Antiseptic solution in Operating theatre

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Antiseptic solution in Operating theatre

• Patricia Kan

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Antiseptic solutions in operating theatre
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Joseph Lister (1827-1912)

• Hospitalism outcomes of pyaemia, septicaemia,
  erysipelas, hospital gangrene and tetanus
• One of the giants of infection control
• Laid down the principles of antisepsis in surgery
• In late 1800s, he started to use carbolic acid to
  clean the operation site before incision.

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Topical antiseptic solution in OT

• 1. Preoperative skin preparation
• 2. Regional anaesthesia (epidural, spinal, etc)
• 3. Central line insertion
• 4. Hand hygiene

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• Topical antiseptic are antimicrobial agents that
  kill, inhibit or reduce the no. of microorganisms
  on the skin.
• Human skin is colonized by a wide variety of
  microorganisms that may provide a protective
  mechanism to the host, but also a source of
  infection.

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Normal skin flora

• Transient
• contracted from the environment or from other
  people
• thrive in the environment of sweat, dirt and oil
• can be easily removed by soap and water.
• Resident
• live in the skin pores and stratum corneum
• continually work towards the skin surface
• Difficult to remove and require antimicrobial
  agents with residual action to be effective

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• Topical antiseptic are active against both
  resident and transient flora by both mechanical
  and chemical action.
• Apply enough pressure and friction to remove
  dirt, debris and microbes. (except superficial
  malignancy, areas of carotid plaque)
• Common antiseptics Alcohol, Iodine and
  iodophors, Chlorhexidine

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Alcohol

• Protein coagulation and denaturation
• Alcohol-mediated disruption of cytoplasmic
  integrity, cell lysis and interference with
  cellular metabolism
• 100 alcohol is not effective
• it deprives bacterial cell walls of water
• induce the formation of impermeable protein
  layers which prevent the alcohol from penetrating
  in to the cell

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• Alcohol is defined by FDA as having one of the
  following active ingredients
• Ethyl alcohol, 60-95 by volume in aqueous
  solution
• Isopropyl alcohol, 50-91.3 by volume in aqueous
  solution
• Most common concentration 70
• Effective, less dessicating, less expensive

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Advantages

• Onset of action is most rapid, 10-15 sec
• Broad antimicrobial spectrum
• Excellent bactericidal effect on G, G-
• Effective against tubercle bacillus, fungi and
  virus (certain enveloped viruses HSV, HIV,
  influenza virus, RSV)
• Not sporicidal, poor activity against certain
  nonenveloped viruses (e.g. poliovirus,
  enterovirus, HAV, rotavirus)
• Alcohol antiseptic has been used since 1930s and
  there have been no reports of alcohol resistant
  bacterial strains

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Disadvantages

• No residual activity
• Effectiveness is reduced by organic materials
  such as blood, mucus, excreta
• Volatility and Flammability?
• Drying of skin, allergic contact dermatitis
• Emollients, may enhance the antimicrobial
  activity
• Toxic reactions have been reported in children
  after sponge bathing with isopropyl alcohol to
  reduce fever (1950-60s). The vapors may be
  absorbed through the lungs and cause acute
  poisoning.

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Iodine and iodophors
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Iodine and iodophors

• Tincture of iodine was used as early as 1839 by
  French war surgeon who treated battle wound
  during the Civil War
• Action
• Iodine molecules rapidly penetrate the cell wall
  of microorganisms
• inactivate cell s by forming complex with amino
  acid and unsaturated fatty acids
• Impaired protein synthesis, alteration of cell
  membrane
• Most effective concentration is 1-2
• Cause stinging and irritation, discoloration
• Must be removed with 70 alcohol after drying

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• Iodophors solutions in which iodine is
  chemically bound to polymer carrier (complexing
  agents of high molecular weight) e.g.
  polyvinylpyrrolidone
• Povidone-iodine Betadine
• Water soluble, less staining, less irritating to
  skin, eye and mucous membrane
• Allows slow and continuous release of free iodine
  which determines the antimicrobial activity
• 10 povidone-iodine contains 1 iodine

