) of these cases it was reconstructed that the CHX-ALC was confused with the local anaesthetic because it was put in a “galley pot” and accidentally injected. In such an instance, there is a clear path set for damage. Both CHX and alcohol, when injected into live tissue (not talking about superficial keratinized skin), are very destructive substances. CHX is known to be neurotoxic, and alcohol will coagulate proteins and kill cells.
For several cases, it was apparently never fully clarified what caused the tragedy, and these cases remain a matter of speculation. It was speculated, for example, that the CHX-ALC mix could have been drawn in by capillary action along the needle track. But how the capillary action could draw such a substantial amount is unclear, and it is biologically plausible that this would not have happened if the antiseptic had dried before needle insertion, as it is supposed to do.
The CHX-ALC swabsticks certainly eliminate the problem of accidental injection, because they cannot be confused with the anaesthetic.
The replacement of 2% CHX plus alcohol with 0.5% CHX plus alcohol as suggested in the ANZCA (which I have not yet seen) and UK guidelines is based on pure assumption, and this may or may not eliminate or alleviate the problem, depending on how the CHX-ALC makes its way into the tissues.
It also needs to be pointed out again that contrary to what the UK guideline says, there is no documented evidence that CHX-ALC is superior to povidone-iodine combined with alcohol for this particular application. The only clinical application for which there is clear documented evidence of superiority of CHX-ALC over other antiseptics is vascular catheters. But this is a different application. The cited evidence in the UK guideline is either based on unequal comparisons (e.g. CHX-ALC versus povidone-iodine without ALC), or based on microbiological tests where there is insufficient documentation about whether neutralisers have been used (note, neutralisers are a prerequisite when assessing microbial counts after antisepsis).
So, for all intents and purposes, povidone-iodine-alcohol remains a suitable (and distinctly coloured) alternative.
There is also an interesting little paper here:
Sviggum HP et al. Neurologic complications after chlorhexidine antisepsis for spinal anesthesia. Reg Anesth Pain Med. 2012 Mar-Apr;37(2):139-44.
https://www.ncbi.nlm.nih.gov/pubmed/22286519
The authors examined 12,465 spinal anaesthesias at Mayo Clinic and found no specific complications associated with CHX-containing skin antiseptics, i.e. the complication rate was small and within expected ranges. This is reassuring.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387
Hi Verily,
The 2015 Australian ANZCA guideline is similar to the 2014 UK safety guideline which is specific to central neuraxial blockade(CNB) and states the following:
* “Given the lack of convincing evidence of the antimicrobial superiority of a 2% solution of chlorhexidine in alcohol over a 0.5% solution, but the presence of clear evidence of the neurotoxicity of chlorhexidine, the Working Party has concluded that the use of a 0.5% solution should be preferred over a 2% solution for skin antisepsis before CNB”.
The UK document also includes and extensive review of chlorhexidine, alcohol and neurotoxicity and methods of application.
In terms of the type of applicator you mention the document states the following:
* “The applicators are manufactured with a reservoir containing 3 ml or 10.5 ml of antiseptic, and the solution may be dyed to allow identification of the area of prepared skin. Because the antiseptic solution is contained within the hollow of the handle, crossover errors are impossible and fluid spillage should be minimised. However, it has been observed that leakage of antiseptic solution over the operator’s gloves may occur via a hole at the end of the handle when the device is held upside down (the hole below the level of the antiseptic reservoir) to clean a patient’s back [19]”.
Hence it seems there are some risks with these types of applicators not just that the concentration of chlorhexidine is higher than recommended in the device you are currently utilising.
See attached and link below:
* Association of Anaesthetists of Great Britain & Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014, 69, 1279-1286
https://www.aagbi.org/sites/default/files/skin%20antisepsis%20for%20central%20neuraxial%20blockade_0.pdf
regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.au
Hi Michael
Kindly forward this email to members for advise and comment, much appreciated.
Kind Regards
Verily Thomas
Clinical Nurse Consultant | Infection Prevention and Control
SWSLHD-Bankstown/Lidcombe Hospital
Eldridge Road, Bansktown.NSW 2200
Tel 02 97228000 pager 28230
Tel 02 9722 8633 | Fax 02 9722 7822 | verily.thomas@sswahs.nsw.gov.au
http://www.health.nsw.gov.au
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LET’S KEEP OUR HOSPITAL ENVIRONMENT CLEAN
HAND HYGIENE SAVES LIVES
Hi Verily,
The chlorhexidine swabs sticks that were trialled for neuraxial blocks in perioperative services were 2% chlorhexidine in 70% Alcohol, the ANZCA guidelines on infection control in Anaesthesia PS28 state that 0.5% chlorhexidine in 70% Alcohol is to be used for neuraxial blocks, due to the neurotoxicity of chlorhexidine. We need to assess if the risk of using 2% chlorhexidine swab sticks mitigates the risk of using 0.5% Chlorhexidine liquid and gauze swabs for skin prep for neuraxial blocks. The swab sticks prevent any risk of chlorhexidine being injected into the epidural or subarachnoid space and splashing into other solutions on the sterile field. We also need to assess if the use of 2% has any benefit over 0.5% in terms of infection control and prevention.
Kind Regards,
Bridie
Bridie Treloar
Clinical Nurse Consultant Perioperative Services
Bankstown-Lidcombe Hospital
Monday Week 1 and 3, Tuesdays, Wednesdays
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