A review of suspected intraoperative antiseptic burns: A quality improvement review

The use of antiseptics in theatre is mainstay treatment in reducing cutaneous bioburden and, in turn, preventing surgical site infection and sepsis. Typically, aqueous betadine and chlorhexidine in alcohol are preferred. Aqueous betadine is a broad-spectrum antiseptic with a quick kill rate but is deactivated by organic material on the patient's skin. More effective than aqueous betadine is chlorhexidine gluconate - it is also a broad-spectrum antiseptic but is not deactivated by organic compounds on the patient's skin.


Introduction
The use of antiseptics in theatre is mainstay treatment in reducing cutaneous bioburden 1 and, in turn, preventing surgical site infection and sepsis 2,3 .Typically, aqueous betadine and chlorhexidine in alcohol are preferred 3 .Aqueous betadine is a broad-spectrum antiseptic with a quick kill rate but is deactivated by organic material on the patient's skin 3 .More effective than aqueous betadine is chlorhexidine gluconateit is also a broad-spectrum antiseptic but is not deactivated by organic compounds on the patient's skin 3 .
The incidence of antiseptic chemical burns is a rare but recognised potential adverse intra-operative event 4 .Wall and colleagues 5 highlighted that antiseptic burns are also termed 'irritant contact dermatitis'.Symptoms include pain at the area of direct contact 5 and skin changes including changes from erythema and blistering to skin necrosis 5 .These changes are symptomatic of burns ranging in severity from superficial burns to deep dermal-subcutaneous (full thickness) burns 6 .Antiseptic burns require management via the burns protocol pathway and are reported to take several weeks to heal 6 .There are several known factors which contribute to the development of antiseptic burns intra-operatively.These include 1,5,7  • 'Alcoholic preparations are a fire risk; therefore, it is vital to prevent pooling of solution, remove under pads that are soaked with skin preparation solutions prior to draping and allow time for skin preparations to dry prior to placement of drapes to prevent a build-up of vapour.' 8 (p,1) • 'Selection of antimicrobial agent is based on: patient sensitivity, the operative site, conditions of the patient's skin, surgeons' preference, patients preoperative shower and/or compound scrub; all should be of the same antimicrobial solution.' 8 (p,1) • '… the prevention of pooling of solutions underneath the patient and beneath the pneumatic tourniquet, to minimise the risks of chemical burns to the skin and or a source of ignition.p,1) Peer-reviewed article

Method
This quality improvement activity required a review of all operating theatre incidents logged for 2015 through the hospital's incident database.A chart review was then conducted of all suspected intraoperative burns injuries.Seven charts were highlighted in the review.
Results and outcomes were reported to management with strategies put in place to improve patient outcomes and minimise future risk.