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• Onset
• iodophors require 2 min of contact time to allow
  release of free iodine
• after dried
• Broad spectrum of bactericidal activity
• Effective against G, G-, tubercle bacillus ,
  fungi, virus and certain spore forming bacteria
  (e.g. clostridia, Bacillus spp.)
• Not sporicidal in concentration used in
  antiseptic

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• Rapidly neutralized in the presence of organic
  materials such as blood, mucus, sputum, urine,
  faeces, etc
• Antimicrobial activity is affected by
• pH (6)
• temperature (esp sporicidal activity is markedly
  temperature-dependent, ?temp ? ?activity)
• exposure time, conc of total available iodine,
  etc
• Greater activity when the cpd is in dry state
• Some residual effect
• If washed away, 30-60 min (except 1 study 6 hrs)
• Bacteriostatic effect as long as on the skin

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To dry or not to dry???

• Wipe the skin dry after apply the antiseptic
  agent to allow adherence of disposable adhesive
  drapes
• Kutarski, Grundy. To dry or not to dry? An
  assessment of the possible degradation in
  efficiency of preoperative skin preparation
  caused by wiping skin dry. Annuals of the Royal
  College of Surgeons of England (1993) vol 75,
  181-185.
• Skin flora were obtained from subjects at 5, 30,
  60 and 120 min
• No significant difference in the reduction of
  baseline count of skin flora between wiping the
  agent off after 30 sec of application and leaving
  it to dry
• Author suggested a longer period of application
  time may be worthwhile , particularly where
  infection would prove disastrous, e.g. implanting
  prostheses

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Povidone-iodine related chemical burns

• 24/F, R hand flexor tendon repair (2hrs)
• Preparation ran down the patients arm and
  absorbed by the padding under the tourniquet cuff
  

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• 45 yrs old, epidural anaesthesia for
  femoro-popliteal bypass graft, gauze soaked in
  povidone-iodine antiseptic solution and was then
  covered with occlusive transparent waterproof
  dressing
• ? blistered area in the shape
• of the gauze at the back

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• PI after closed and prolonged exposure can damage
  the skin
• over bony prominence, pressure points, underneath
  an area constricted with a tourniquet dressing or
  bandage
• Recommendations
• Skin must not be abraded excessively before the
  final skin preparation solution is applied
• The agent should not be allowed to pool and
  become trapped under the tourniquet or the torso
  of the patient
• The agent should be allowed to dry before the
  patient is draped.

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Transcutaneous iodine absorption

• Topical application of PI in burn patients
• renal failure, metabolic acidosis,
  hypernatraemia, hyperosmolarity, hypothyroidism
• Hypothyroidism in infants
• Skin is very thin and permeable
• High plasma iodine conc ? transient inhibition
  of thyroid hormone production, ?serum thyroxine
  level (Wolff-Chaikoff effect)
• Usu lasts only 48hrs, even if the plasma iodine
  level remain high
• Prolonged hypothyroidism esp in preterm infants
• Recommendations
• Avoid iodine containing antiseptic in
  infantslt3mths old
• Iodine should be washed off with sterile saline
  solution

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Chlorhexidine gluconate
CHG 0.015 cetrimide 0.15

• CHG 0.05 aqueous

• CHG 0.05 aqueous (25ml)

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Chlorhexidine gluconate (CHG/ Hibitane)

• Cationic bisbiguanide
• Action
• attachment, disruption of cytoplasmic membranes
• precipitation of cellular contents
• Broad antimicrobial spectrum
• Good activity against G
• Less activity against G-, fungi
• Poor activity against tubercule bacilli
• Not sporicidal
• In vitro activity against enveloped virus (HSV,
  HIV, CMV, influenza, RSV)
• Less activity towards non-enveloped virus
  (rotavirus, adenovirus, enterovirus)

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• Introduced to Europe in 1950s and US in 1970s
• Bacterial resistance not common, limited to some
  resistant strains of Pseudomonas, Proteus,
  Staphylococcus aureus
• Antimicrobial activity is not affected by the
  presence of organic material
• ?cationic ?activity reduced by natural soaps,
  inorganic anions, nonionic surfactants, hand
  cream containing anionic emulsifying agents
• pH dependent (5-8), if pH above 9 ? precipitation
  of active component

