Atlas of Procedures in Neonatology, 4th Edition

Preparation and Support

4

Aseptic Preparation

Chrysanthe G. Gaitatzes

Khodayar Rais-Bahrami

  1. Definitions
  2. Antiseptic
  3. Bactericidal or bacteriostatic substance that can be safely applied to skin
  4. Not reliable as a sporicidal
  5. Reduces but does not eliminate bacterial counts on the skin
  6. Has an immediate effect
  7. May have variable residual activity by binding to the stratum corneum of the skin
  8. Disinfectant
  9. Chemical germicidal
  10. Not sporicidal
  11. Too harsh to be used on skin
  12. Resident flora
  13. Organisms, usually of low virulence, which survive and multiply on skin and can be cultured repeatedly, e.g., Staphylococcus epidermidis
  14. Cannot be completely eradicated without destroying the skin
  15. Regenerate rapidly on skin when surgical gloves are worn
  16. Transient flora
  17. Organisms that are sometimes pathogenic but do not survive and multiply on skin, e.g., gram-negative organisms such asEscherichia coli
  18. Can be transmitted to patients on the hands of health care workers
  19. Do not usually remain on the skin for more than 24 hours
  20. Can be eradicated completely by hand washing with antiseptic solutions
  21. Background

Bloodstream bacterial infection is an extremely common complication of prematurity. The majority of etiologic pathogens are nosocomial, most often transmitted by health care personnel. Use of aseptic technique is critical in reducing the number of bloodstream infections as well as in decreasing the number of contaminated blood cultures, which in turn leads to a decrease in the unnecessary use of antibiotics and the potential for antibiotic resistance. Protocols and procedures for aseptic technique in neonatal intensive care units (NICUs) are constantly being re-evaluated and updated, and hand hygiene guidelines are routinely published by the U.S. Centers for Disease Control (CDC) (1,2). Hospital managers continuously develop and update strict policies and regulations (3) as well as quality improvement projects aimed to promote adherence to aseptic technique and hand hygiene (4).

  1. Indications
  2. Preparation of patient's skin and the hands of personnel prior to performing a procedure
  3. To remove transient flora
  4. To remove and temporarily suppress most resident skin flora
  5. Decontamination of hands after a procedure
  6. Contraindications
  7. Iodine solutions for preparation of skin in newborns [may cause skin and thyroid problems in high concentrations (5, 6 and 7)]
  8. Halogenated bisphenols (e.g., hexachlorophene) for preparation of skin in premature infants (see E7)
  9. Chlorhexidine for preparation of external auditory meatus
  10. Precautions
  11. Universal (8,9)
  12. Definition:A method of infection control in which all human blood and certain human body fluids are treated as if known to be contaminated with human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens

