Neurologic Complications After Chlorhexidine Antisepsis for Spinal Anesthesia:

Standards of practice for peripheral nerve blocks at a tertiary care center in a low-middle income country- a prospective observational study

BACKGROUND

Peripheral nerve blocks (PNB) have gained tremendous interest as a means of providing anesthesia and analgesia. Heterogeneity exists in the standards of practice (SoP) for PNB, especially in resource limited settings. Therefore, this study aimed to determine the SoP for administration of PNB at a tertiary care, University teaching hospital, in a low-middle income country (LMIC).

METHODS

This was a prospective observational study conducted between September 2021 and March 2023. The SoP were collected through either direct or indirect observation, using a self-developed proforma. Data were collected for various domains and were mapped to structure, process and outcome. They were then benchmarked to identify best practices and deficiencies.

RESULTS

A total of 386 PNBs were recorded, of which 196 (50.8%) were directly observed. Majority were administered to low-risk individuals without comorbidities (61.9%). In the structure metrics resuscitation equipment was available in 76% while availability of resuscitation drugs (29%) was identified as needing improvement. Individual components of process metrics such as intravenous access, use of personal protective equipment, ultrasound guided block technique and use of short bevel needles exceeded the 95% benchmark, while components such as monitoring (54%), aseptic site preparation (76.5%), the Stop Before You Block procedure (61.9%) and use of block additives (70.2%) fell short of the benchmark. Postoperative multimodal analgesia prescription (4.7%) was identified as needing improvement. Of the outcome metrics, while immediate post-block complications (0%) and conversion rate to general anesthesia (8.3%) exceeded the benchmark (< 10%), cumulative toxic dose was exceeded (36.6%) when a mixture of local anesthetics was used.

CONCLUSION

Standards of practice for structure, process and outcome were partly achieved for PNB at this tertiary care center in a low-middle income country. Strategies to improve SoP have been proposed and will need to be evaluated in future quality improvement initiatives.

Does intraoperative antiseptic solution soaking reduce microbial contamination in spine surgery? A randomized controlled trial

BACKGROUND CONTEXT

Surgical site infections (SSIs) are a significant complication in spine surgery, particularly in instrumented procedures, leading to increased morbidity and healthcare costs. Despite standard preoperative disinfection protocols, bacterial contamination remains prevalent. Strategies such as intraoperative antiseptic irrigation have been explored to mitigate contamination, yet the comparative efficacy of different antiseptic solutions remains unclear.

PURPOSE

This study aimed to evaluate the effectiveness of intraoperative antiseptic solution soaking with normal saline (NS), povidone-iodine (PVP-I), and chlorhexidine gluconate (CHG) in reducing bacterial contamination in lumbar instrumented fusion surgery.

STUDY DESIGN/SETTING

A single-center, single-blinded, randomized controlled trial was conducted at a tertiary medical center in Taiwan.

PATIENT SAMPLE

A total of 105 patients undergoing posterior lumbar interbody fusion surgery were enrolled and randomly assigned to three groups: NS (n=35), PVP-I (n=35), or CHG (n=35). Patients with prior lumbar procedures, known allergies to antiseptics, previous spinal infections, trauma, or tumors were excluded.

OUTCOME MEASURES

The primary outcome was the reduction in bacterial contamination, assessed via intraoperative cultures from three sites-superficial tissues, deep tissues, and implant surfaces-before and after antiseptic irrigation. Secondary outcomes included the incidence of postoperative SSIs and clinical complications over a 6-month follow-up period.

METHODS

Patients were randomized into three groups, each receiving a 3-minute soak with the assigned antiseptic solution before wound closure, followed by normal saline irrigation. Swab samples were collected pre- and postirrigation for bacterial culture and 16S rRNA PCR analysis. Statistical analysis was performed using logistic regression and Bonferroni correction for multiple comparisons.