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• Onset 3-5 min
• Good residual activity
• It binds to skin and mucous membrane and remain
  active for at least 6 hrs
• Not absorbed through skin , low irritancy
  potential
• Should not come into contact with eyes, meninges
  (neurotoxic), middle ear (ototoxicity)

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Allergy/ Anaphylaxis to chlorhexidine

• Most of the case reports from Japanese literature
• Application to skin, mucous membrane,
  chlorhexidine-sulphadiazine-coated central venous
  catheter
• (In our ICU, the antibiotic-coated central venous
  catheter is minocycline/ rifampicin coated)

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Summary
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Alcohol based antiseptic solution
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Alcohol based antiseptic solution

• low concentration (0.5-1) CHG is added to
  alcohol (70)
• Combination of Alcohol and PI
• Advantages
• Rapid action of alcohol
• Persistent action of CHG
• Decrease the drying time

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Operating theatre fire and alcohol based
antiseptics
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Case reports

• Barker S, Polson J. Fire in the operating room a
  case report and laboratory study. Anesth. Analg.
  2001 93 960-5
• Fong E, et al. Diathermay and alcohol skin
  preparations potential disastrous mix. Burns
  2000 26 673-5
• Chang BW, et al. Patient fire safety in the
  operation room. Plast. Reconstr. Surg. 1994 93
  519-21
• Magruder G, et al. Fire prevention during
  surgery. Arch. Ophthalmol. 1970 84 237
• Briscoe C, et al. Infammable antiseptics and
  theatre fires. Br. J. Surg. 1976 63 981-3
• Nicholson M. Comments. Anesth. Analg 1972 51
  646
• Waitemata Distric Health Board. Report into
  operating theatre fire accident, 17 Aug 2002.
  Witemata Distric Health Board Final Report. New
  Zealand Waitemata Hospital, 2002.
• Toother R, et al. Surgical fires and
  alcohol-based skin preparations. ANZ J Surg.2001
  74 382-385 ..

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• 32/F, R axillary abscess for ID under GA
• Diathermy is used
• Upon removal of surgical drapes, the underlying
  incontinence pad was on fire, curling up at the
  edges (alcohol burns with an invisible flame)
• large area of full thickness burn involving
  mainly the dependent sites where the solution had
  pooled soaking the incontinence pad

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• 17/F, LSCS under epidural anaesthesia
• 0.5 CHG with 70 alcohol was used to prepare the
  abdomen
• Diathermy was used
• woomph noise was heard
• Patient complained of heat and the anaesthetist
  felt the heat and saw a flame/shimmer
• Fire was put out with fire and CS completed with
  birth of a healthy baby
• The mother suffered 12-16 full thickness burns
  to her inner thighs and both flanks
• due to pooling of alcohol-based skin antiseptic
  underneath the adhesive surgical drapes which
  produced alcohol vapour which was ignited by a
  spark from diathermy
• No oxygen supplement is given

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Recommendations

• Alcohol-based solutions are not recommended for
  skin preparation in the presence of ignition
  source ( electrocautery unit, laser)
• Any alcohol based solution should be clearly
  labelled
• Run-off and pooling of alcohol based antiseptic
  should be avoided by
• Using minimum amount necessary
• Allowing solution to dry completely prior to
  draping
• Preparation that contains dye are recommended
  because they make it easier to see what skin has
  been painted ? less likely to use excessive amt
  and pooling
• Temporary absorptive sheets around the surgical
  site while using alcohol based solution and
  removed after use

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• The drying time for skin preparation might need
  to be longer than the manufacturers
  recommendation (usu 2-3 min), 5 min might be
  preferable
• Electrosurgical instruments should be used on the
  lowest power setting to minimize the risk of
  sparking and excessive temperatures
• Dont put diathermy and laser foot pedals side by
  side
• Dont leave diathermy in the quiver each time
  after use
• The creation of oxygen rich atmosphere should be
  avoided
• Not to create O2 tents by placing drapes over
  nasal cannula or oxygen mask
• In event of fire , oxygen and nitrous oxide
  supply should be ceased immediately