P.22

  1. Indications:Reasonably anticipated risk of skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials, including semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in oral procedures, and any body fluid that is visibly contaminated with blood.
  2. Major components
  3. Use gloves when touching blood, body fluids, mucous membranes, or nonintact skin and when handling items or surfaces soiled with blood or body fluids.
  4. Use a mask and eye protection during procedures that might generate splashing or droplets in the air.
  5. Use a gown or a plastic apron when splashing of blood or body fluid is likely.
  6. Wash hands carefully if they become contaminated with blood or body fluids.
  7. Take extraordinary care in handling needles and other sharp objects, and dispose of them in puncture-resistant containers.
  8. Exclude from patient care all personnel with exudative lesions or weeping dermatitis until these conditions have resolved.
  9. Recognize that no antiseptic is totally effective or without risk (Table 4.1).
  10. Always allow antiseptics to dry before starting procedure.
  11. Drying time of at least 30 seconds is required for optimal effect (10).
  12. Contamination of instruments with antiseptic is undesirable and may invalidate specimens taken for culture.
  13. Avoid removal of iodophore preparations prior to procedure. Removal negates the residual slow-release effect.
  14. After the procedure, remove iodophore from all but immediate area of procedure to prevent absorption through skin (5,6 and 7).
  15. Never allow antiseptic to pool under infant. Skin damage may result (16).
  16. Use hexachlorophene for skin preparation in newborns only as recommended by the American Academy of Pediatrics (17).
  17. Use only in term infants during outbreak of Staphylococcus aureusinfection.
  18. Do not apply more than twice to each infant, unless application is restricted to diaper area (18).
  19. Wash off solution completely.
  20. Reapply alcohol prior to each attempt at procedure or with any delay, as efficacy is short-lived and flora will regenerate quickly.
  21. Keep all antiseptics away from eyes.
  22. Store antiseptics in closed containers. Reusable dispensers should be thoroughly cleaned, dried, and refilled frequently. Disposable containers are available.
  23. Remember that gloving cannot be used as an alternative to hand washing.
  24. The warm, wet skin surface under gloves offers an ideal environment for bacterial multiplication.
  25. Gloves are not completely impermeable to microorganisms.
  26. Latex and vinyl gloves offer comparable permeability, but vinyl gloves leak more readily.
  27. Special Circumstances
  28. In clinical situations where traditional hand-washing facilities are unavailable, such as during patient transport, alcohol-based hand rinses, foams, or wipes may be used for hand cleaning. When alcohol solution is used, make three to five applications of 3 to 5 mL each; rub hands well until completely dry. Gloves should be used as otherwise indicated. This technique is not adequate when hands are soiled with organic matter.
  29. In cases of medical emergency, aseptic technique should be used as allowed by the situation, with at least use of skin preparation of the patient with an antiseptic, use of gloves, and sterile field as large as possible under the circumstances.
  30. Personnel suffering from allergies to antimicrobial soaps may wash thoroughly for 3 to 5 minutes with plain soap or 70% isopropanol with glycerin prior to gloving (19).
  31. Personnel suffering from skin cracking due to frequent use of antiseptic soaps may use skin lotions after hand washing. Products with a bacteriostatic ingredient, such as gels containing 60% ethanol, and emollients, are safe and effective in reducing skin problems (20). Containers with a flip top, rather than a screw cap, are recommended. Doebbeling et al. (21) have shown that a hand disinfection system using an antimicrobial agent (chlorhexidine) reduces the rate of nosocomial infection more effectively than one using alcohol and soap.
  32. Non—latex-containing gloves should be available for staff with latex allergy and to avoid allergic reactions in the patient, particularly in susceptible patients such as those with myelomeningocele (22,23).

P.23

 

TABLE 4.1 A Comparison of Commonly Used Antiseptics (11,14,15)

Considerations

Iodophor

Chlorhexidine (0.5%–4%)

Alcohol (70%–90%)

Iodine (1%)

Hexa-chlorophene 3%)

Chloroxylenol (PCMX) (0.5%–3.5%)

1. Indications

Hand washing
Skin preparation

Hand washing: 4%
Skin preparation: 0.5% in 70% alcohol optimal. May be superior to alcohol alone or iodophor in preventing central line infection (adult data).a

Skin preparation for minor procedures
Preparation of external auditory canal

Surgical hand washing as tincture with alcohol

Hand washing
Use limited to term infants during epidemics of MRSA

Hand washing
Skin and wound disinfection

2. Effective concentration

  a. Nontoxic

Hypothyroidism

Yes,b but local ototoxicity

Yesc

Hypothyroidism

CNS vacuolation

Yesb

  b. Nonsensitizing

Yes

Yes

Yes

No

Yes

Low

  c. Nonirritating

Yes

Yes

Burns in premature infants

No

Yes

Yes

3. Mode of action

Oxidation

Cell wall disruption

Protein denaturation

Oxidation

Cell wall disruption

Cell wall disruption and enzyme inactivation

4. Bactericidal

Yes

Yes

Yes

Yes

No

Yes

5. May be used with detergent

Yes

Yes

No

No

Yes

Neutralized by nonionic surfactants

6. Persistent local action

Yes

Yes

No

Yes

Yes, but only with repeated use; reduced by concomitant use of alcohol

Good

7. Effective against

  a. Gram-positive bacteria

Yes

Yes

Yes

Yes

Yes
(bacteriostatic)

Good (better against Streptococcus than Staphylococcus)

  b. Gram-negative bacteria

Yes

Yes

Yes

Yes

No

Fair, improved by EDTA

  c. Spores

No

No

No

No

No

No

  d. Tubercle bacillus

No

No

Yes

Yes

No

Fair

  e. Viruses

Yes

Yes

Lipophilic viruses only

Yes

Yes

Fair

  f. Fungi

Yes

Yes

Yes

Yes

Yes

Fair

8. Use associated with resistance

No

Contamination withPseudomonasand Proteusspecies

No

No

Yes

Not effective against Pseudomonas species

9. Rapid action

No
Requires 4–5 min of scrubbing

Yes (better when combined with alcohol)