RESULTS

Among 105 patients, preirrigation bacterial culture positivity rates were 49.5% in superficial tissues, 31.4% in deep tissues, and 32.4% on implants. Postirrigation, NS showed no significant bacterial reduction, while PVP-I reduced superficial contamination (55.0%, p=.015) but no significant effect in deeper tissues and implants. CHG showed the greatest bacterial reduction, significantly outperforming NS (OR: 0.06, 95% CI: 0.01-0.54, p=.011) and PVP-I (OR: 0.06, 95% CI: 0.01-0.56, p=.012) on implant surfaces. Despite these differences in culture rate, SSI rates remained low and comparable among groups (p=.72), with no reported antiseptic-related complications.

CONCLUSION

This study confirms that bacterial contamination remains high despite standard preoperative disinfection in lumbar fusion surgery. Among the tested antiseptic solutions, CHG demonstrated superior efficacy in reducing bacterial residues, particularly on implant surfaces. These findings support CHG as a promising antiseptic for intraoperative irrigation in spine surgery. Further multi-center studies are needed to validate its impact on reducing SSIs and improving long-term outcomes.

LEVEL OF EVIDENCE

Level II.

Imidazolium salt as potent Amoebicide for rapid inactivation of Acanthamoeba spp. trophozoites and cysts

Acanthamoeba spp. are amphizoic protozoa capable of causing several severe diseases in humans and other animals, including granulomatous amoebic encephalitis and Acanthamoeba keratitis (AK). The high resistance of Acanthamoeba genus, especially in its cystic form, to most conventional disinfectants poses a challenge for its management through aseptic practices based on chemical disinfectants. The imidazolium salt (IS) (C16MImCl) demonstrated significant acanthamoebicidal potency against both trophozoites and cysts. However, its biocidal efficacy over a short exposure time, which will shed light on its potential use as a disinfectant, still needs to be studied. Therefore, the acanthamoebicidal effect of IS against trophozoites and cysts of Acanthamoeba polyphaga and Acanthamoeba spp. exposed for 5 and 20 min to concentrations of 250, 125, 62.5, 31.25, 15.62, and 7.81 μg/mL was evaluated in the present study. Exposure of trophozoites of both strains to IS for 20 min significantly reduced trophozoite viability at concentrations ≥62.5 μg/mL. All trophozoites of both strains were inactived 20 min after cessation of IS exposure at concentrations of ≥125 μg/mL for 5 min or ≥15 μg/mL for 20 min. Cyst viability of all strains was significantly reduced after 20 min of exposure to IS at 62.5 and 125 μg/mL, based on the viability exclusion assay with trypan blue dye. However, all cysts exposed to IS at ≥ 125 μg/mL for 20 or 5 min were unable to excyst when incubated for 10 days on non-nutrient agar with Escherichia coli. The acanthamoebicidal efficacy of IS, upon short exposure to concentrations below the cytotoxic value for human keratinocyte cells (IC50 = 171.50 μg/mL), combined with its previously reported bactericidal and fungicidal effects, suggests that IS has the potential to be used in the formulation of multipurpose disinfectants.

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.

RESULTS

The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

Surgical site antiseptic preparations for otolaryngology - Head and neck surgery: A current review

OBJECTIVE

To review current literature and guidelines on antiseptic surgical site preparations for preventing surgical site infections with consideration of contraindications specific to head and neck surgery.

DATA SOURCES

PubMed/MEDLINE, clinicaltrials.gov, accessdata.fda.gov, Manufacturer websites.

REVIEW METHODS

A scoping review on the literature and clinical studies comparing the efficacy of different surgical site preparations. Studies were included if they were a randomized controlled trial (RCT) comparing at least two commonly used and available antiseptic preparations. Additionally, a compilation of warnings and contraindications from manufacturer labels and articles are included. Due to the lack of randomized controlled trials concerning antiseptic preparation use in head and neck surgery specifically, an additional search was executed for articles not limited to randomized controlled trials that compared different antiseptic preparation used in surgeries concerning the head and neck.

RESULTS

Of 56,983 resulting abstracts and 3798 of them being screened, 25 RCTs were included. These RCTs included a variety of surgeries including gastrointestinal, obstetric, gynecologic, orthopedic, and vascular procedures. When searching for abstracts concerning head and neck surgeries, 9 studies were found and included.

