Brian D. Lewis

Preoperative Shower Revisited: Can High Topical Antiseptic Levels Be Achieved on the Skin Surface Before Surgical Admission?

BACKGROUND Skin asepsis is a sentinel strategy for reducing risk of surgical site infections. In this study, chlorhexidine gluconate (CHG) skin concentrations were determined after preoperative showering/skin cleansing using 4% CHG soap or 2% CHG-impregnated polyester cloth. STUDY DESIGN Subjects were randomized to one of three shower (4% soap)/skin cleansing (2% cloth) groups (n = 20 per group): (group 1 A/B) evening, (group 2 A/B) morning, or (group 3 A/B) evening and morning. After showering or skin cleansing, volunteers returned to the investigators laboratory where CHG skin surface concentrations were determined at five separate skin sites. CHG concentrations were compared with CHG minimal inhibitory concentration that inhibits 90% (MIC(90)) of staphylococcal skin isolates. RESULTS CHG MIC(90) for 61 skin isolates was 4.8 parts per million (ppm). In group 1A, 4% CHG skin concentrations ranged from 17.2 to 31.6 ppm, and CHG concentrations were 361.5 to 589.5 ppm (p < 0.0001) in group 1B (2%). In group 2A (4%), CHG levels ranged from 51.6 to 119.6 ppm and 848.1 to 1,049.6 ppm in group 2B (2%), respectively (p < 0.0001). CHG levels ranged from 101.4 to 149.4 ppm in the 4% CHG group (group 3A) compared with 1,484.6 to 2,031.3 ppm in 2% CHG cloth (group 3B) group (p < 0.0001). Effective CHG levels were not detected in the 4% CHG group in selected sites in seven (35%) subjects in group 1A, three (15%) in group 2A, and five (25%) in group 3A. CONCLUSIONS Effective CHG levels were achieved on most skin sites after using 4% CHG; gaps in antiseptic coverage were noted at selective sites even after repeated application. Use of the 2% CHG polyester cloth resulted in considerably higher skin concentrations with no gaps in antiseptic coverage. Effective decolonization of the skin before hospital admission can play an important role in reducing risk of surgical site infections.

Home support of patients with end-stage malignant bowel obstruction using hydration and venting gastrostomy

Palliative terminal care of patients with malignant bowel obstruction is a major clinical and ethical challenge. These patients are often mentally alert and ambulatory, but are kept in the hospital for hydration, nasogastric suction, and pain control. Parenteral nutrition requires frequent metabolic monitoring, is expensive, and is ethically questionable. We have used an alternative method of home management for 27 patients who met the following criteria: inoperable bowel obstruction due to untreatable cancer, an estimated life expectancy of between 2 weeks and 3 months, and understanding of the goals and limits of therapy. Hydration was provided by 10 percent dextrose and electrolyte solutions administered as overnight infusions through long-term central venous catheters. Thirteen patients with complete bowel obstruction required a venting gastrostomy which, when connected to passive drainage, relieved nausea and vomiting. The mean duration of survival was 64 days (range 9 to 223 days). Acceptance by patients and families was excellent, although most acknowledged increased costs due to limited insurance coverage for outpatient care. Seven patients returned to the hospital for terminal care (average stay 3.2 days), and 20 chose to die at home. The mean daily expense for fluids and supplies was +73.50, with an overall cost decrease of

Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients

900,000 compared with inpatient care. Home support with fluids and gastric venting is a humane, cost-effective alternative to in-hospital care for selected patients.

Computed Tomography Angiography to Evaluate Thoracic Outlet Neurovascular Compression

IMPORTANCE To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection. OBJECTIVES To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation. DESIGN, SETTING, AND PARTICIPANTS A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance. INTERVENTION Preadmission showers using chlorhexidine gluconate, 4%. MAIN OUTCOMES AND MEASURES The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing. RESULTS The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses. CONCLUSIONS AND RELEVANCE A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

The effect of Surgical Care Improvement Project measures on national trends on surgical site infections in open vascular procedures.

The objective was to evaluate the efficacy of computed tomography angiography with upper extremity hyperabduction to diagnose thoracic outlet syndrome. Over 5 years, 21 patients were treated surgically for neurogenic symptoms of thoracic outlet syndrome. For patients whose diagnosis was unclear after history and physical examination, adjunctive tests (duplex, magnetic resonance angiography, or computed tomography angiography) were performed to help establish the diagnosis. Five of the 6 computed tomography angiograms were positive. The sixth computed tomography was deemed to be an incomplete study. With mean follow-up of 9.4 months, 95% (n = 19) of patients with a positive hyperabduction test on physical examination were free of symptoms postoperatively. All patients with a positive computed tomography angiogram, with their neurovascular compression localized to the thoracic outlet, had successful operative decompression. Computed tomography angiogram with abduction of the arm can be used as an adjunct to confirm the diagnosis of neurovascular compression and then predict successful operative decompression.

Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving Patient Compliance with Preadmission Showering Protocol

OBJECTIVE The Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications, including postoperative surgical site infection (SSI), through protocol-driven antibiotic usage. This study aimed to determine the effect SCIP guidelines have had on in-hospital SSIs after open vascular procedures. METHODS The Nationwide Inpatient Sample (NIS) was retrospectively analyzed using International Classification of Diseases, Ninth Revision, diagnosis codes to capture SSIs in hospital patients who underwent elective carotid endarterectomy, elective open repair of an abdominal aortic aneurysm (AAA), and peripheral bypass. The pre-SCIP era was defined as 2000 to 2005 and post-SCIP was defined as 2007 to 2010. The year 2006 was excluded because this was the transition year in which the SCIP guidelines were implemented. Analysis of variance and χ(2) testing were used for statistical analysis. RESULTS The rate of SSI in the pre-SCIP era was 2.2% compared with 2.3% for carotid endarterectomy (P = .06). For peripheral bypass, both in the pre- and post-SCIP era, infection rates were 0.1% (P = .22). For open, elective AAA, the rate of infection in the post-SCIP era increased significantly to 1.4% from 1.0% in the pre-SCIP era (P < .001). Demographics and in-hospital mortality did not differ significantly between the groups. CONCLUSIONS Implementation of SCIP guidelines has made no significant effect on the incidence of in-hospital SSIs in open vascular operations; rather, an increase in SSI rates in open AAA repairs was observed. Patient-centered, bundled approaches to care, rather than current SCIP practices, may further decrease SSI rates in vascular patients undergoing open procedures.

Management of Carotid Stenosis in Women

BACKGROUND Surgical site infections (SSIs) are responsible for significant morbidity, mortality, and excess use of health care resources. The preadmission antiseptic shower is accepted as an effective strategy for reducing the risk for SSIs. The study analyzes the benefit of an innovative electronic patient alert system (EAS) for enhancing compliance with a preadmission showering protocol with 4% chlorhexidine gluconate (CHG). STUDY DESIGN After providing informed consent, 80 volunteers were randomized to 4 CHG showering groups. Groups A1 and A2 showered twice. Group A1 was prompted to shower via EAS. Groups B1 and B2 showered 3 times. Group B1 was prompted via EAS. Subjects in groups A2 and B2 were not prompted (non-EAS groups). Skin-surface concentrations of CHG (μg/mL) were analyzed using colorimetric assay at 5 separate anatomic sites. Study personnel were blinded to the randomization code; after final volunteer processing, the code was broken and individual groups were analyzed. RESULTS Mean composite CHG skin-surface concentrations were significantly higher (p < 0.007) in EAS groups A1 (30.9 ± 8.8 μg/mL) and B1 (29.0 ± 8.3 μg/mL) compared with non-EAS groups A2 (10.5 ± 3.9 μg/mL) and B2 (9.5 ± 3.1 μg/mL). Overall, 66% and 67% reductions in CHG skin-surface concentrations were observed in non-EAS groups A2 and B2 compared with EAS study groups. Analysis of returned (unused) CHG (mL) suggests that a wide variation in volume of biocide was used per shower in all groups. CONCLUSIONS The findings suggest that EAS was effective in enhancing patient compliance with a preadmission showering protocol, resulting in a significant (p < 0.007) increase in skin-surface concentrations of CHG compared with non-EAS controls. However, variation in amount of unused 4% CHG suggests that rigorous standardization is required to maximize the benefits of this patient-centric interventional strategy.

The extent of lower extremity occlusive disease predicts short- and long-term patency following endovascular infrainguinal arterial intervention

The management of carotid stenosis in women remains a topic of controversy. In this review article, we aimed to define carotid disease burden in women, review outcomes of carotid endarterectomy and carotid artery stenting in women, discuss differences in practice patterns based on sex, and provide guidelines for management of women with carotid stenosis. Symptomatic women with high-grade stenosis derive benefit from carotid endarterectomy, although they have different risk profiles than men and are often not taking appropriate medical therapy. Women with asymptomatic carotid artery stenosis have less stroke risk reduction with CEA than their male counterparts; therefore, they should be screened for other treatable risk factors for stroke, with the institution of lifestyle changes and the appropriate medical therapy. After medical optimization, the decision to proceed with CEA in asymptomatic women must be made by carefully assessing that the benefits of stroke risk reduction outweigh perioperative risks.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations.

BACKGROUND Endovascular revascularization of the femoral-politeal arterial segment has gained acceptance despite lower patency than surgical bypass due to lower morbidity. Choosing patients that are ideal candidates for endovascular therapy remains controversial. We have assessed hemodynamic factors that might predict longer primary patency after endovascular therapy. METHODS Ninety-nine limbs were treated with endovascular therapy from January 2001 to January 2005 with a mean and median follow-up of 338 and 293 days. Primary patency was considered lost when recurrent symptoms developed, ankle-brachial index (ABI) decreased following initial improvement, or a subsequent procedure was required. Kaplan-Meier analysis was used to evaluate patency. RESULTS Patients with an ABI > or =.5 prior to intervention had longer primary patency compared to those with an ABI less than .5 (P = .043). Having 1 or more patent tibial runoff vessels was associated with improved patency for the first 24 months post-procedure (P = .001). CONCLUSIONS Patients with an ABI > or =.5 or at least 1 patent tibial vessel runoff have significantly higher hemodynamic and clinical success following endovascular therapy of the femoral-popliteal arterial segment.

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay

OBJECTIVE Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG). DESIGN, SETTING, AND PARTICIPANTS Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites. INTERVENTION Preadmission application of chlorhexidine gluconate, 2% RESULTS Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively). CONCLUSION The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.