Yes (drying time)

Yes

No

Intermediate

10. Easily inactivated by extraneous organic matter

No
Low surface tension for good crevice and fat penetration

No

May be inactivated by nonbacterial protein

Yes

Yes

Minimal

MRSA, methicillin resistant staphylococcus aureus; CNS, central nervous system; EDTA, ethylenediaminetetra-acetic acid.
aData from Maki et al. (11).
bSkin absorption not studied in very low-birthweight infants.
cData from Harpin and Rulter (39).

P.24

 

  1. Technique (See Procedures DVD for Video)

A 3- to 5-minute “scrub” (vigorous washing up to the elbows) is necessary upon entering the nursery. Subsequently, a 15- to 30-second handwashing is indicated prior to and after each patient contact.

  1. Preparation for a minor procedure
  2. Definition of a minor procedure
  3. Short duration (5 to 10 minutes); noncomplex
  4. Does not involve an area, such as the central nervous system (CNS), which is especially vulnerable to infection
  5. Does not require skin incision
  6. For example, blood drawing, placement of percutaneous peripheral venous line, bladder tap, punch-skin biopsy
  7. Preparation of personnel
  8. Wear cap/beard cover if hair is likely to contaminate the field.
  9. Remove all jewelry from hands and arms.
  10. Wash hands, wrist, forearms, and elbows using a small amount of antiseptic preparation (e.g., iodophore or chlorhexidine). Iodophore preparations appear to be equally effective when applied with disposable sponges or brushes. Vigorous scrubbing with a brush leads to skin breakdown and possible contamination and is contraindicated. Be sure to include between the fingers and the lateral surface of the fifth finger.
  11. Clean nails with stick.
  12. Wash/scrub hands and forearms to elbow with antiseptic for a further 2 to 3 minutes.
  13. Rinse hands and forearms with running water, keeping them elevated above elbows.
  14. Use towel to shut off water if knee- or foot-operated faucets are not available.
  15. Dry hands with clean towel prior to drying forearms.
  16. Wear gloves.
  17. Preparation of patient skin
  18. If necessary, cut hair in area of procedure with small scissors, taking care not to nick skin. Avoid shaving, as that may cause skin compromise and increases the risk of infection.
  19. Apply antiseptic.
  20. Alcohol may be used. Preparation with iodophore may be optimal, but color tends to obscure underlying vessels.
  21. Apply three times in circles progressing away from procedure site.
  22. Apply with some friction.
  23. Allow to dry. Do not wipe off antiseptic.
  24. Never touch skin after application of antiseptic and before initiation of the procedure.
  25. If using alcohol, reapply it prior to every attempt at procedure.
  26. Preparation for a major procedure
  27. Definition of major procedure
  28. Invasive or involving skin incision
  29. For example, central line placement, cutdown, chest tube, lumbar puncture
  30. Duration longer than 5 to 10 minutes
  31. Masks, drapes, and gowns. Clothing is an important barrier to microorganisms shed into the air from the skin and mucous membranes. The pore size of gowns and masks should prevent bacterial passage even when wet [use 140 thread count or higher unless plasticized (24)]. Disposable gowns and drapes manufactured from nonwoven materials are effective in reducing infection (25). When woven reusable materials are used, they should be tightly woven and treated with a water repellent.
  32. Put on cap and mask.
  33. Clean nails and “scrub” as for minor procedure, but continue for 4 to 5 minutes.
  34. Rinse forearms and hands, keeping them elevated above elbows.
  35. Dry hands and then forearms with two sterile towels. Keep wrists and hands elevated until drying is complete.
  36. Put on sterile gownwith the aid of an assistant (Fig. 4.1).
  37. Put on sterile gloves, without contaminating external surface with ungloved hand (Fig. 4.2).
  38. Have assistant open packet without contaminating contents.
  39. Pull gloves well over sleeve ends.
  40. Preparation of patient skin
  41. Prior to procedure, have assistant:
  42. Wash area, if soiled, with soap and water.
  43. If necessary, remove hair using small scissors, taking care not to nick skin. Do not shave the area.
  44. Apply antiseptic with three separate sponges. Start at center of circle, and work centrifugally to at least 5 cm outside immediate area of procedure. Alcohol (70%) should not be used. An iodophore preparation is commonly used in nurseries in the United States.