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Alcohol vs non-alcohol based antiseptics ??
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1. Surgical site infection (SSI)

• An audit of pre-operative skin preparative
  methods practised by the surgeons in Northern
  Ireland in 2005

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CDC guideline for prevention of surgical site
infection, 1999

• Use an appropriate antiseptic agent for skin
  preparation. Category IB (Strongly recommended
  for implementation and supported by some
  experimental, clinical or epidemiological
  studies and strong theoretical rationale)
• .The iodophors, alcohol-containing products and
  chlorhexidine gluconate are most commonly used
  agents.
• .No studies have adequately assessed the
  comparative effects of these preoperative
  antiseptics on SSI risk in well-controlled,
  operation specific studies.

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The Cochrane Database of Systematic Reviews
Preoperative skin antiseptic for preventing
surgical wound infections after clean surgery
(2004)

• There is insufficient evidence from randomised
  trials to support or refute the use of antiseptic
  preparation of skin at operative sites, or of one
  antiseptic over another.
• Only one RCT (Berry 1982) demonstrated a
  significant difference in infection rates between
  two different antiseptics (in favour of CHG over
  iodine)

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Berry A, et al. A comparison of the use of
povidone-iodine and chlorhexidine in the
prophylaxis. J. of Hospital infection 1982 3
(1) 55-63.

• 371 clean operations
• Results
• Gp1. povidone-iodine 10 in alcohol
• 28/176 , 15.9
• Gp2. chlorhexidine 0.5 in spirit
• 8/195, 4.1
• Limitation
• Lack of extensive FU, underestimate the infection
  rates

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• Hibbard, et al. Analyses comparing the
  antimicrobial activity and safety of current
  antiseptic agents A Review. J. of infusion
  nursing 2005, 28 (3) 194-207.
• CHGIPA provided the best immediate, persistent,
  cumulative antimicrobial activity
• Ostrander, et al. Efficacy of surgical
  preparation solutions in foot and ankle surgery.
  J. Bone joint Surg Am 87 980-985, 2005.
• ChloraPrep ( 2 chlorhexidine and 70 IPA) was
  most effective for eliminating bacteria from the
  forefoot prior to surgery, when compared with
  DuraPrep (0.7 iodine 74 IPA) or 3
  chloroxylenol
• Bibbo C, et al. Chlorhexidine provided superior
  skin decontamination in foot and ankle surgery.
  Clinical orthopaedics and related research 438
  204-208, 2005.

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2. Epidural catheter insertion

• A survey of fellows of ANZCA with a special
  interest in obstetric practice, about their
  beliefs regarding aseptic precautions for
  insertion of epidural catheter in labour ward in
  2002

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• Mechanisms of epidural infection
• Skin flora introduced either at the time of
  puncture or bacterial migration along a catheter
  or needle tract
• (soiling of the back by amniotic fluid, urine
  and feces during labour and delivery ? ?catheter
  contamination)
• Contamination of drug or material
• Haematogenous spread from another site of
  infection
• Catheter colonization arising from clinicians
  and nurseshandling of syringes and solutions,
  via catheter hub

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Clevenot D, et al. Critical review of the
literature concerning the comparative use of two
antiseptic soultions before intravascular or
epidural catheterization. Ann Fr Anesth Reanium
2003 Nov 22(9) 787-97

• Chlorhexidine in alcoholic solution seems more
  efficient than povidone iodine in aqueous
  solution in the clinical setting.
• The place of povidone iodine in alcoholic
  solution, whose performances on the healthy skin
  are similar to those of alcoholic chlorhexidine,
  is being in evaluation.

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Birnbach, et al. Comparison of povidone iodine
and DuraPrep (iodophor in IPA) for skin
disinfection prior to epidural catheter insertion
in parturients. Anesthesiology 2003 98(1) 164-9.
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• Explanation
• Alcohol provides rapid antisepsis
• Long lasting effect
• Duraprep, when placed on skin, produces a film of
  disinfectant
• This film resists being washed away by fluids and
  blood

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Kinironsm et al. Chlorhexidine versus povidone
iodine in preventing colonization of continuous
epidural catheters in children. Anesthesiology
2001 94 239-44.

