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Patient Skin Antisepsis

Get clinical answers to frequently asked questions about Patient Skin Antisepsis. 


Which antiseptic should be used for vaginal antisepsis?

The collective evidence indicates that povidone-iodine is commonly used for vaginal antisepsis in gynecological procedures.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Which antiseptic should be used for vaginal antisepsis if the patient is allergic to iodine?

There are currently no FDA-approved (ie, Category I, New Drug Application) antiseptic alternatives on the market for use in the vaginal vault when povidone-iodine is contraindicated (eg, patient allergy). The perioperative team members should collaboratively evaluate the risks and benefits of using Class II or III FDA-approved antiseptics or other alternative solutions (eg, soaps, saline). (See Table 1)

Two alternatives to vaginal povidone-iodine, sterile saline and baby shampoo, were discussed in the literature. Both studies suggest that these alternatives are as effective as povidone-iodine for preoperative vaginal antisepsis. In a position statement from the American Congress of Obstetricians and Gynecologists (ACOG), the committee recommends off-label use of 4% CHG with low alcohol content (eg, 4%) as a safe and effective alternative for vaginal preparation when povidone-iodine is contraindicated or CHG is preferred by the surgeon.

Table 1. FDA Categories of Patient Preoperative Skin Preparations¹

Active Ingredient Category
Benzalkonium chloride IIIE
Chlorhexidine gluconate "New drug"
Chloroxylenol IIIE
Hexachlorophene II
Iodine tincture USP I
Iodine topical solution USP I
Povidone-iodine 5% to 10% I
Triclosan IIIE
Iodine Povacrylex/Isopropyl Alcohol² New Drug²
E= Effectiveness

Reference

¹ US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule. Fed Regist. 1994;59(116):31402-31452.
² US Food and Drug Administration. New Drug Application (NDA) #21-586.


Resources

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Amstey MS, Jones AP. Preparation of the vagina for surgery. A comparison of povidone-iodine and saline solution. JAMA. 1981;245(8): 839-841.
  • Lewis LA, Lathi RB, Crochet P, Nezhat C. Preoperative vaginal preparation with baby shampoo compared with povidone-iodine before gynecologic procedures. Journal of Minimally Invasive Gynecology. 2007;14(6): 736-739.
  • American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstetrics & Gynecology. 2013;122(3): 718-720.

Updated November 6, 2014 


Should Chlorhexidine (CHG)-impregnated cloths be used for preoperative bathing?

There is a growing body of evidence supporting the use of 2% CHG-impregnated cloth products for preoperative bathing. CHG-impregnated cloths may increase the amount of CHG on the skin at the surgical site, which could enhance the activity and residual effect of CHG. Based on the collective evidence, this practice remains an unresolved issue and warrants additional generalizable, high-quality research to confirm the benefit of CHG-impregnated cloths for prevention of surgical site infection.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Our organization’s protocol for preoperative skin antisepsis is to use an alcohol-based antiseptic, but the dry time for the antiseptic in hair is 60 minutes which is not feasible. This conflicts with our protocol not to remove hair at the surgical site. Should we use an alcohol-based antiseptic or remove the hair at the surgical site?

When using an alcohol-based skin antiseptic for procedures involving an ignition source (eg, electrosurgery, laser), hair at the surgical site should be clipped before application of the antiseptic. Hair removal at the surgical site should be performed only in select clinical situations, such as when the presence of hair may contraindicate the use of flammable antiseptics (eg, alcohol-based) according to manufacturer's instructions for use.

There was no evidence found that describes the length or amount of hair that constitutes a fire risk when using alcohol-based skin antiseptics. When hair removal is necessary, clipping the hair may be associated with a lower risk of developing an SSI than hair removal with a razor.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Should sterile gloves be worn when performing preoperative patient skin antisepsis?

Sterile gloves should be worn when performing preoperative patient skin antisepsis. Nonsterile gloves may be worn if the antiseptic applicator is of sufficient length to prevent contact of the gloved hand with the antiseptic solution and the patient’s skin.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


What protective measures should I take to prevent prolonged patient contact with skin antiseptics?

  • Sheets, padding, positioning equipment, and adhesive tape should be protected from the dripping or pooling of skin antiseptics beneath and around the patient.

  • Electrodes (eg, electrocardiogram [ECG], electrosurgical unit [ESU] dispersive electrode) and tourniquets should be protected from contact with skin antiseptics.

  • A fluid-resistant pad should be placed under the patient's buttocks during preoperative patient skin antisepsis for patients in the lithotomy position. The pad should be removed after the antiseptic is dry and before sterile drapes are applied.

  • Any material near the patient that is in contact with the skin antiseptic solution, including electrodes (eg, ECG, ESU) and tourniquet materials (ie, cuff, padding) should be removed and replaced, as necessary.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Is it necessary to wear long sleeves when performing preoperative patient skin antisepsis?

Yes, the arms should be covered by surgical attire when performing preoperative patient skin antisepsis. The recommendation for nonscrubbed perioperative personnel to wear long-sleeves has been a part of the AORN “Recommended practices for surgical attire” since 1994. Wearing long-sleeved attire helps contain skin squames shed from bare arms. If the RN circulator performs the preoperative skin antisepsis without wearing a long-sleeved jacket, skin squames from his or her bare arms may drop onto the area that is being prepped and may increase the patient’s risk for a surgical site infection.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Is it necessary to remove nail polish or artificial nails when performing preoperative patient skin antisepsis on a patient having hand or foot surgery?