P.25

 

  1. Allow antiseptic to dry. Do not wipe off antiseptic prior to procedure.
 

FIG. 4.1. Correct technique for putting on a sterile gown. Operator is assisted into gown. A: The assistant pulls the gown up and back over the operator's shoulders by grasping the inside surface and ties the neck ties at the back of the operator's neck. B: Operator hands tip (protected with a removable cardboard tab) of sterile tie to assistant. C, D: Operator carries the tie around to the front where the operator takes tie (without the cardboard tab) and ties the gown.

  1. Complications
  2. Dry skin with repeated use
  3. Hexachlorophene
  4. Transcutaneous absorption with CNS vacuolation (26,27,28 and 29)
  5. Possible teratogenicity when used for hand washing by pregnant staff member (30,31)
  6. Iodine
  7. Burns
  8. Allergic contact dermatitis has been reported (32).
  9. Skin absorption/hypothyroidism (5,6 and 7)
  10. A high incidence of transient neonatal hypothyroidism has been observed in premature infants in Europe after routine skin cleansing with iodine. The same high incidence has not been noted in North America. This difference in incidence may be due to the prior iodine status of the neonate (5).
  11. Iodophore
  12. Burns possible when allowed to pool under infant
  13. Absorption through skin reported in burn patients and neonates (6)
  14. Alteration of thyroid function (5,7)
  15. Chlorhexidine

P.26

 

  1. Similarity in name and preparation has led to some confusion between chlorhexidine and hexachlorophene. These compounds are different in structure and properties (Table 4.1).
  2. Ototoxicity when instilled into middle ear (33)
  3. Burns possible when allowed to pool under infant
  4. Absorption through skin and from umbilical stump (34,35). No associated pathology was documented.
  5. Contamination with gram-negative organisms has been reported, in particular, Pseudomonasand Proteus species(36,37).
  6. There is no evidence that the detergent or alcohol preparations are susceptible to contamination.
  7. Alcohol burns in premature infants (38,39)
  8. Latex allergy in operators and in infants with neural tube defects (22,23).
 

FIG. 4.2. Correct technique for putting on sterile gloves. A: Assistant has opened outer pack, allowing removal of uncontaminated inner pack by operator. B: Correct method for lifting second glove with gloved hand to avoid contact with skin as second glove is pulled up over sleeve ends. C: Pulling first glove up over sleeve ends. The inside surface of the glove is never touched by the gloved hand.

References

  1. Centers for Disease Control and Prevention.Guideline for hand hygiene in health-care settings. MMWR. 2002;51:1.
  2. Centers for Disease Control and Prevention.Guidelines for the prevention of intravascular catheter-related infections. MMWR.2002;51:1.
  3. Kilbride HW, Powers R, Wirtschafter DD, et al. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia. Pediatrics.2003;111:504.
  4. Pittet D.Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Inf Dis. 2001;7:234.
  5. Brown RS, Bloomfield S, Bednarek FJ, et al. Routine skin cleansing with povidone–iodine is not a common cause of transient neonatal hypothyroidism in North America: a prospective controlled study. Thyroid.1997;7:395.
  6. Mitchell IM, Pollock JC, Jamieson MP, et al. Transcutaneous iodine absorption in infants undergoing cardiac operation. Ann Thorac Surg.1991;52:1138.
  7. Gordon CM, Rowitch DH, Mitchell ML, et al. Topical iodine and neonatal hypothyroidism. Arch Pediatr Adolsc Med.1995; 149:1336.
  8. Perspectives in Disease Prevention and Health Promotion Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood borne pathogens in health-care settings. MMWR.1988;37:377.
  9. Guidelines for prevention of transmission of human immunodeficiency and hepatitis B virus to health-care and public safety workers.MMWR.1989;38:3.