CONCLUSIONS

To reduce surgical site infections and avoid application in situations with contraindications, practicing surgeons need to be familiar with the existing literature regarding different surgical preparations and what warnings manufacturers have listed on the products. Optimal surgical site preparation for head and neck surgery is challenging as proximity to oxygen contraindicates newer alcohol-based options that are potentially flammable. We summarize evidence-based surgical site preparation for head and neck surgery.

Aseptic meningitis following spinal anaesthesia: An uncommon and challenging diagnosis

Drug-induced aseptic meningitis (DIAM) or chemical meningitis following spinal anaesthesia has rarely been reported. DIAM is caused by meningeal inflammation due to intrathecally administered drugs or secondary to systemic immunological hypersensitivity. We hereby present a case of a young adult with aseptic meningitis following neuraxial anaesthesia possibly provoked by bupivacaine. The initial cerebrospinal fluid (CSF) picture revealed neutrophilic pleocytosis and normal glycorrhachia. CSF culture was negative. The patient was put on invasive mechanical ventilation and started on intravenous antibiotics. There was a rapid improvement in clinical condition without any residual neurological deficit within the next few days. Aseptic meningitis following neuraxial anaesthesia can be prevented by strict aseptic protocols and careful inspection of visible impurities while administering the intrathecal drug. Detailed history taking, clinical examination, and focused investigations can distinguish between bacterial and chemical meningitis. Appropriate diagnosis of this entity may guide the treatment regimen, reducing hospital stay and cost.

Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients

Introduction

Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months.

Methods

An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart.

Results

Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001).

Conclusion

This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

Review, analysis, and education of antiseptic related ocular injury in the surgical settings

Preoperative skin antiseptic preparation is the gold standard for prevention of surgical infection. However, improper use of antiseptics may lead to severe ocular damage. Currently, the most common surgical antiseptics can be divided into aqueous-based and alcohol-based disinfectants, with chlorhexidine and iodine/iodophors being the two major components. Chlorhexidine has a persistent antimicrobial effect and is resistant to neutralization by blood or organic products in surgical wounds. Nevertheless, due to its toxicity to the ears, meninges, and eyes, application of chlorhexidine should be prohibited in these surgical fields. Iodine/iodophor is better tolerated by the ocular surface and is the recommended antiseptic for ophthalmic or head and neck surgeries close to the periocular area. Alcohol is less pricey and has a rapid antiseptic effect, though its desiccating effect and flammability restrict the use in mucosal or laser surgeries. The single or combined use of these antiseptics may inadvertently induce severe ocular damage, especially during time-consuming head and neck surgeries with prone, hyperextension, or lateral tilt positions, or surgeries under general anesthesia. Apart from the choice of antiseptics, appropriate selection and attachment of bio-occlusive dressings are key to avoiding antiseptic-related ocular injuries. In this review, we provided a comprehensive summary of the characteristics of antiseptics used in surgical settings and the possible mechanisms and outcomes of antiseptic-related ocular injuries. The prevention, diagnosis, and acute management of these complications were also discussed.

Spinal anesthesia in a patient on monoclonal antibody treatment: a poisoned chalice? A case report

BACKGROUND

Paraplegia is a rare complication of spinal anesthesia.

CASE PRESENTATION

We report a case of a 68-year-old man who developed postoperative paraplegia and hypoesthesia after spinal anesthesia for an otherwise uncomplicated transurethral resection of the prostate. Acute transverse myelitis was diagnosed based on urgent MRI. A prior history of similar though less severe neurological symptoms after obinutuzumab treatment for follicular lymphoma suggested a potential causative role for obinutuzumab, a novel monoclonal antibody that has not been associated with such devastating neurological side effects yet. High-dose steroid treatment partially attenuated the symptoms, but debilitating hypoesthesia and motor deficit remained present 3 months postoperatively.

CONCLUSION

The presented case warrants caution when performing neuraxial anesthesia in patients on monoclonal antibody therapies.

