Some practical aspects of surgical skin preparation

Abstract

I N THE NINETY-EIGHT YEARS since Lister introduced the concept of antisepsis, surgeons have been unabIe to evolve any uniform method of surgical skin preparation. In keeping with their individualistic nature, each has his own ritual of preparation and the belief that he is pecuIiarIy cIean. The effectiveness of mechanical scrubbing in removal of skin bacteria has been demonstrated and remains generally accepted. A long series of antiseptic agents have been enthusiastically introduced, investigated, and for the most part discarded. OnIy 70 per cent alcohol, Zephiran,@ hexachlorophene preparations, and iodophors remain in general use. Rubber gloves are used universally because of inability to attain adequate degermation but they are subject to frequent puncture. In spite of this continuing diIemma, Iittle effort has been directed toward the study of the characteristics of the skin flora which we are attempting to remove and contro1. In 1938, Price [I] divided aerobic skin flora into transient and resident populations and noted that the size of the resident flora and its rate of removal by scrubbing were characteristic for each individual person. He also pointed out [2] that this size varied widely from one person to another and that it was not predictable on the basis of age, sex or complexion. On the basis of a few experiments [I,?], a pattern for regrowth of skin flora folIowing surgical degermation was proposed. This early curve suggested slow muItiplication during the first two or three days folIowing a surgical scrub, an observation that has led some to a false sense of security during the immediate postoperative period onIy. More recently has the prompt initiation of a rapid rate of floral regeneration been appreciated [4,3]. Although the detrimenta effect of increased bacterial multiplication under gown and gloves has been mentioned by many authors [6-101, only Price [I], on the basis of two serial basin experiments, and Dull et al. [ r~], using single basin washings, gave any information as to the actual magnitude of that factor. Price demonstrated an eightfold increase in bacterial count in approximately three hours while Dull reported from twenty-nine subjects an average increase of 28 to 79 per cent of prescrub levels during a two hour period. Other technics such as finger impression, gIove culture and skin swabs have provided corroborative evidence of considerable regrowth. These studies, however, as well as investigations of the chemica1 control of regrowth under gIoves [12-131, usuaIIy test either smaIl areas of skin or measure the exfoliated bacteria shed into gloves, and have yielded variable results. Improper use of drugs antidotes to neutralize antiseptic agents in culture has also Ied to many false interpretations of drug effectiveness. None of the studies gives direct insight into the actuaI changes occurring in the bacterial popuIation on the skin. The individua1 variations in the size of the skin flora, its rate of regrowth following degermation, the effect of gown and gloves on bacterial multiplication, and the controI of