P.27

 

  1. Intravenous Nurses Society.Intravenous nursing standards of practice. J Intrav Nurs. 1998;21:51.
  2. Maki DG, Ringer M, Alvarado CJ.Prospective randomized trial of povidone–iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338:339.
  3. Webster J.Hand-washing in a neonatal intensive care unit: comparative effectiveness of chlorhexidine gluconate 4% w/v and triclosan 1% w/v. J Aust Coll Midwives. 1991;4:25.
  4. Webster J, Faoagali JL.An in-use comparison of chlorhexidine gluconate 4% w/v, glycol-poly-siloxane plus methylcellulose and a liquid soap in a special care baby unit. J Hosp Infect. 1989;14:141.
  5. Kinironos B, Mimoz O, Lafendi L, et al. Chlorhexidine versus povidone–iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anesthesiology.2001;94:239.
  6. Herruzo-Cabrera R, Vizcaino-Alcaide MJ, Fdez-Acinero MJ.Usefulness of an alcohol solution of N-duopropenide for the surgical antisepsis of the hands compared with handwashing with iodine–povidone and chlorhexidine: clinical essay. J Surg Res. 2000;94:6.
  7. Wilkinson AR, Baum JD, Keeling JW.Letter to the editor: superficial skin necrosis in babies prepared for umbilical arterial catheterization. Arch Dis Child. 1981;56:237.
  8. American Academy of Pediatrics, American College of Obstetricians and Gynecologists.Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American College of Obstetricians and Gynecologists; 2002.
  9. American Academy of Pediatrics.Report of the Committee on Infectious Diseases. 19th ed. Evanston, IL: American Academy of Pediatrics; 1982:243.
  10. Rotter ML.Hygienic hand disinfection. Infect Control. 1984; 5:18.
  11. Newman JL, Seitz JC.Intermittent use of an antimicrobial hand gel for reducing soap-induced irritation of health care personnel.Am J Infect Control. 1990;18:194.
  12. Doebbeling BN, Stanly GL, Sheetze CT, et al. Comparative efficiency of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med.1992;327:88.
  13. Pittman T, Kiburz J, Gabriel K, et al. Latex allergy in children with spina bifida. Pediatr Neurosurg.1995;22:96.
  14. Banta JV, Bonanni C, Prebluda J.Latex anaphylaxis during spinal surgery in children with myelomeningocele. Dev Med Neurol.1993;35:543.
  15. Moylan JA, Fitzpatrick KT, Davenport KE.Reducing wound infections. Arch Surg. 1987;122:152.
  16. Laufman H, Eudy WW, Vandernoot AM, et al. Strike-through of moist contamination by woven and non-woven surgical materials.Ann Surg.1975;181:857.
  17. Curley A, Hawk RE, Kimbrough RD, et al. Dermal absorption of hexachlorophene in infants. Lancet.1971;2:296.
  18. Anderson JM, Cockburn F, Forfar JO,et al. Neonatal spongioform myelinopathy after restricted application of hexachlorophene disinfectant. J Clin Pathol. 1981;34:25.
  19. Rossiter EJR.Hexachlorophene—time to stop. Aust Paediatr J. 1980;16:236.
  20. Martin-Bouyer G, Lebreton R, Toga M, et al. Outbreak of accidental hexachlorophene poisoning in France. Lancet.1982;1:91.
  21. Check W.New study shows hexachlorophene is teratogenic in humans. JAMA. 1978;240:513.
  22. Halling H.Suspected link between exposure to hexachlorophene and malformed infants. Presented at the New York Academy of Science, July 1978.
  23. Lee SK, Zhai H, Maibach HI.Allergic contact dermatitis from iodine preparations: a conundrum. Contact Dermatitis. 2005;52:184.
  24. Brickwell PG.Sensorineural deafness following myringoplasty operations. J Laryngol Otol. 1971;85:957.
  25. Agett PJ, Cooper LV, Ellis SH, et al. Percutaneous absorption of chlorhexidine in neonatal cord care. Arch Dis Child.1981;56:878.
  26. Cowan J, Ellis SH, McAinsh J.Absorption of chlorhexidine from the intact skin of newborn infants. Arch Dis Child. 1979;54:379.
  27. Bassett DC, Stokes KJ, Thomas WRG.Wound infection with Pseudomonas multivorans. Lancet. 1970;1:1188.
  28. Wishart MM, Riley TV.Infection with Pseudomonas maltophilia. Hospital outbreak due to contaminated disinfectant. Med J Aust.1976;2:710.
  29. Bonacci H.Letter to the editor: hazard in the nursery. N Engl J Med. 1970;282:633.
  30. Harpin V, Rulter N.Percutaneous alcohol absorption and skin necrosis in a premature infant. Arch Dis Child. 1982;57:477.