Alcohol (70%) versus alcoholic chlorhexidine solution (0.5%) in skin antisepsis for neuraxial blocks: a randomized clinical trial

OBJECTIVE

to compare the use of 0.5% alcoholic chlorhexidine and 70% alcohol in skin antisepsis for neuraxial blocks.

METHOD

this is a non-inferiority randomized clinical trial, with two parallel arms. Seventy patients who were candidates for neuraxial block were randomly allocated to group A (n = 35), in whom antisepsis was performed with 0.5% alcoholic chlorhexidine, or to group B (n = 35), in whom we used 70% hydrated ethyl alcohol. Swabs were harvested for culture at three times: before antisepsis, two minutes after application of the antiseptic, and immediately after puncture. The samples were sown in three culture media and the number of colony forming units (CFU) per cm² was counted.

RESULTS

there was no difference between the groups regarding age, sex, body mass index, time to perform the block or type of block. There were no differences between groups in the CFU/cm² counts before antisepsis. There was less bacterial growth in group B two minutes after application of the antiseptic (p = 0.048), but there was no difference between the groups regarding the number of CFU/cm² at the end of the puncture.

CONCLUSION

70% alcohol was more effective in reducing the number of CFU/cm² after two minutes, and there was no difference between the two groups regarding skin colonization at the end of the procedure. These results suggest that 70% alcohol may be an option for skin antisepsis before neuraxial blocks. Trial registration: ClinicalTrials.gov, NCT02833376.

Chlorhexidine Gluconate Bathing Reduces the Incidence of Bloodstream Infections in Adults Undergoing Inpatient Hematopoietic Cell Transplantation

Bloodstream infections (BSIs) occur in 20% to 45% of inpatient autologous and allogeneic hematopoietic cell transplant (HCT) patients. Daily bathing with the antiseptic chlorhexidine gluconate (CHG) has been shown to reduce the incidence of BSIs in critically ill patients, although very few studies include HCT patients or have evaluated the impact of compliance on effectiveness. We conducted a prospective cohort study with historical controls to assess the impact of CHG bathing on the rate of BSIs and gut microbiota composition among adults undergoing inpatient HCT at the Duke University Medical Center. We present 1 year of data without CHG bathing (2016) and 2 years of data when CHG was used on the HCT unit (2017 and 2018). Because not all patients adhered to CHG, patients were grouped into four categories by rate of daily CHG usage: high (>75%), medium (50% to 75%), low (1% to 49%), and none (0%). Among 192 patients, univariate trend analysis demonstrated that increased CHG usage was associated with decreased incidence of clinically significant BSI, defined as any BSI requiring treatment by the medical team (high, 8% BSI; medium, 15.2%; low, 15.6%; no CHG, 30.3%; P = .003), laboratory-confirmed BSI (LCBI; P = .03), central line-associated BSI (P = .04), and mucosal barrier injury LCBI (MBI-LCBI; P = .002). Multivariate analysis confirmed a significant effect of CHG bathing on clinically significant BSI (P = .023) and MBI-LCBI (P = .007), without consistently impacting gut microbial diversity. Benefits of CHG bathing were most pronounced with >75% daily usage, and there were no adverse effects attributable to CHG. Adherence to daily CHG bathing significantly decreases the rate of bloodstream infection following HCT.

Preoperative Antisepsis with Chlorhexidine Versus Povidone-Iodine for the Prevention of Surgical Site Infection: a Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Chlorhexidine (CH) and povidone-iodine (PI) are the most commonly used preoperative skin antiseptics at present. However, the prevention of the surgical site infection (SSI) and the incidence of skin adverse events do not reach a consistent statement and conclusion. This meta-analysis aimed to evaluate the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative surgical site infection and the incidence of corresponding skin adverse events.

METHOD

Substantial studies related to "skin antiseptic" and "surgical site infection" were consulted on PUBMED, Web of Science, EMBASE, and CNKI. The primary outcome was the incidence of postoperative SSI. The secondary outcome was associated with skin adverse events. All data were analyzed with Revman 5.3 software.

RESULTS

A total of 30 studies were included, including 29,006 participants. This study revealed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.55-0.77; p < 0.00001, I² = 57%). Further subgroup analysis showed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI in clean surgery (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.67-0.98; p = 0.03), I² = 28%) and clean-contaminated surgery (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.47-0.73; p < 0.00001, I² = 43%). However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

CONCLUSION

Chlorhexidine was superior to povidone-iodine in preventing postoperative SSI, especially for the clean-contaminated surgery. However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

Chlorhexidine locking device for central line infection prevention in ICU patients: protocol for an open-label pilot and feasibility randomized controlled trial

Background

Critically ill patients in the intensive care unit (ICU) are at risk for central line-associated bloodstream infection (CLABSI) with an incidence up to 6.9 per 1000 catheter days. CLABSI has a significant attributable mortality and increases in-hospital length of stay, readmissions, and costs. Chlorhexidine gluconate (CHG), a broad-spectrum biocide, has been shown to effectively reduce infections including CLABSI; however, few trials have utilized CHG for prevention of central line infections. Our preclinical work has demonstrated a device that diffuses CHG into the intravenous lock solution of central venous catheters and decreases bacterial growth on the catheter lumen. We designed a clinical trial to test the feasibility of using a CHG device in an ICU patient population.

Methods

The proposed pilot trial will be a single centre, open-label, two-arm, parallel group feasibility randomized controlled trial (RCT). Participants will have a central line in situ and will be enrolled within 72 h of admittance to 3 ICUs at a single academic hospital. Exclusion criteria will include suspected infection, chronic indwelling catheters, and CHG allergy. Informed consent will be obtained from eligible participants or their substitute decision maker prior to randomization. Participants will be randomized to receive either usual care or the CHG locking device. Blood cultures will be drawn from all participants every 48 h. The primary objective of this study will be to determine the feasibility of using this protocol to conduct a larger trial. Feasibility will be assessed through the following outcomes: (1) consent rate, (2) recruitment rate, (3) protocol adherence, and (4) comfort level with the device. The secondary objective of this study will be to establish the preliminary efficacy of the device.

Discussion

This study will be the first human RCT to investigate a CHG locking device for the prevention of central line infections. Findings from this trial will inform the feasibility of conducting a large RCT and provide preliminary data on the efficacy of a CHG locking device.

Trial registration

ClinicalTrials.gov, NCT03309137, registered on October 13, 2017.

Calgary Shunt Protocol, an adaptation of the Hydrocephalus Clinical Research Network shunt protocol, reduces shunt infections in children

OBJECTIVE

The shunt protocol developed by the Hydrocephalus Clinical Research Network (HCRN) was shown to significantly reduce shunt infections in children. However, its effectiveness had not been validated in a non-HCRN, small- to medium-volume pediatric neurosurgery center. The present study evaluated whether the 9-step Calgary Shunt Protocol, closely adapted from the HCRN shunt protocol, reduced shunt infections in children.

METHODS

The Calgary Shunt Protocol was prospectively applied at Alberta Children's Hospital from May 23, 2013, to all children undergoing any shunt procedure. The control cohort consisted of children undergoing shunt surgery between January 1, 2009, and the implementation of the Calgary Shunt Protocol. The primary outcome was the strict HCRN definition of shunt infection. Univariate analyses of the protocol, individual elements within, and known confounders were performed using Student t-test for measured variables and chi-square tests for categorical variables. Multivariable logistic regression was performed using stepwise analysis.

RESULTS

Two-hundred sixty-eight shunt procedures were performed. The median age of patients was 14 months (IQR 3-61), and 148 (55.2%) were male. There was a significant absolute risk reduction of 10.0% (95% CI 3.9%-15.9%) in shunt infections (12.7% vs 2.7%, p = 0.004) after implementation of the Calgary Shunt Protocol. In univariate analyses, chlorhexidine was associated with fewer shunt infections than iodine-based skin preparation solution (4.1% vs 12.3%, p = 0.02). Waiting ≥ 20 minutes between receiving preoperative antibiotics and skin incision was also associated with a reduction in shunt infection (4.5% vs 14.2%, p = 0.007). In the multivariable analysis, only the overall protocol independently reduced shunt infections (OR 0.19 [95% CI 0.06-0.67], p = 0.009), while age, etiology, procedure type, ventricular catheter type, skin preparation solution, and time from preoperative antibiotics to skin incision were not significant.