Analysis Incident and chart reviews
Table 1 summarises patient demographics, adverse events, antiseptic and occlusion time.
• This patient grouping did not recover in a single post-operative ward -both a specialised surgical ward and a maternity ward accepted these patients.
• There is no consistency -asepsis was provided by treating teams, surgeons and nursing staff who included a diversity of skill level, that is, junior and senior staff.
• There are no consistent comorbidities or surgical procedures among those harmed.
• Only aqueous betadine or chlorhexidine in alcohol were used as antiseptics.
A total of seven patients were highlighted with suspected antiseptic burns.Three patients were confirmed to have developed the injury post-operatively.This assessment was completed by the hospital's specialised wound service.
Two of these patients are known to have antiseptic burns.They were both maternity patients who had caesarean sections.The burns took 48 hours to develop into blisters.Initial injury noted was 'erythema'.
One of these patients was referred for a 'pressure injury'; upon review it was noted that the injury was not consistent with a pressure injury and that an antiseptic burn was the likely cause.The other patient had reported the injury upon discharge to the hospital's patient liaison officer.With the latter patient, it was known that her skin was compromised preoperatively as she had developed a rash, polymorphic eruption of pregnancy (PEP), which may have increased the permeability of the antiseptic through the damaged skin 9 .This patient consented for her injuries to be photographed (see figures 1 to 3).It should be noted that on day two postoperative, this patient reported developing erythema, blistering and pain on her thighs (Figure 1).This progressed to a wound with epidermal loss into the dermis (Figure 2) and the wound healing with immature scar tissue present (Figure 3).
The third patient who was reviewed was asked to seek the opinion of a dermatologist.At the time of injury development and during subsequent reviews this patient reported a life-long skin sensitivity to tapes; therefore, despite the injuries occurring intra-operatively, a differential diagnosis of blistering disorder needs to be considered.
Two patients had tourniquet injuries.
One young male sustained injury after 23 minutes and an elderly gentleman had an injury develop after 93 minutes of tourniquet application.The elderly patient had an internal review of the incident at the time and it was suspected that the injury may have been related to prolonged use of the tourniquet, although the duration was considered appropriate.In light of recent skin injuries, burn by antiseptic cannot be ruled out.
Another patient reported a groin burn post hysteroscopy dilation and curettage (D & C) for vaginal bleeding.The patient's notes highlighted that there was no cauterisation required.The only likely source of burn in this instance may have been the end of the light cord which can become hot during use.Therefore, it is not an antiseptic burn; however, it has been included in this brief due to the nature of the injury and its relation to current Work Unit Guidelines (WUGs) in place.Finally, an injury was caused by a diathermy plate rather than an antiseptic.However, it has been included in this brief due to the nature of the injury and its relation to current WUGs in place.

Discussion
Antiseptic burns are considered a rare adverse intra-operative event.In this quality improvement review, the development of these burns is likely due to several factors.A suspected commonality is that patients may have been resting for prolonged periods of time on moistened surfaces or moistened tourniquets.In regards to risk factors highlighted previously: • concentration of the antisepticaqueous betadine and chlorhexidine in alcohol were used • humidity and moisture -it can only be assumed that there was increased humidity as the surfaces in contact with skin had no moisture vapour transfer capabilities.In particular, the tourniquets may have retained moisture after contact with the antiseptics.It was also assumed that staff members may have applied excessive amounts of antiseptic which saturated drapes and sheets, therefore increasing the risk of injury.The linear lesions in Figure 1 are consistent with 'wet' bedsheets.

Lessons learnt: Recommendations and changes to practice
A cluster of incidents occurred prompting immediate action by nursing leaders.At the time of the original review, February 2016, there had been one further suspected antiseptic burn which occurred during changeover of new surgical (Registrar) teams at our hospital.On prompt review of the patient's clinical notes, it was determined that the theatre protocol, such as changing wet sheets and applying protection under tourniquet, was not followed.
At the time of the cluster of suspected intra-operative chemical burns, immediate action involved: • review of Australian College of Perioperative Nurses (ACORN) Standard 5 with nurse unit managers (NUM) and theatre staff • review of WUGs in conjunction with literature review • reiteration by the Nurse Educator of WUGs for review within theatre and among theatre staff.
Planning for the future (Accountable staff: NUM and Nurse Educators of theatre) • The review highlights the importance of pre-operative and post-operative skin assessment.
• There is a need for ongoing education to support staff in theatre, including new graduates or new employees.
• Further actions taken following review and discussion: • changes to theatre orientation checklist, to ensure saturated drapes and tourniquets are changed prior to the procedure Planning for the future (Accountable staff: Wound Management Service) • Review patients referred for suspected antiseptic burns.
• Provide support (patient review and implementation of treatment plans) to theatre, recovery or day procedure staff in relation to patients with altered skin integrity who may be at risk of further intraoperative injury.
• Educational sessions about skin assessment and wound management held by the Would Management Service and disseminated to nursing, allied health and medical staff.
Dissemination of results to a wider nursing and theatre staff community • In-service for theatres were completed (Nurse Educator will provide further ongoing sessions locally).
• Presentations were prepared for Nursing Grand Rounds and Multidisciplinary Grand Rounds locally.
• Presentations to theatre and surgical staff within the Australian and international community.
• Publication to share lessons learnt, with the wider operating theatre team community.Ethics approved HREC/16/QPCH/52.

Table 1 :
Chart review from injuries identified via incident reports