Anaesthesia 2015, 70, 361–372
Recommending AAGBI antisepsis guidance to other medical professionals Recent guidelines on skin antisepsis for central neuraxial blockade are timely for practising anaesthetists [1], having been widely discussed in the literature following the devastating consequences suffered by previously fit, healthy individuals in three highly publicised cases [2–4]. We recently asked 19 neurosurgeons, neuroanaesthetists and neurologists at a tertiary referral neurosurgical centre about their practice in relation to skin preparation before lumbar puncture and lumbar drain insertion. Five (26%) were unsure of the concentration of chlorhexidine they used, and 12 (63%) used a 2% solution rather than the recommended 0.5% solution. Nine (47%) admitted to unsafe practice by pouring the chlorhexidine solution into a receptacle next to insertion equipment. Surgeons and physicians performing procedures in close proximity to neural tissue must be made aware of the AAGBI’s recommendations for antisepsis, and we urge anaesthetists to take the lead in disseminating this guidance among these professions. M. Dransfield A. Richardson N. Robinson Northwick Park Hospital, Northwick Park, UK Email: m.dransfi[email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corres366
Correspondence
pondence website: www.anaesthesiacorrespondence.com.
References 1. Association of Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279– 86. 2. Sutcliffe v Aintree Hospitals NHS Trust [2008]. EWCA Civ 179. 3. Killeen T, Kamat A, Walsh D, Parker A, Aliashkevich A. Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. 4. Bogod D. The sting in the tail: antisepsis and the neuraxis revisited. Anaesthesia 2012; 67: 1305–9. doi:10.1111/anae.13010
Skin antisepsis guidelines – time to rethink the ‘rapid sequence spinal’? We read with great interest the new guideline for central neuraxial blockade (CNB) [1], which provides much needed clarification about skin antisepsis. We feel this guideline reignites the debate over the safety of the ‘rapid sequence spinal’ for category-1 caesarean sections. The rapid sequence spinal involves measures aimed at reducing the time to establish spinal anaesthesia in urgent obstetric cases [2]. Our institution has implemented the rapid sequence spinal to reduce general anaesthesia rates for category-1 caesarean sections. However, a number of the AAGBI antisepsis guideline recommendations differ from some of components of the rapid sequence spinal, which has made us question the safety of this technique. The new guideline recommends optimum sterile technique before
CNB, including thorough handwashing with surgical scrub solution and the wearing of a cap, mask, sterile gown and gloves. The rapid sequence spinal technique recommends a no-touch technique with only sterile gloves for barrier precautions. The NAP3 project identified rare but potentially devastating complications of CNB such as epidural abscess and meningitis, in which poor aseptic technique was indicated [3]. Case reports have supported operator oropharyngeal commensals as the source for bacterial meningitis after spinal anaesthetic [4]; however, the use of surgical masks eliminates this infective source [5]. We understand the time-critical nature of a category-1 caesarean section, but argue that carrying out CNB without full aseptic precautions, as with the rapid sequence spinal, goes against national guidelines, increases the risk of a known serious complication, and therefore could be seen as substandard. Secondly, there is an issue with skin preparation. The antisepsis guideline states that the anaesthetist must take measures to ensure that chlorhexidine does not reach the cerebrospinal fluid (CSF). The original rapid sequence spinal paper recommended a single wipe of 0.5% chlorhexidine. Our institution changed this to one spray of 0.5% chlorhexidine in alcohol. However, the devastating consequences of chronic adhesive arachnoiditis in recent, well publicised case reports [6] highlights the importance of allowing the chlorhexidine to dry before the skin is punctured, to ensure none reaches the CSF. We
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
are concerned that in the stressful, time-critical environment during a category-1 caesarean section, the anaesthetist may perform spinal anaesthesia before the chlorhexidine has completely dried, increasing the risk of rare but devastating complications. We would therefore recommend a single spray of 0.5% chlorhexidine, which is allowed to dry while the anaesthetist gowns with full barrier precautions and prepares the equipment. Although we understand the concept and theory of the rapid sequence spinal for category-1 caesarean sections, the publication of this AAGBI antisepsis guideline and recent devastating case reports highlight the importance of a thorough and safe skin antisepsis regimen before CNB. We feel that if the extra time required for full barrier precautions and drying of antiseptic solution is not appropriate due to the urgency of the caesarean section, general anaesthesia should be considered first. B. Parsons S. Saha Barnet Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References 1. Association of Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade 2014. Anaesthesia 2014; 69: 1279–86.