CONCLUSIONS

This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small- to medium-volume pediatric neurosurgery setting. Implementation of the Calgary Shunt Protocol independently reduced shunt infection risk. Chlorhexidine skin preparation and waiting ≥ 20 minutes between administration of preoperative antibiotic and skin incision may have contributed to the protocol's quality improvement success.

Does Wound Irrigation with Clorhexidine Gluconate Reduce the Surgical Site Infection Rate in Closure of Temporary Loop Ileostomy? A Prospective Clinical Study

BACKGROUND

The aim of this study was to investigate the effect of irrigating the surgical site with 0.05% chlorhexidine gluconate (CHG) on surgical site infection (SSI) in temporary loop ileostomy closure.

METHODS

In this observational cohort, patients who underwent diverting loop ileostomy and elective ileostomy closure for any reason between September 2014 and July 2016 were enrolled. Irrigation of the surgical site with 0.05% CHG or saline were compared regarding post-operative incision complications. Infection risk was estimated by the National Nosocomial Infection Surveillance System (NNIS) and Study of the Effect of Nosocomial Infection Control (SENIC) scores. Post-operative follow-up was performed by a surgeon blinded to the treatment. Diagnosis of SSI was recorded according to the Guidelines for Prevention of Surgical Site Infection. Wound healing was evaluated by the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS) score.

RESULTS

There were 122 patients meeting the inclusion criteria: 60 in the saline (control) and 62 in the CHG (study) group. The mean age was 56.5 ± 13.5 (standard deviation [SD]); 74 patients were male. The groups were similar regarding age, sex, indication for ileostomy, neoadjuvant therapies, and SENIC and ASEPSIS scores. The overall SSI rate was 18%: 19 patients (31.6%) in the control group and 3 (4.8%) patients in the study group (p < 0.001). The mean ASEPSIS score was higher in the control group (12.8 ± 17.7) than in the study group (3.7 ± 7.8) (p < 0.001). Patients in the control group had significantly higher rates of seroma (13.3% vs 1.6%; p = 0.014) and incision dehiscence (31.6% and 4.8%; p = 0.001). Time to healing was 9.9 ± 5.1 days in the control group and 7.3 ± 5.3 days in the study group (p = 0.007).

CONCLUSIONS

Irrigation of the incision with 0.05% CHG reduces the SSI rate compared with saline irrigation. There is a need for randomized and wider trials to clarify the effect and standards of incision irrigation.

Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients

OBJECTIVE The aim of this study was to determine the efficacy of 2 common preoperative surgical skin antiseptic agents, ChloraPrep and Betadine, in the reduction of postoperative surgical site infection (SSI) in spinal surgery procedures. METHODS Two preoperative surgical skin antiseptic agents-ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) and Betadine (7.5% povidone-iodine solution)-were prospectively compared across 2 consecutive time periods for all consecutive adult neurosurgical spine patients. The primary end point was the incidence of SSI. RESULTS A total of 6959 consecutive spinal surgery patients were identified from July 1, 2011, through August 31, 2015, with 4495 (64.6%) and 2464 (35.4%) patients treated at facilities 1 and 2, respectively. Sixty-nine (0.992%) SSIs were observed. There was no significant difference in the incidence of infection between patients prepared with Betadine (33 [1.036%] of 3185) and those prepared with ChloraPrep (36 [0.954%] of 3774; p = 0.728). Neither was there a significant difference in the incidence of infection in the patients treated at facility 1 (52 [1.157%] of 4495) versus facility 2 (17 [0.690%] of 2464; p = 0.06). Among the patients with SSI, the most common indication was degenerative disease (48 [69.6%] of 69). Fifty-one (74%) patients with SSI had undergone instrumented fusions in the index operation, and 38 (55%) patients with SSI had undergone revision surgeries. The incidence of SSI for minimally invasive and open surgery was 0.226% (2 of 885 cases) and 1.103% (67 of 6074 cases), respectively. CONCLUSIONS The choice of either ChloraPrep or Betadine for preoperative skin antisepsis in spinal surgery had no significant impact on the incidence of postoperative SSI.