• Alcoholic solution of 0.5 chlorhexidine vs
  aqueous solution of 10 povidone iodine

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• Catheter inserted after skin preparation with
  chlorhexidine were one sixth as likely and less
  quickly colonized as catheters inserted after
  skin preparation with povidone iodine

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Sakuragi, et al. Bactericidal activity of skin
disinfectants on MRSA. Anesth Analg 1995 81
555-8.

• Most frequently detected organism in the normal
  human skin flora is S. epidermidis (65-69).
• The prevalence of S. aureus is 1-2 but is the
  most common organism in epidural abscess.

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3. Central line insertion

• Two main routes by which intravascular devices
  become contaminated
• Intraluminal contamination
• consequence of improper handling of the catheter
  hub at the time of connection and disconnection
  of the administration set
• Most common origin after the first week of
  catheter placement
• To prevent this, strict asepsis must be observed
  in hub and fluid handling

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• Extraluminal contamination
• Bacterial invasion from the catheter entry site
  along the external surface of the catheter
• Bacteremia during the week following catheter
  placement
• Prevented by appropriate skin disinfection and
  the adoption of maximal antiseptic barriers at
  the time of catheter insertion

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Chaiyakunapruk, et al. Chlorhexidine compared
with povidone-iodone solution for vascular
catheter-site care A Meta-analysis. Ann Intern
Med 2002 136 792-801.
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• The overall risk ratio for catheter colonization
  in chlorhexidine group compared with
  povidone-iodine is 0.49
• Chlorhexidine rather than povidone-iodine can
  reduce the risk for catheter-related bloodstream
  infection by approximately 50 in hospitalized
  patients who require short-term catheterization.

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• Subset analyses of aqueous and nonaqueous
  solutions showed similar effect sizes, but only
  the subset analysis of the five studies that used
  alcoholic solution produced a statistically
  significant reduction in catheter-related
  bloodstream infection.
• Few studies used chlorhexidine aqueous solution

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Parienti, et al. Alcholic povidone-iodine to
prevent central venous catheter colonization A
randomized unit-crossover study. Crit care med
2004 32(3) 708-713.
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CDC guidelines for the prevention of intravscular
catheter-related infections, 2002

• Disinfect clean skin with an appropriate
  antiseptic before catheter insertion and during
  dressing changes
• Although a 2 chlorhexidine based preparation is
  preferred, tincture of iodine, an iodophor, or
  70 alcohol can be used.
• Allow the antiseptic to remain on the insertion
  site and to air dry before catheter insertion
• Allow povidone iodine to remain on the skin for
  at least 2 min or longer if it is not yet dry
  before insertion
• Do not apply organic solvents (e.g. acetone and
  ether) to the skin before insertion of catheter
  or during dressing changes

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NICE (National Institute for Clinical Excellence)
guideline for infection control, 2003

• Catheter site care
• An alcoholic chlorhexidine gluconate solution
  should be used to clean the catheter site during
  dressing changes, and allowed to air dry.
• An aqueous solution of chlorhexidine gluconate
  should be used if the manufacturers
  recommendation prohibit the use of alcohol with
  the product.

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Conclusion

• Skin antisepsis plays an important role in
  infection control and prevention of nosocomial
  infection (e.g. surgical site infection, epidural
  infection, catheter related infection, etc)
• An understanding of the properties of different
  antiseptic solutions is needed to facilitate the
  selection and proper use of them.

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• It should be remembered that antiseptic solution
  is only a small part of infection control.
• Aseptic techniques such as cap, gowning, glove,
  mask, proper scrubbing, etc are also very
  important.

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Best antiseptic solution???
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My opinion

• Ideal antiseptic solution does not exist
• The current evidence seems to favour the alcohol
  based antiseptic solution (esp alcoholic
  chlorhexidine)
• If alcohol based solution is avoided in view of
  OT fire, povidone-iodine is an alternative.
• The effect of aqueous chlorhexidine is unsure as
  most of the studies involve alcoholic
  chlorhexidine.

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The End

• Thanks