Surgical Skin Preparation

 

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Surgical skin preparation is a critical component in reducing the risk of surgical site infections (SSIs). This article reviews the essential elements of preoperative skin care, including patient cleansing, hair removal methods, and the application of antiseptic agents—particularly chlorhexidine gluconate. Evidence-based practices and guidelines underscore the importance of these procedures in ensuring optimal surgical outcomes.

Introduction

Surgical procedures carry inherent risks, one of the most serious being the development of SSIs. These infections can prolong hospital stays, increase healthcare costs, and, most importantly, jeopardize patient safety. Effective skin preparation before surgery significantly reduces the microbial load on the skin, thereby decreasing the likelihood of postoperative infections [1]. This article discusses the rationale behind surgical skin preparation and details the techniques used to optimize this process.

1. Importance of Surgical Skin Preparation

The primary goal of surgical skin preparation is to eliminate or reduce microorganisms present on the patient’s skin at the surgical site. A successful skin preparation protocol not only minimizes the risk of SSIs but also enhances overall surgical outcomes by creating a cleaner operative field [1].

2. Preoperative Patient Cleansing

Preoperative cleansing often begins before the patient even enters the operating room. Patients are typically advised to bathe or shower using an antiseptic solution—frequently containing chlorhexidine gluconate—either on the day of surgery or the night before. This step is crucial because it lowers the initial microbial burden, setting the stage for more focused antiseptic measures in the surgical suite [2].

3. Hair Removal: Clippers vs. Razors

Hair removal is another essential aspect of skin preparation. However, the method of hair removal can influence the risk of infection:

Clippers: Clippers cut the hair close to the skin without abrading it, thereby reducing the risk of microtrauma. Since microabrasions can serve as entry points for bacteria, clippers are generally recommended for preoperative hair removal [1].

Razors: In contrast, razors remove hair at skin level, which can inadvertently cause tiny cuts or abrasions. This disruption of the skin barrier increases the potential for bacterial colonization and subsequent SSIs [1].

4. The Role of Chlorhexidine Gluconate

Chlorhexidine gluconate is one of the most widely used antiseptics in surgical skin preparation. Its popularity is attributed to several key factors:

Broad-Spectrum Antimicrobial Activity: Chlorhexidine is effective against a wide range of pathogens, including gram-positive and gram-negative bacteria, and some fungi and viruses [3].

Substantivity: A unique property of chlorhexidine is its ability to bind to the skin and remain active for an extended period. This prolonged effect helps maintain a reduced microbial load even after the initial application [3].

Enhanced Efficacy with Alcohol: When combined with alcohol, chlorhexidine provides both rapid antimicrobial action and sustained protection. Alcohol works quickly to reduce microbial counts, while chlorhexidine offers a lasting residual effect, making the combination particularly effective for surgical skin preparation [3].

5. Application Techniques and Best Practices

For optimal results, antiseptic agents must be applied correctly. The recommended techniques include:

Systematic Application: Using either back-and-forth strokes or circular motions ensures even coverage of the surgical area and a margin around it.

Adequate Drying Time: Allowing the antiseptic to dry completely before draping is essential. This drying period maximizes the antimicrobial efficacy of the agent and minimizes risks—especially the fire hazard associated with alcohol-based solutions in the operating room [2].

Adherence to Guidelines: Institutions should follow evidence-based guidelines such as those issued by the Centers for Disease Control and Prevention (CDC) and the Association of periOperative Registered Nurses (AORN) to maintain high standards of care [1, 2].

Read as well: Standard Operating Procedure (SOP) for surgical site preparation. 

References

[1] Berríos-Torres, S. I., Umscheid, C. A., et al. (2017). Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery.

[2] Association of periOperative Registered Nurses. (2019). Guidelines for Surgical Attire and Preparation. AORN.

[3] Darouiche, R. O., et al. (2010). Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. New England Journal of Medicine, 362(1), 18-26.

[4] World Health Organization. (2018). Guidelines on Surgical Site Infection Prevention. WHO.