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Efficacy of a spray disinfection technique

AORN Journal, March, 2007 by George Allen

British Journal of Anaesthesia

January 2007

Disinfection of the skin is required before any intervention is performed that will penetrate intact skin. The increasing use of epidural anesthesia highlights the importance of using aseptic technique during catheter placement because rare but serious infections associated with epidural anesthesia, such as bacterial meningitis and epidural abscess, can have devastating consequences.

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Methods for skin disinfection vary; although the most common method for epidural catheter insertion involves disinfecting the puncture site with sterile swabs soaked in a disinfectant, another conventional disinfection technique is the use of a disinfectant spray. There is very little evidence, however, regarding the superiority of either method. The purpose of this prospective, randomized study was to compare the efficacy of conventional swab disinfection with spray disinfection before epidural catherization. (3)

Patients at a medical center in Hungary were enrolled in the study if they had requested epidural anesthesia and were undergoing one of a variety of surgical procedures, including

* lung resection,

* gastrectomy,

* liver resection,

* esophagus resection,

* colon resection,

* choledochojejunostomy,

* femoropopliteal bypass, and

* hip arthroplasty.

Patients were excluded if they were younger than 18 years of age, had a fever or diabetes, received antibiotics before the procedure, were receiving steroid therapy, were immuno-compromised or had HIV, had a pre-existing skin condition at the planned puncture site, or had an iodine allergy.

All epidural catheter insertions were carried out before the initiation of general anesthesia. The disinfection solution that was used consisted of 63 g 2-propanol, 0.025 g benzalkonium chloride, water, and dye in 100 g solution.

For patients in the swab group (n = 35), an area 20 cm in diameter around the planned puncture site was disinfected using sterile forceps and sterile swabs soaked in the disinfectant. The procedure was repeated three times, and after three minutes of drying time, the site was covered with a sterile sheet. The epidural catheter was inserted at the lumbar or thoracic level using standard procedures, and a sterile, adhesive, semipermeable, polyurethane dressing was placed over the area surrounding the epidural insertion site.

In the spray group (n = 35), the skin was disinfected with the same disinfectant using a multi-dose pressurized plastic container from which the disinfectant was sprayed on an area approximately 20 cm in diameter. The same procedures that were used in the swab group for repeating the sterilization, drying the area, covering the site, and inserting the catheter were followed for the spray group.

Three cultures were taken from each patient. The first sample was obtained from an area adjacent to the planned puncture site just before the skin was disinfected. The second sample was obtained from the same area immediately after the three minutes of drying time after skin disinfection was completed. The third sample was obtained from the distal tip of the epidural catheter after it was aseptically removed. The patients' demographic data were recorded, as were

* the epidural site;

* the time needed to insert the epidural catheter;

* the hours the catheter remained in situ;

* the type of prophylactic antibiotic used;

* the type of surgical procedure performed;

* any signs of local irritation during catheter removal; and

* the syndrome of possible epidural infection (ie, two major symptoms including back pain and neurological deterioration, two minor symptoms including elevated white blood cell count and fever).

Common statistical procedures, including the Student's t test and chi-square test, were used to analyze the data.

Findings. Of the 70 patients enrolled, three from each group were excluded because of accidental removal of the epidural catheter. Patients in the swab and spray groups were similar with respect to height, weight, gender, and age. There were no significant differences in thoracic versus lumbar insertion site, time of successful placement, and rate of irritation at the puncture site at the time of removal. In both groups, cultures from the nondisinfected skin showed normal skin flora with the most common isolate being coagulase-negative Staphylococci. Samples collected three minutes after skin disinfection were sterile except for one specimen from the swab group. Six epidural catheter tips from the swab group and two from the spray group were colonized. The difference was not statistically significant ([X.sup.2], P = .257). None of the patients had any signs of epidural infection at the time of catheter removal.

Clinical implications. The results of this study revealed that spray disinfection was equally effective compared to the conventional swab disinfection technique for disinfecting the site before placement of an epidural catheter. Perioperative nurses and managers should understand that this is a small study, and they should be prepared to assist in larger studies of this sort.

Health Care Industry

Efficacy of a spray disinfection technique

AORN Journal, March, 2007 by George Allen

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