Risk assessment of morbidly obese parturient in cesarean section delivery: A prospective, cohort, single-center study

BACKGROUND

Up to 40% of women gain excessive weight during pregnancy. Obesity complications and risks in parturient women undergoing cesarean section (CS) with different anesthetic methods remain unknown. This study aimed to assess the safety and risk of obese women undergoing CS delivery with various perioperative anesthetic methods.

METHODS

Seven hundred ninety parturient women underwent CS under general anesthesia (GA), intraspinal anesthesia including epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA). They were divided into morbid (n = 255), severe (n = 274), and non-obesity (n = 261) groups. This study is registered with ClinicalTrials.gov (number NCT03002636).

RESULT

Between 2013 and 2016, 790 pregnant were assessed. Compared with the non-obesity group, there were significantly more fetal distress and higher body mass index (BMI) in the morbid obesity group (P = .0001 and P = .001, respectively). Significantly more patients showed preeclampsia, multifetation, amniotic fluid abnormality, and high bleeding amounts in the morbid obesity group compared with the non-obesity group (P = .0001, P = .048, P = .017, and P = .018, respectively); more patients were administered EA and GA compared with the non-obesity group (P = .0001 and P = .0001, respectively). More post-anesthesia care unit (PACU) patients were found in the severe obesity group no more than the non-obesity group. Significantly increased anesthesia puncture times for 5 > n ≥ 3 and n ≥ 5 were obtained in the morbid obesity group (P = .0001 and P = .0001, respectively), with more patients in the puncture sitting position, compared with the non-obesity group (P = .0001).

CONCLUSION

GA, EA, and CSEA are safe and effective in severely or morbidly obese patients. Morbidly obese parturient show increased likelihood for fetal distress, PACU, sitting position puncture, puncture difficulty, and other pregnancy complications. There were more anesthesia puncture times in morbidly obese patients.

The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management

INTRODUCTION

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique.

METHODS

The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations.

RESULTS

The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices.

CONCLUSION

Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Spinal anaesthesia in outpatient and conventional surgery: A point of view from experienced French anaesthetists

INTRODUCTION

The objective of this investigation was to evaluate the practice of spinal anaesthesia among French anaesthetists in inpatient and outpatient settings.

METHODS AND MATERIALS

A questionnaire was sent to members of the French Association of Anaesthetists involved in regional anaesthesia during the first 4months of 2015. The questionnaire included items on the practice of spinal anaesthesia (type of needle, local anaesthetic available, puncture and disinfection techniques, etc.) and on the anaesthetic techniques usually used in 5 surgical situations eligible for outpatient surgery (knee arthroscopy, inguinal hernia, transobturator tape, haemorrhoids, varicose veins in the lower limbs).

RESULTS

Responses from 703 anaesthesiologists were analysed. Spinal anaesthesia was usually performed in a sitting position (76%) using a Whitacre needle (60%) with a 25 G (57%) diameter. Ultrasound before puncture was reported in 26% of cases due to obesity or spinal abnormalities. Among the 5 surgical situations eligible for outpatient spinal anaesthesia, the technique was typically proposed in 29-49% of cases. Bupivacaine was the most used local anaesthetic. Concerns over delays in attaining readiness for hospital discharge, urine retention, operation length, and surgeon's preference were the main reasons for choosing another anaesthetic technique in these situations.

DISCUSSION

New local anaesthetics are beginning to be used for outpatient spinal anaesthesia due to their interesting pharmacodynamic profile in this context. This study will provide a basis for evaluating future changes in practice.

