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Skin Prep Pop Quiz
Surprise! Here are 5 surgical prep questions you need to ace.
Linda Greene
Publish Date: November 4, 2008   |  Tags:   Infection Prevention

It's time to test your surgical prep knowledge. Do you know the difference between preps' active ingredients? What about the proper way to apply preps? We'll see. You may begin ??? now. Good luck!

1. Which surgical prep is universally accepted as the most effective?
a. alcohol
b. povidone-iodine
c. chlorhexidine gluconate
d. none of the above

Answer: d

Antiseptic properties vary and research has not yet identified one formulation as the best skin prep. The two most commonly used prep solutions are povidone-iodine and chlorhexidine gluconate (CHG). Both are comparable in their spectrum of antimicrobial activity, although CHG does exhibit prolonged activity on the skin's surface.

Here's a summary of the major types of agents as classified by the Centers for Disease Control and Prevention's Guideline for the Prevention of Surgical Site Infections:

  • Alcohol. Offers the most rapid-acting microbial kill of all the prep solutions. It is rated excellent in its effectiveness against gram-positive and gram-negative bacteria and good against tuberculosis, fungi and viruses. But it has no residual activity, may dry the skin and is a volatile substance.
  • Chlorhexidine. Has an intermediately fast microbial kill and excellent residual activity. While rated excellent against gram-positive bacteria, it's only good against gram-negative bacteria and viruses and fares poorly against tuberculosis and fungi.
  • Povidone-iodine. Intermediately fast in its microbial kills, but with limited residual activity. Against gram-positive bacteria, it's rated excellent; against gram-negative bacteria, tuberculosis, viruses and fungi, it's rated good. Its absorption may cause skin irritation or toxicity.
  • Chloroxylenol (PCMX). Chloroxylenol's microbial kill is intermediately fast and its residual activity is good. Its effectiveness is adequate against gram-positive bacteria and fair against gram-negative bacteria, tuberculosis, viruses and fungi. The guideline notes that insufficient data exists to determine its toxicity.

2. What factor should you consider first when deciding between skin preps?
a. ease of use
b. cost
c. antiseptic effectiveness
d. dry time

Answer: c

Choosing the best skin prep largely depends on the chemical compositions and concentrations that promote optimal antiseptic effectiveness. That effectiveness, in turn, hinges on the patient's condition, the location of the surgical site, the manner in which the solution is applied and the amount of time the solution is in contact with the skin, since the solution must be allowed enough time to dry in order to achieve maximum antiseptic efficacy.

Alcohol-based products can't be used around the body's mucous membranes. Chloroxylenol is a better choice for prepping those areas. It's also important to consider gentle prepping techniques for patients with fragile skin, such as the elderly and diabetics. Using chlorhexidine products might be an issue here, as caregivers must use friction to properly apply those preps. Finally, patients with sensitive skin or allergies might drive your prepping choice away from povidone-iodine.

Cost is always an issue, but it shouldn't be your primary concern when deciding between preps. Yes, you need to be fiscally responsible, polling surgeons and frontline staff for their prepping preferences and performing a cost analysis of their recommendations, but a prep's efficacy should always trump budgetary concerns.

Consider the steps needed to apply preps, weighing cost against ease of use. A variety of single-step applicators are available; many are effective in improving case efficiencies and ensuring that staff use the right amount of prep each time. Pre-mixed, ready-to-use applicators are typically more expensive than trays, gauze and forceps, but some facilities have found that the additional expense evens out when ease of storage, ease of use and time savings are factored into the cost equation.

3. What's the best way to apply chlorhexidine preps?
a. broad, concentric circles
b. short, side-to-side strokes

Answer: b

Concentric circles work well for povidone-iodine preps, but effective application of chlorhexidine products demands short, back-and-forth strokes to create the friction necessary for the formulation to penetrate the skin. A formulation's mode of action is tied directly to its correct application, so reviewing and understanding manufacturers' directives are essential to effective prepping practices.

Apply skin preps with sterile supplies. Antiseptic products marketed with applicators can be applied with clean gloves per the manufacturers' current recommendations. Work outward from the surgical site when applying preps and avoid recoating where the prep has already been applied in order to maintain the area's sterility.

4. Which prepping agent has the quickest dry time?
a. chloroxylenol
b. alcohol
c. chlorhexidine
d. povidone-iodine

Answer: b

In order to exhibit their full antiseptic properties, prep formulations must dry before incisions are made. Drying times range from 15 seconds to five minutes, depending on the agent, the area prepped and the amount of solution applied. Prepping products containing alcohol dry quickly, typically in between 10 and 15 seconds.

While alcohol dries and kills bacteria quickly, it lacks antimicrobial persistence. Chlorhexidine has persistent antiseptic activity, making it well suited for long cases. It also takes longer to dry — and therefore to reach — an effective kill rate when compared to chloroxylenol and povidone-iodine, which offer moderate persistence and intermediate speed in their actions against harmful bacteria.

Waiting for preps to dry before making a cut makes perfect sense on paper. In busy, efficiency-conscious surgical facilities, however, allowing for enough dry time before cases can be a challenge. Reemphasize the importance of prep drying with your frontline staff and surgeons. They all need to be on the same page when implementing this important prepping essential.

5. Effective prepping practices depend on which of the following?
a. the area to be prepped
b. procedure type
c. experience
d. all of the above

Answer: d

The volume of applied solution should be sufficient to enact optimal results and proportionate to the size of the treatment area. Prepped areas must be large enough to accommodate an extension of the incision, the need for additional incisions and potential drain sites. Those considerations depend on the type of procedure for which you're prepping. A bowel resection with a possible ruptured appendix, for example, might call for starting the prep at the neck, continuing it across the entire abdomen and down the legs. Procedures performed in the outpatient setting, however, typically involve small incisions and less area to prep.

Take extra care when prepping for electrosurgery and laser procedures. Allow adequate time for preps to dry and avoid applying excess solution to prevent the dripping and pooling of prepping agents around the surgical site. While those precautions should be taken prior to any procedure, the risk for surgical fires is greatly increased when electrical equipment is added to the prepping equation.

Facilities often have procedure-specific guidelines in place that dictate prepping practices. Experience will also serve as a guide. Review the case that's scheduled, anticipate and plan for potential additions to the targeted incision site and when in doubt, err on the side of caution by extending the prep beyond where it might need to go.

Pencils down
How'd you do? Now it's time to test your staff. Everyone at your facility needs to study and learn the basics of surgical prepping and grasp its fundamental role in skin antisepsis and preventing surgical site infections. The OR, after all, isn't the place for a cram session.