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Industry: Email Alert RSS FeedPreoperative skin preparation of cardiac patients
AORN Journal, Nov, 2002 by Cynthia G. Segal, Jacqueline J. Anderson
Sternal surgical site infection (SSI) after coronary artery bypass graft (CABG) surgery is a complication that increases patient morbidity and mortality and costs for patients, payors, and the health care system. (1) Although the incidence of SSI reportedly is low (ie, ranging from 1% to 5%), the effects can be deforming and fatal. Numerous publications discuss the problem, its possible causes, predictive factors, and preventive measures in an attempt to reduce the incidence of this devastating complication. (2) A 900-bed tertiary hospital in the southwestern United States undertook an initiative to optimize the preoperative skin preparation of patients undergoing CABG procedures to reduce the risk of sternal SSIs.
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RISK MODEL DEVELOPMENT
Many preexisting comorbid conditions have been identified in the literature as risk factors for SSIs, including diabetes, obesity, smoking, steroid use, malnutrition, and renal failure. Additional factors specific to patients undergoing CABG procedures put them at risk for sternal SSIs. These include age, chronic obstructive pulmonary disease (COPD), the use of the internal mammary artery (IMA) for grafting, prolonged mechanical ventilation, surgical time, the use of bone wax, preoperative nasal carriage of Staphylococcus aureus, and the extensive use of electrosurgery. (3)
Retrospective outcome data from the hospital regarding patients who underwent CABG procedures from Oct 1, 1994, to April 30, 1997, were analyzed for factors that placed patients at a higher risk for developing sternal SSIs. Regression analysis of patient data identified five factors that were predictive of increased risk:
* diabetes,
* obesity,
* COPD,
* postoperative tracheostomy, and
* total time on cardiopulmonary bypass.
The analysis provided the basic elements for the development of a preoperative model that can be used to identify patients scheduled to undergo CABG procedures who are at higher risk for developing a sternal SSI. Patient factors that exist preoperatively could be used as indicators for the high-risk model; in other words, patients with a history of diabetes, obesity (ie, defined as a body mass index greater than 120% of ideal weight for the purposes of this initiative), or COPD would be identified as at high risk for developing a sternal SSI. Approximately 50% or more of patients undergoing CABG at the hospital had one or more of the identified risk factors. The historical incidence of diabetes in this particular population ranges from 25% to 35%, and the incidence of patients with documented COPD is less than 5%. Pilot data from the model suggested that nearly 50% of the patients who underwent CABG at the hospital met the criteria for obesity.
PURPOSE
The eight cardiovascular surgeons at the hospital practiced various methods of preoperative skin preparation before performing open heart surgery. The majority used povidone-iodine paint only, one used a five-minute povidone-iodine scrub and paint, and another used a one-step iodophor/alcohol water insoluble film. Traditionally, incise drapes were not used. All patients received similar preoperative instructions to take two antimicrobial soap showers before surgery, one the evening before surgery and one the morning of surgery. The morning of surgery, a trained patient care assistant clipped patients' hair in their rooms. In the OR, the circulating nurse performed the preoperative skin preps. As the institution is a teaching hospital, different assistant surgeons rotated though the ORs, ensuring consistency of the prepping methods. In this era of increased awareness of patient outcomes, standardization, and cost effectiveness, the question was whether one method of skin preparation is better than another for reducing postoperative sternal SSIs in patients undergoing CABG who are at high risk for developing SSIs.
BACKGROUND
Joseph Lister, MD, developed the principles and practice of antisepsis in the 1800s after he used antiseptic solutions on open bone fractures. He generalized that if contaminated wounds healed well with antiseptics, simple incised wounds would benefit from the application of antiseptic as well. (4) Thus began the principles of asepsis, which continually evolve and provide the theoretical framework for this study.
Publications regarding surgical skin preparations and infections are overwhelming in number. The US Food and Drug Administration (FDA) requires skin preps to be safe and fast-acting, have broad spectrum, and significantly reduce microbial skin count. (5) AORN recommends that a skin prep also inhibit rapid rebound growth of microorganisms. (6) Although alcohol has remained the main antimicrobial agent used in many parts of Europe for handwashing and preoperative skin preparation, in the United States a variety of preparations with different combinations of active agents, including chlorhexidine gluconate (CHG), iodophors, and alcohols, are used. (7)
Chlorhexidine gluconate has been noted as a highly effective antimicrobial in studies relating to handwashing and central line insertion and maintenance. (8) The use of CHG in aqueous form has been less embraced as a preoperative skin preparation, even though it is used frequently when a patient is allergic to iodine. A powerful broad-spectrum bactericidal, CHG has little activity as a sporicidal. Against most viruses, it has significant activity, except for enteric viruses, poliomyelitis, and papilloma virus. Chlorhexidine gluconate also is noted for its persistent effect on the skin. (9) A few anaphylactic reactions to CHG have been reported but are considered rare considering its widespread use. It is known to be neurotoxic to the brain and meninges. Resistance to CHG and other biocides has been observed in resistant strains of Staphylococcus aureus and Pseudomonas aeruginosa, with genetic linkage through plasmid encoding. (10) At the second Asian Pacific congress on antisepsis in 1993, J. Gordon, BA, MB, ChB, chair of the meeting, noted how CHG resistance is encoded in multiresistant plasmid determinants of Staphylococcus aureus and suggested limited use of CHG to avoid the persistence and spread of a combined antiseptic-antibiotic multiresistant staphylococci. (11) The widespread use of CHG and other cationic biocides in the clinical and veterinary areas continues to be questioned for the selection of certain genes that have been found on several multi-antibiotic resistant plasmids. (12)
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