Best Practice in Aseptic TechniqueDavid Bogod, Nottingham

324,950 spinals

Abscess - 2 Arachnoiditis - 1Meningitis - 2

J Pathology Bacteriology 1955; 70: 167-178

CetrimideTwo other cationic detergentsOne anionic detergentOne non-ionic detergent1:6-Di-4’-chlorophenyldiguanidohexane diacetate

1:6-Di-4’-chlorophenyldiguanidohexane diacetate

Chlorhexidine

✤ 0.02% Microscopic changes

✤ 0.05% Death at 7 days, dilated ventricles

✤ 0.1% Death at 24 hours after fitting

Chlorhexidine

✤ Direct degeneration of nervous tissue

✤ Cellular proliferation and inflammation of meninges → blockage

✤ Necrosis of vascular media and adventitia → luminal obliteration

“There are known knowns. These are things we know that we know. There are

known unknowns. That is to say, there are things that we now know we don’t know. But there are also unknown unknowns.

These are things we do not know we don’t know.” We don’t know what happened to Angelique, but at least now we know we

don’t know.

Anaesthesia News 2010; 271: 7-8

The Importance and Implications of Aseptic Techniques During Regional Anesthesia

Hebl, JR

Reg Anesth Pain Med 2006; 31: 311-323

✤ Neither Chlorhexidine nor Povidone approved by FDA - lack of clinical data

✤ Povidone less effective than Chlorhexidine:

✤ Requires longer contact

✤ Limited duration of action

✤ Neutralised by organic material

✤ Acute skin reactions

✤ Bacterial resistance esp. Staph Aureus

“...alcohol-based chlorhexidine solutions should be considered the antiseptic of choice before regional anesthetic techniques (Grade A)”

Reg Anesth Pain Med 2006; 31: 311-323

“If we use povidone-iodine for skin preparation and the patient develops a bacterial meningitis after a spinal puncture, we could be criticized for not using CHG as recommended by the guidelines. Alternatively, if we use CHG and the patient develops a neural deficit for whatever reason, we could be criticized for using CHG. It then becomes a battle of the experts”.

Chlorhexidine or Povidone-IodineDo We Follow the Guidelines or the Package Insert?

Dailey PA. CSA Bulletin, Summer 2009

British Journal of Anaesthesia 2009; 103: 456–57

Antiseptic solutions for central neuraxial blockade: which concentration of

chlorhexidine in alcohol should we use?

British Journal of Anaesthesia 2009; 103: 456–57

Can the authors please comment on whether they reached any conclusion after their audit on which concentration of chlorhexidine in alcohol is the safest antiseptic solution to use?

British Journal of Anaesthesia 2009; 103: 456–57

The use of a concentration of CHG > 0.5% cannot be supported; this concentration is evidently effective, but a greater one might increase the risk of neurotoxicity from inadvertent contamination, and should be avoided... It is our opinion (a poor level of evidence!) that, on the limited evidence available to us, chlorhexidine 0.5% in alcohol 70% is the optimal skin preparation for neuraxial procedures

British Journal of Anaesthesia 2009; 103: 456–57

The use of a concentration of CHG > 0.5% cannot be supported; this concentration is evidently effective, but a greater one might increase the risk of neurotoxicity from inadvertent contamination, and should be avoided... It is our opinion (a poor level of evidence!) that, on the limited evidence available to us, chlorhexidine 0.5% in alcohol 70% is the optimal skin preparation for neuraxial procedures

British Journal of Anaesthesia 2009; 103: 456–57

The use of a concentration of CHG > 0.5% cannot be supported; this concentration is evidently effective, but a greater one might increase the risk of neurotoxicity from inadvertent contamination, and should be avoided... It is our opinion (a poor level of evidence!) that, on the limited evidence available to us, chlorhexidine 0.5% in alcohol 70% is the optimal skin preparation for neuraxial procedures

✤ Four further cases:✤ Progressive leg weakness and pain✤ Hydrocephalus✤ Serial shunts✤ Paraplegia

✤ Seven other cases

Regional Anesthesia and Pain Medicine 2012; 37: 131-8

Regional Anesthesia and Pain Medicine 2012; 37: 131-8

Regional Anesthesia and Pain Medicine 2012; 37: 131-8

2% chlorhexidine

22-gauge Quinke needle

1 ml of LA

1:145773 dilution

0.0001372%

Regional Anesthesia and Pain Medicine 2012; 37: 139-44

Regional Anesthesia and Pain Medicine 2012; 37: 139-44

0.04% incidence

12,465 spinals

Antiseptic Precautions

✤ Continue to use chlorhexidine 0.5% in alcohol

✤ Keep equipment covered

✤ Remove antiseptic and sponges from vicinity before uncovering

✤ Check for glove contamination

✤ Allow to dry

What We Don’t Know

✤ Dry or wet?

✤ Optimal prep technique

✤ Effect of alcohol

✤ Physiological vs morphological effects

✤ Possibility of genetic sensitivity

For copy of presentationemail

david.bogod@me.com