Anaesthesia 2015, 70, 361–372 2. Scrutton M, Kinsella SM. The immediate caesarean section: rapid-sequence spinal and risk of infection. International Journal of Obstetric Anesthesia 2003; 12: 143–4. 3. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit of The Royal College of Anaesthetists. British Journal of Anaesthesia 2009; 102: 179–90. 4. Schneeberger PM, Janssen M, Voss A. Alpha-haemolytic streptococci: a major pathogen of iatrogenic meningitis following lumbar puncture. Case reports and a review of the literature. Infection 1996; 24: 29–33. 5. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JAW. Surgical facemasks are effective in reducing bacterial contamination caused by dispersal from the upper airway. British Journal of Anaesthesia 1992; 62: 407–8. 6. Killeen T, Kumat A, Walsh D, Parker A, Aliashkevich A. Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. doi:10.1111/anae.13025
Skin antisepsis guidelines – presentation or concentration? We were interested to read the recent AAGBI guidelines on skin antisepsis for central neuraxial blockade [1]. We note the concerns surrounding the use of chlorhexidine in 70% alcohol and its potential to cause adhesive arachnoiditis if injected or allowed to contaminate anything injected into the spinal canal. The letter in response to the recommendation to use 0.5% chlorhexidine in 70% alcohol from West and Pawa appeared sensible and balanced [2]: skin antisepsis using a swabstick to apply chlorhexidine in alcohol prevents the solution being injected, so long as it is allowed to dry completely. The only
© 2015 The Association of Anaesthetists of Great Britain and Ireland
formulation currently available as a swabstick is 2% chorhexidine in 70% alcohol. Therefore, whilst a lower concentration of chlorhexidine may reduce the risk of neurotoxicity, it is not available in the safest form of applicator, and is not likely to be released in that form in the forseeable future. We welcome a full and open discussion about this topic, which affects not just all anaesthetists but anyone that performs neurosurgery, lumbar punctures or spinal drain insertions. We suggest that there are certain core principles that are not in dispute: 1) The technique of skin disinfection must avoid any possibility of chlorhexidine in alcohol’s contaminating any fluid that is injected into the spinal canal; 2) The safest current method of applying skin antisepsis is to use a swabstick that can be disposed of immediately after use. This avoids the risk of antiseptic solutions’ being injected, splashed or aerosolised and contaminating the sterile procedure trolley; 3) The lowest concentration of chlorhexidine that achieves the maximal degree of skin disinfection should be employed, provided that it is available in a swabstick; 4) The antiseptic solution applied must be allowed to dry completely and the gloves used for its application changed to a new, dry, sterile pair before the procedure trolley is accessed; 367
Recommending AAGBI antisepsis guidance to other medical professionals Recent guidelines on skin antisepsis for central neuraxial blockade are timely for practising anaesthetists [1], having been widely discussed in the literature following the devastating consequences suffered by previously fit, healthy individuals in three highly publicised cases [2–4]. We recently asked 19 neurosurgeons, neuroanaesthetists and neurologists at a tertiary referral neurosurgical centre about their practice in relation to skin preparation before lumbar puncture and lumbar drain insertion. Five (26%) were unsure of the concentration of chlorhexidine they used, and 12 (63%) used a 2% solution rather than the recommended 0.5% solution. Nine (47%) admitted to unsafe practice by pouring the chlorhexidine solution into a receptacle next to insertion equipment. Surgeons and physicians performing procedures in close proximity to neural tissue must be made aware of the AAGBI’s recommendations for antisepsis, and we urge anaesthetists to take the lead in disseminating this guidance among these professions. M. Dransfield A. Richardson N. Robinson Northwick Park Hospital, Northwick Park, UK Email: m.dransfi[email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corres366
Correspondence
pondence website: www.anaesthesiacorrespondence.com.
