Chlorhexidine droplet splash – time to revisit the swabstick?

Abstract

Dr Saha is right to imply that the debate on skin preparation for neuraxial block is a fluid one. The paper by Evans et al. 1 provides evidence to support the view that the mode of application may be as important as the choice and concentration of antiseptic, a point which I emphasised in my original editorial 2. I am aware that CareFusion (Basingstoke, UK) have changed some of their labelled warnings, which now show consistency across the range of their devices for applying 2% chlorhexidine in 70% alcohol, with or without tint (ChloraPrep®), and no longer include ‘lumbar puncture’ as a contra-indication. This means that using the device for skin preparation for spinal anaesthesia will no longer be in breach of the product licence, but this is still unlikely to provide legal protection if contamination leading to arachnoiditis occurs. While the use of such devices must go some considerable way towards minimising the risk of contamination, it does not remove it altogether, and precautions must be particularly taken to hold the swabstick with the handle uppermost, to avoid the contents' dripping down on to the gloved hand or sterile field. The probable reduced chance of contamination must still be balanced against the potential risk of using a 2% solution rather than 0.5%, although some comfort can be taken from the fact that very little chemical appears to be carried on the point of a needle inserted in experimental conditions through skin that has been allowed to dry 3. I note Dr Saha's contention that some precautionary measures for preventing contamination would be difficult for the unassisted anaesthetist to implement. I am firmly of the view that, as for any aseptic procedure, the presence of an assistant during the siting of an epidural for labour analgesia is essential.