Spinal anesthesia revisited: toxicity of new and old drugs and compounds

PURPOSE OF REVIEW

Neural toxicity of substances injected into the intrathecal space has been a matter of debate since the introduction of spinal anesthesia in clinical practice. In recent years, new local anesthetics and adjuvants have been proposed for intrathecal use, and new techniques such as the use of ultrasound have been propagated. The present review summarizes recent clinical and experimental data on the neurotoxic effects of drugs and substances used for or in conjunction with spinal anesthesia.

RECENT FINDINGS

Chloroprocaine has been demonstrated to be associated with a lower risk of transient neurologic symptoms compared with lidocaine. However, despite extensive research, the issue of chloroprocaine or bisulfite neurotoxicity has not yet been resolved.Recent experimental data have identified a smaller neurotoxic potential for ropivacaine compared to levobupivacaine, procaine and bupivacaine. The addition of epinephrine has not been shown to increase lidocaine neurotoxicity. In-vivo experimental data suggest that lidocaine and bupivacaine neurotoxicity is not enhanced in diabetic patients.Furthermore, intrathecal introduction of aqueous ultrasound gel has been demonstrated to cause a distinct neuroinflammatory reaction. Finally, a large cohort study did not find the use of chlorhexidine gluconate for skin disinfection before neuraxial block to be associated with the risk of adhesive arachnoiditis.

SUMMARY

Clinical data suggest a high safety profile for intrathecal drugs and substances used for or in conjunction with spinal anesthesia. Recent experimental models for toxicity have provided further insight into the mechanisms and demonstrated possible, albeit clinically small differences in the relative neurotoxic potential of intrathecal drugs. This may contribute to a further increase in the safe use of spinal anesthesia in the clinical setting.

Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections

Background:

Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections.

Methods:

A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process.

Results:

Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration.

Conclusion:

Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Disinfection Agents and Antiseptics

Germicidal agents are nonspecific antimicrobial agents that are too toxic to be administered internally but are safe and effective when used topically. When applied to living tissue (e.g., the skin), they are termed antiseptics. When applied to inanimate objects (e.g., environmental surfaces or instruments used to perform medical procedures), they are termed disinfectants. All of these agents work at least by damaging microbial surfaces, often by alkylation, oxidation, or reaction with proteins. Products capable of destroying all forms of microbial life, including bacterial spores, are termed sterilizing agents.

Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit?

Chlorhexidine gluconate (CHG) has been available as a topical antiseptic for over 50 years, having broad clinical application throughout the health care environment. Evidence-based clinical studies have shown chlorhexidine gluconate to be a safe and effective perioperative skin-prepping agent. Renewed interest has emerged for use of the antiseptic bath/shower to reduce the microbial skin burden prior to hospital admission. Recent clinical studies have documented that multiple applications of 2% or 4% CHG using a standardized protocol results in high skin surface concentrations sufficient to inhibit/kill skin colonizing flora, including methicillin-resistant Staphylococcus aureus. A new focus for the use of CHG in surgical patients involves irrigation of the wound prior to closure with 0.05% CHG followed by saline rinse. Recent laboratory studies suggest that, following a 1-minute exposure, 0.05% CHG produces a >5-log reduction against selective health care-associated pathogens and reduces microbial adherence to the surface of implantable biomedical devices. General, orthopedic, cardiothoracic, and obstetrical surgical studies have documented the safety of selective CHG formulations in elective surgical procedures. The following discussion will address both the evidence-based literature and preliminary findings suggesting that CHG has a broad and safe range of applications when used as an adjunctive interventional strategy for reducing the risk of postoperative surgical site infections (SSI).

[Infection prevention by the anesthesia team]

The anesthesia team acts every day in a highly complex and high risk environment for the transmission of pathogenic organisms and the induction of infectious complications. With strict adherence to standard precautions and infection control practices in particular regular hand disinfection before and after direct patient contact and before performance of aseptic tasks during anesthesia and an optimized perioperative process the members of the anesthesia team can become infection control pioneers within the hospital. In order to be successful, structural and organizational resources in the form of training, personnel, materials and time, need to be adequate for the situation. This review summarizes the infection control recommendations for anesthesia practice based on the most recent literature and guidelines and offers practical advice for commonly observed mistakes.