References 1. Association of Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279– 86. 2. Sutcliffe v Aintree Hospitals NHS Trust [2008]. EWCA Civ 179. 3. Killeen T, Kamat A, Walsh D, Parker A, Aliashkevich A. Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. 4. Bogod D. The sting in the tail: antisepsis and the neuraxis revisited. Anaesthesia 2012; 67: 1305–9. doi:10.1111/anae.13010
Skin antisepsis guidelines – time to rethink the ‘rapid sequence spinal’? We read with great interest the new guideline for central neuraxial blockade (CNB) [1], which provides much needed clarification about skin antisepsis. We feel this guideline reignites the debate over the safety of the ‘rapid sequence spinal’ for category-1 caesarean sections. The rapid sequence spinal involves measures aimed at reducing the time to establish spinal anaesthesia in urgent obstetric cases [2]. Our institution has implemented the rapid sequence spinal to reduce general anaesthesia rates for category-1 caesarean sections. However, a number of the AAGBI antisepsis guideline recommendations differ from some of components of the rapid sequence spinal, which has made us question the safety of this technique. The new guideline recommends optimum sterile technique before
CNB, including thorough handwashing with surgical scrub solution and the wearing of a cap, mask, sterile gown and gloves. The rapid sequence spinal technique recommends a no-touch technique with only sterile gloves for barrier precautions. The NAP3 project identified rare but potentially devastating complications of CNB such as epidural abscess and meningitis, in which poor aseptic technique was indicated [3]. Case reports have supported operator oropharyngeal commensals as the source for bacterial meningitis after spinal anaesthetic [4]; however, the use of surgical masks eliminates this infective source [5]. We understand the time-critical nature of a category-1 caesarean section, but argue that carrying out CNB without full aseptic precautions, as with the rapid sequence spinal, goes against national guidelines, increases the risk of a known serious complication, and therefore could be seen as substandard. Secondly, there is an issue with skin preparation. The antisepsis guideline states that the anaesthetist must take measures to ensure that chlorhexidine does not reach the cerebrospinal fluid (CSF). The original rapid sequence spinal paper recommended a single wipe of 0.5% chlorhexidine. Our institution changed this to one spray of 0.5% chlorhexidine in alcohol. However, the devastating consequences of chronic adhesive arachnoiditis in recent, well publicised case reports [6] highlights the importance of allowing the chlorhexidine to dry before the skin is punctured, to ensure none reaches the CSF. We
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
are concerned that in the stressful, time-critical environment during a category-1 caesarean section, the anaesthetist may perform spinal anaesthesia before the chlorhexidine has completely dried, increasing the risk of rare but devastating complications. We would therefore recommend a single spray of 0.5% chlorhexidine, which is allowed to dry while the anaesthetist gowns with full barrier precautions and prepares the equipment. Although we understand the concept and theory of the rapid sequence spinal for category-1 caesarean sections, the publication of this AAGBI antisepsis guideline and recent devastating case reports highlight the importance of a thorough and safe skin antisepsis regimen before CNB. We feel that if the extra time required for full barrier precautions and drying of antiseptic solution is not appropriate due to the urgency of the caesarean section, general anaesthesia should be considered first. B. Parsons S. Saha Barnet Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References 1. Association of Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade 2014. Anaesthesia 2014; 69: 1279–86.
Anaesthesia 2015, 70, 361–372 2. Scrutton M, Kinsella SM. The immediate caesarean section: rapid-sequence spinal and risk of infection. International Journal of Obstetric Anesthesia 2003; 12: 143–4. 3. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit of The Royal College of Anaesthetists. British Journal of Anaesthesia 2009; 102: 179–90. 4. Schneeberger PM, Janssen M, Voss A. Alpha-haemolytic streptococci: a major pathogen of iatrogenic meningitis following lumbar puncture. Case reports and a review of the literature. Infection 1996; 24: 29–33. 5. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JAW. Surgical facemasks are effective in reducing bacterial contamination caused by dispersal from the upper airway. British Journal of Anaesthesia 1992; 62: 407–8. 6. Killeen T, Kumat A, Walsh D, Parker A, Aliashkevich A. Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. doi:10.1111/anae.13025
Skin antisepsis guidelines – presentation or concentration? We were interested to read the recent AAGBI guidelines on skin antisepsis for central neuraxial blockade [1]. We note the concerns surrounding the use of chlorhexidine in 70% alcohol and its potential to cause adhesive arachnoiditis if injected or allowed to contaminate anything injected into the spinal canal. The letter in response to the recommendation to use 0.5% chlorhexidine in 70% alcohol from West and Pawa appeared sensible and balanced [2]: skin antisepsis using a swabstick to apply chlorhexidine in alcohol prevents the solution being injected, so long as it is allowed to dry completely. The only
© 2015 The Association of Anaesthetists of Great Britain and Ireland
formulation currently available as a swabstick is 2% chorhexidine in 70% alcohol. Therefore, whilst a lower concentration of chlorhexidine may reduce the risk of neurotoxicity, it is not available in the safest form of applicator, and is not likely to be released in that form in the forseeable future. We welcome a full and open discussion about this topic, which affects not just all anaesthetists but anyone that performs neurosurgery, lumbar punctures or spinal drain insertions. We suggest that there are certain core principles that are not in dispute: 1) The technique of skin disinfection must avoid any possibility of chlorhexidine in alcohol’s contaminating any fluid that is injected into the spinal canal; 2) The safest current method of applying skin antisepsis is to use a swabstick that can be disposed of immediately after use. This avoids the risk of antiseptic solutions’ being injected, splashed or aerosolised and contaminating the sterile procedure trolley; 3) The lowest concentration of chlorhexidine that achieves the maximal degree of skin disinfection should be employed, provided that it is available in a swabstick; 4) The antiseptic solution applied must be allowed to dry completely and the gloves used for its application changed to a new, dry, sterile pair before the procedure trolley is accessed; 367