Nails on the operative extremity should be clean and natural without artificial nail surfaces or polish. The evidence review for this recommended practices document found no cases of patient incision-site contamination related to wearing artificial nails or nail polish on the operative hand and foot. In two separate studies, researchers found that the amount of potentially pathogenic bacteria cultured from the fingertips of health care personnel wearing artificial nails was greater than for those with natural nails, both before and after hand washing. Artificial nail surfaces or polish may harbor microorganisms, which could contaminate the surgical site or reduce the effectiveness of preoperative patient skin antisepsis.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Is it acceptable to dilute the skin antiseptic solution when performing preoperative patient skin antisepsis?

In a drug safety communication, the FDA recommended that health care professionals do not dilute antiseptic products after opening them to reduce the possibility of these products becoming contaminated. Skin antiseptics should be applied according to the manufacturer’s instructions for use. Antiseptic manufacturers’ instructions for use convey important safety and efficacy instructions to the user.

Skin antiseptics are designed and tested by the manufacturer to provide the safest and most effective reduction of skin microbes at specific concentrations. Diluting antiseptic solutions and failing to adhere to the manufacturer’s instructions for use may result in patient harm or ineffectiveness of preoperative patient skin antisepsis.

Resources

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Over-the-counter topical antiseptic products: drug safety communication—FDA requests label changes and single-use packaging to decrease risk of infection. FDA.gov 

Updated November 6, 2014 


Is it acceptable to use multiuse containers of skin antiseptic solution when performing preoperative patient skin antisepsis?

In November 2013, the FDA issued a Drug Safety Communication requesting that manufacturers’ package antiseptics indicated for preoperative skin preparation in single-use containers to reduce the risk of infection from improper antiseptic use and contamination of products during use. In several case reports and non-experimental studies, contaminated skin antiseptics have been linked to patient infections. Skin antiseptics should be purchased in single-use containers, discarded after use (one patient, one time), and not refilled.

Resources

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Over-the-counter topical antiseptic products: drug safety communication—FDA requests label changes and single-use packaging to decrease risk of infection. FDA.gov 

Updated November 6, 2014 


Are there special methods that should be used when performing preoperative patient skin antisepsis of the hand or foot?

When performing preoperative patient skin antisepsis of the hand or foot, perioperative team members should take care to apply the antiseptic to all surfaces between fingers or toes. Antisepsis may be difficult in the areas between the fingers and toes due to reaching all surfaces of the skin.

In a randomized controlled trial of 50 patients undergoing foot surgery, researchers reported a significant reduction in bacterial recolonization of the foot with additional cleaning of the area between the toes. International studies from England, Australia, and New Zealand describe a novel technique for skin antisepsis of the hand or foot that involves using a sterile bag. Researchers have found the bag technique to be effective in reducing bacterial counts and application time. One researcher reported reducing musculoskeletal injury as an additional benefit of the bag technique.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


Why do we remove cosmetics before the preoperative skin prep?

Cosmetics may contribute to increased soil and contamination and impede the effectiveness of the antiseptic agent. The removal of facial cosmetics also may be indicated to prevent debris from irritating the eyes, to facilitate securing the endotracheal tube, or for other reasons identified by the surgical team.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


What precautions should providers take when removing hair at the surgical site?

If the presence of hair will interfere with the surgical procedure and removal is in the best interest of the patient, the provider should take the following precautions:

  • Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room.

  • Only hair interfering with the surgical procedure should be removed.

  • Hair should be clipped using a single-use electric or battery-operated clipper.

Resource

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated November 6, 2014 


How can I minimize the fire risk when using flammable patient skin antiseptic products?

Because the potential for a fire exists in the presence of the triad of oxygen; energy sources (eg, electrosurgical units, lasers, light cords); and alcohol, it is critical that perioperative personnel receive education on the flammability of certain antiseptic products. In addition, the following interventions relating to the use of prep antiseptic products can minimize the fire risk in the OR:

  • Allow sufficient drying time, including time for the vapors to dissipate, before applying surgical drapes, using a potential ignition source.

  • Flammable skin antiseptics should be prevented from pooling or soaking into linens or the patient’s hair.

  • Communicate use of flammable skin antiseptics as part of the fire risk assessment involving the entire perioperative team before beginning a surgical procedure.

Resources

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Guideline for a safe environment of care. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Fire Safety Tool Kit. AORN, Inc.

Updated November 6, 2014 


Which patient skin antiseptic products are flammable?

Alcohol-based antiseptics are rated as flammable patient antiseptic products. It is important to note, however, that chlorhexidine gluconate and providone-iodine without alcohol are not flammable but may be combustible. The National Fire Protection Association (NFPA) defines flammable as having a flash point below 100 degrees Fahrenheit. Those products with a flash point above 100°F are considered to be combustible. The flash point for all manufactured products can be found on the SDS sheets.

Resources

  • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Guideline for a safe environment of care. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • National Fire Protection Association. NFPA 30: Flammable and Combustable Liquids Code. 2008 ed. Quincy, MA: National Fire Protection Association; 2008.
  • AORN Fire Safety Tool Kit. AORN, Inc.
  • Surgical fire prevention. ERCI Institute.

Updated November 6, 2014 


For a procedure that involves the genitalia, should a urinary catheter be inserted before or after preoperative patient skin antisepsis?

When the surgical area involves the genitalia and the patient requires a urinary catheter, the nurse should insert the catheter after performing the preoperative patient skin antisepsis.

Resource

  • Burlingame, BB. Perineal preps and urinary catheter insertion. [Clinical Issues]. AORN Journal. 2011;94(1):100.

Updated November 6, 2014 

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