In 2008, the Association of periOperative Registered Nurses revised its recommendations regarding preoperative skin preparation for surgical patients. The new recommendation is that patients who are scheduled for open, class I surgical procedures that take place on a body part below the chin have 2 preoperative showers or baths with a chlorhexidine gluconate (CHG) preparation (unless contraindicated).[1] Showering or bathing with a CHG product essentially reduces the patient’s skin flora. This recommendation is based on the significance of surgical site infections, which are a commonly reported healthcare-associated infection in the United States. Adequate preparation of the patient’s skin before surgery can minimize this risk.

Class I surgical procedures are considered “clean.” These incisions are carefully and deliberately created in the surgical (or procedure) setting. They are nontraumatic; have no inflammation; the respiratory or gastrointestinal tracts are not entered; the wound is closed with a primary closure (sutured, stapled, or taped); and if any drains are placed in surgical site, a closed drainage system is used. Operative incisional wounds that follow nonpenetrating (blunt) trauma are included in this category if they meet the criteria. Clean wounds carry a 1% to 5% risk for infection.

A preoperative shower with a 4% CHG product accomplishes 3 objectives: it removes soil, dirt, oil, and transient microorganisms from the epidermis; reduces the resident microbial count to minimal levels in a short time; and prevents regrowth and multiplication of the dermal microbes. A 4% CHG is an effective broad-spectrum antimicrobial product that is effective against gram-negative and gram-positive bacteria, as well as against viruses.

When you provide preoperative education, first ask whether the patient has ever had a skin reaction with any previous surgical procedures. Although reactions to CHG are infrequent, patients with a known hypersensitivity should not use the product.

The salient points to include in patient preoperative education are:

  • The night before surgery: shower or bathe with the CHG product. After the CHG shower or bath, rinse thoroughly; use a fresh, clean towel to dry; and don clean clothing; and

  • Morning of surgery: repeat the same procedure as the evening before.

If the patient is having a surgical procedure on the head (and the patient’s tympanic membrane is intact), instruct them to:

  • Shampoo with CHG twice (the evening before and the morning of the surgery);

  • Avoid using any conditioners, shampoo, hair spray, or other alcohol-based hair products; and

  • Avoid getting the CHG preparation in their eyes, ears, nose, or mouth.

For hand or wrist surgery, instruct the patient to:

  • Keep nails short and natural; and

  • Remove artificial nail surfaces;

Other general information (for all patients):

  • Do not shave or use a depilatory on the surgical site;

  • Remove cosmetics; and

  • Remove all jewelry, including body jewelry (eg, body piercing ornaments).

Infections that develop in clean surgical wounds are primarily caused by exogenous microbes. Educating patients about preoperative showers or baths with CHG products can lower their risk for infection following class I surgical procedures.

Thanks,

JTM, MD