Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives

chlorhexidine (CHG) 4 percent, CHG washcloths 2 percent or soap. This process prevents exogenous contamination in the hospital and operating room as well as rendering their skin physically clean. Patients unable to use CHG due to a prior adverse reaction, published guidelines also rec- ommend the use of plain soap which removes bacteria, oils and debris from skin’s surface. There are some facilities using a topical immune skin health system applied head to toe after the patient bathes to maintain a healthy acidic skin pH and healthy microbiome. This topical skin cleansing system was demonstrated to be non-inferior to CHG. 17 ➍ Surgical Skin Preparation Starting with physically clean skin, the goal of surgical skin preparation is to prepare and decolonize the incision site. Today, the popular choice for skin prep agents include either an iodine or chlorhexidine (CHG)-based alcoholic solution in a sterile applicator. The benefit of alcohol in skin preparations is its rapid and broad-spectrum of antimicrobial activity. 18 Alcohol-based solutions that contain CHG or iodophors have sustained and durable antimicrobial activity that lasts long after alcohol evaporation. Because alcohol dries on exposed skin within minutes of application, these can be applied with a single step as opposed to a scrub-and-paint technique. ➎ Surgical Irrigation Surgical wound irrigation is the cornerstone in keeping the tissues moist, removing debris, and preparing the wound for closure. Unfortunately, there is no consensus on the ideal solution, volume, or even pressure one should use to deliver irrigation to the wound. 19 Depending upon the surgical procedure and the individual surgeon, the solution and additives, if any, often vary greatly. In order to comply with national guidelines, institu- tions should prepare the sterile irrigation solution in the pharmacy following USP standards or choose to use a commercially available irrigation solution. 20 Some healthcare institutions have standardized their irrigation solution choices which reduced the risk for medication errors and it saved them approximately 7 minutes per surgical procedure when the OR circulator didn’t need to mix the irrigation solution. 21 ➏ Antimicrobial-Impregnated Sutures In 2002, the Food and Drug Administration (FDA) approved the first surgical suture that was coated with an antimicrobial agent called triclosan. It is one of the most used antibacterial agents over the counter for products such as toothpaste, deodorant and antibacterial soap. Triclosan exhibits a broad-spectrum activity against both 28 Gram-negative and Gram-positive organisms. The amount of triclosan in the antimicrobial suture has been deemed a safe and effective biocide, showing insignificant tissue reactions post-operatively. 22-23 Sutures act as a foreign body and it only takes 100 colony-forming units (CFU) of bacteria colonized in tissue to contribute to an infection. There have been no published studies showing that triclosan coated sutures are associated with the development of multidrug-resistant organisms (MDRO). To date, there have been 13 published meta-analyses documenting the clinical benefits of the antimicrobial suture in preventing surgical site infections, where reductions in surgical site infections range from 20 percent to 60 percent. 24 The Centers for Disease Control and Prevention, World Health Organization and the American College of Surgeons all endorse and recommend the use of the antimicrobial sutures in their SSI prevention guidelines. 25-27 ➐ Post-operative Dressings Appropriate postoperative incision manage- ment is imperative to prevent complications, including wound dehiscence, exogenous contami- nation with body fluids and potential development of surgical site infection. Postoperative wound management are applicable to healing by primary intention, secondary intention where the wound edges cannot be brought together and tertiary intention when a wound is heavily contaminated. In tertiary intention the wound is closely watched and cleansed for several days and when it appears to be on its way to healing, it is closed surgically. When there is an injury that results in tissue loss, the wound closure is often delayed to control wound debris and necrotic tissue. Infection is frequent in certain types of injuries that almost always become infected (i.e. dog bite injuries, gun shots and avulsion injury); these are frequently closed only when infection is controlled after being left open for a period of time. 28 These factors make it a challenge to standardize skin closure and application of postoperative dressings. Staples have been shown to increase the risk of postop infection in orthopedics and caesarean incisions. 29-31 The staple punctures not only the skin, but also sebaceous glands and hair follicles, where bacteria may be present. As the patient’s skin warms up after surgery, there can be tension applied to the staples resulting in small dehiscence, allowing bacteria and body fluids to enter. An alternative to staples is a knotless barbed suture that provides strong, secure closure appro- priate for high-tension areas, such as fascia. 32-33 If sutures are used the incision can be sealed with occlusive dressings that include topical skin adhesive, a combination of a skin adhesive with a mesh dressing, 34 transparent occlusive dressing, ¡ Appropriate postoperative incision management is imperative to prevent complications, including wound dehiscence, exogenous contamination with body fluids and potential development of surgical site infection. Operating Room Imperatives 2020 • www.healthcarehygienemagazine.com

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