One vs two applications of chlorhexidine/ethanol for disinfecting the skin: implications for regional anaesthesia*

[Arachnoiditis following spinal anesthesia-Case report and review of the literature]

A 61-year-old woman underwent a tension-free vaginal tape (TVT) operation due to stress incontinence. After technically difficult spinal anesthesia with two attempts the patient developed symptoms of nerve irritation, complained about neckache and headache and showed signs of agitation. The regimen was shifted to general anesthesia and surgery was performed. Because of postoperatively persistent headache and sensory disturbances an MRI scan of the lumbar spine was performed on the first postoperative day without pathological findings. The patient was able to leave the hospital after 1 week with significant relief of symptoms but 3 weeks later she developed neurocognitive impairment with memory deficits. A second MRI scan of the head now showed signs of disturbance of CSF circulation with hydrocephalus. Treatment was performed with drainage and ventriculoperitoneal shunt. Further evaluation showed a severe, multisegmental arachnoiditis and the patient developed a progressive paraparesis. The patient presented her case for assessment to a commission on medical malpractice 13 months after anesthesia. The commission detected no treatment errors. In connection to the case report a literature review of characteristics and etiologies of chronic adhesive arachnoiditis is given, which is a known but very rare complication of spinal anesthesia or similar procedures.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

A survey of international antisepsis procedures for neuraxial catheterisation in labour

BACKGROUND

Neuraxial analgesia during labour is a mainstay of anaesthetic practice globally. Despite the potential for significant neurological and infectious complications, international antisepsis practices for neuraxial anaesthesia vary widely.

AIMS

The primary aim of this study was to clarify international antisepsis practices prior to neuraxial analgesia in labour. The secondary aim was to determine an approximate international incidence of neuraxial infections and neurological complications secondary to neuraxial analgesia techniques in labour.

MATERIALS AND METHODS

Heads of Departments of Anaesthesiology were invited to complete an online questionnaire exploring antisepsis practices and complications of neuraxial catheterisation. Data from 151 institutions in 13 countries were collected over 11months.

RESULTS

Data were collected for an estimated 6008540 deliveries and 3770800 neuraxial catheterisations. The average annual birth rate per institution was 3979 births, with an average of 2497 neuraxial catheterizations (representing 62.8% of deliveries). Forty-nine percent of responders reported always wearing sterile gowns for the procedure, whereas 47.7% never wear gowns. Chlorhexidine was used by 88.1% of those surveyed, and 96.7% always wore facemasks. Thirty-four percent of institutions reported infectious complications over a 10-year period. Ninety neuraxial infections were estimated, giving an approximate incidence of 1:41898 catheterisations (2.39 infections per 100000 catheterisations). A total of 202 neurological complications were reported, with an approximate incidence of 1:18667 catheterisations (5.36 neurological complications per 100000 catheterisations).

CONCLUSION

The survey demonstrated marked variation in aseptic practice between both responding centres and countries. The incidence of infectious and neurological complications secondary to neuraxial catherisation in labour has been approximated.

Chlorhexidine avoids skin bacteria recolonization more than triclosan

BACKGROUND

We do not know whether differences exist between the residual effect of 2% chlorhexidine in 70% isopropyl alcohol when compared with 1% triclosan in 70% isopropyl alcohol.

METHODS

Using an analytic, longitudinal, controlled, and comparative experimental trial, with blinded measurements, we recruited healthy, adult volunteers from the University of Guanajuato who completed a stabilization phase of skin microbiota and had no history of skin allergies. Four 25-cm² areas of the inner surface of the forearms were designated for study: unscrubbed control for establishing baseline bacterial counts, scrubbed control with tridistilled water, scrubbed with chlorhexidine, and scrubbed with triclosan. Quantitative cultures were taken of all the areas at 0, 3, and 24 hours, using agar plates with neutralizing agents.

RESULTS

A total of 135 healthy volunteers were tested. At 24 hours, the unscrubbed control counts were 288 CFU/cm², whereas the scrubbed control counts were 96 CFU/cm²; 24 CFU/cm² for chlorhexidine and 96 CFU/cm² for triclosan (Kruskal-Wallis χ²H = 64.27; P <.001).

CONCLUSIONS

Chlorhexidine is the best antiseptic option when a prolonged antiseptic effect is needed; for instance, when implanting medical devices or performing surgical procedures.

Safety guideline: skin antisepsis for central neuraxial blockade

Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade. The Working Party specifically considered the concentration of antiseptic agent to use and its method of application. The advice presented is based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents.