An Iodophor, Alkyl Aryl Polyether Ester Iodine Complex* USED AS AN ANTISEPTIC
SCRUB IN SURGICAL
AARON PRIGOT, M.D. AND SERGE Rot,
From tbe Department of Surgery of tbe Harlem Hospital Center, Department of Hospitals, New York, New York. Tbis investigation was supported, in part, b.y a arant from tbe Huntington Laboratories, Inc., Huntington, Indiana, whose trade name for tbis iodoobor is G.S.I. Germa-San Iodine Scrub.
M.D., New York, New York
12.75 per cent; sodium-n-methylcompIex, cocoanut oil taurate, 8 per cent; and water, 79.25 per cent, afforded a minimum of 0.75 per cent available iodine. EarIy in the investigation a lower concentration of the active component was tested. This preparation, which made avaiIabIe 0.5 per cent iodine, was we11 tolerated, but was found wanting in bacteria1 inhibitory properties. In three instances, after proIonged operations, cuItures made of perspiration in the surgeons’ gloves were positive. Further experiments confirmed the acceptabiIity and efficiency of the compound utilizing 12.75 per cent of the iodophor. ln animaI studies, paired scarified Iesions demonstrated no interference with wound healing when used either to prepare the operative site or for the cIeansing of the wound. The mixture Iathers readiIy, is of good viscosity, is easiIy applied to body surfaces and is not irritatmg to open wounds. When appIied to the skin with water, a yeIIowish lather resuIts and the skin is stained a light yeIIow. The iodophor was used as an antiseptic by members of the surgical staff in the foIlowing situations: (I) For cleansing open wounds; (2) preparation of the body surface for surgery; (3) as a surgica1 scrub.
PORADIC outbreaks of resistant infections in hospitaIs have led to a re-evaIuation of antimicrobial therapy, epidemiologic considerations, and hospital and operating room antiseptic procedures. In the reassessment of hospital practices in the scrubbing of hands, preparation of body surfaces for surgery and the management of open wounds, the search for more efficient antiseptic agents was begun. Iodine I?, although possessed of antiseptic properties, loses its antimicrobial potential in an aqueous solution in which the iodine must be converted to 1~. A tincture can be prepared for clinical use with aIcoho1 and saIts of iodine. This preparation, however, is unstabIe, irritating to the skin, and painful when appIied to open wounds. The high concentrations of iodine in the tincture may result in Iocal burns and have been associated with a high incidence of systemic allergic reactions. The usefulness of iodine obviously wouId be immeasurabIy increased if a suitabIe vehicle couId be found which would eliminate both local and systemic toxicity without impairment of germicida1 effciency. This study was addressed to the clinical evaIuation of a preparation designed to meet these criteria. The mixture of iodine alky1 aryl polyether aIcoho1
In the emergency empIoyed in the
Surgery. phor was
ward the iodopreparation of
FIG. I. A, compound fracture of the Ieft ankle before cleansing and debridement. fracture after LIeansing, debridement and reduction.
Iacerations for suture. When such injuries are not severe enough to require hospitahzation, the Iaceration is sutured in the emergency room and the patient is referred to the outpatient cIinic for further care. In more serious contaminated wounds, necessitating hospitaIization, such as Iacerations, extensive abrasions and compound fractures, the iodophor successfuIIy controIIed infection. At this hospita1 we are confronted with the probIem of management of severeIy traumatized patients. A roentgenogram (Fig. IA) of a compound fracture of the Ieft ankIe demonstrates a frequentIy encountered situation in which the iodophor, as an anciIIary to surgica1 debridement, afforded satisfactory resuIts. Figure I B iIIustrates the successfu1 cIeansing, debriding and reduction of the fracture, after which the patient made an uneventfu1 recovery without IocaI or systemic infection. The iodine compIex was used for the cIeansing of wounds in IOO patients, aIong with such mechanica debridement as was indicated. The patients reported no undue pain nor discomfort. AIthough the skin was stained a Iight yeIIow, this was easiIy removed from the surrounding areas by washing with water. AI1 wounds healed per primam. Preparation of the Operative Site. The iodophor was aIso empIoyed for the cIeansing of the appropriate body area in preparation for surgery in 127 patients as Iisted in Table I.
debris. B, same
Appendectomy ............................ Biopsy, control of hemorrhage. ............. Cecostomy or cIosure of cecostomy .......... ChoIecystectomy .......................... CIosure of coIostomy....................... CIosure of perforated gastric uIcer. .......... DiIatation of recta1 stricture ................ ExpIoratory Iaparotomy .................... ExpIoratory Iaparotomy for adhesions ........ Exploration for foreign body. ............... FistuIectomy ..............................
No. of Cases
6 4 2 3 4 5 2 I
Gastrectomy for ruptured uIcer. ............ GastrointestinaI resection. .................. Gastrostomy ..............................
Hemorrhoidectomy........................ Herniorrhaphy ............................ Incision and drainage of abscess ............. PuII-through operation, rectal stricture and imperforated anus. ...................... PyIoropIasty, vagotomy and antrectomy. .... R amstedt operation for hypertrophic pyIorus. Repair of achilIes tendon ................... Traumatic rupture of the bIadder and cystostomy ................................ . . ........................ w ound evrsceratron Inferior vena cava1 Iigation ................. TotaI ................................
16 I I
25 3 2 3 I I
4 2 I
AIkyI AryI PoIyether
was a single compIaint from the attending staff. One surgeon reported tingIing of the skin of the arms folIowing the scrub. In this instance, however, no erythema nor rash deveIoped. The tingling sensation was not of such severity as to prevent further use of the antiseptic. surgica1 procedures recorded in In 127 Table I, cultures were taken from the surgeons’ hands prior to scrubbing with the iodophor and from the perspiration in the surgeons’ gIoves at the end of the operation, a time lapse of a haIf to three hours. Initially, the following strains of organisms were cuItured from the hands of the surgeons:
Here again, the staining of the skin to a light yellow indicated the extent of coverage. CuItures of the skin, after preparation wit,h the iodophor, showed no bacterial growth. In these patients no irritation of the skin was noted and there was no interference with wound healing. Although sixty-four abdominal procedures were performed in a contaminated GeId, no wound infection occurred. Surgical Scrub. Twenty-five attending surgeons and eleven residents used the iodine complex as a surgical scrub for a period of approximately eighteen months. iLlembers of the attending staff generally scrubbed with it only once a day; whereas, the residents empIoycd it two or three times daily. The tota number of operations in this phase of the investigation was 2,568. They represented the full range of surgical procedures performed in a genera1 hospital and invoIved al1 parts of the bodv. The time for the scrubbing procedure was a fuI1 ten minutes for the first scrub and five minutes for repeated scrubs. In ten emergency which necessitated reducing the patients, scrubbing time to five minutes, cultures of perspiration in the surgeons’ gIove were negative for bacteria1 growth. NevertheIess, it was deemed inadvisabIe to aIter the hospita1 routine with respect to scrub duration. The usual scrubbing technic was unchanged. A brush was used and an orange stick was employed for removing matter from under the fingernaiIs. The hands and arms were washed with the iodophor and then rinsed. An adequate amount of the antiseptic was appIied to the hands to produce a fuI1 Iather and scrubbing was started. As the iodine compIex was diiuted with water, the color of the Iather changed from yeIIow to white. More of the antiseptic was added to maintain the yeIIow color. At the end of the scrub, the skin of the hands and arms was IightIy stained. The yeIIow tinge usuaIIy disappeared 1~~ the end of the surgical procedure. At this Institution, a powder containing starch is applied to the hands prior to putting on gloves. On contact with the skin, a blue color denoted iodine on the hands. The presence of iodine was thus cIearIy discernibIe at al1 times in which the antiseptic was empIoyed as a scrub for the surgeons’ hands. No side effects nor alIergic reactions were reported from the resident staff, by whom the iodine scrub was most frequentIy used. There
StaphyIococcus aureus variety albus. BacilIus subtilis.. Escherichia coli., Streptococcus faecalis. Diphtheroids.. . Beta hernolytic streptococcus. Gamma hemoIytic streptococcus.
I0 5 15 5
In a11 cases in which the duration of surgery was one hour or Iess, cuItures of the perspiration from the glove at the conclusion of the operation showed no growth. Forty-one operations in this series Iasted Ionger than one hour and in ten cases the operation was executed in an infected fieId. In these fifty-one instances, three cuItures of perspiration at the end of surgery were positive for StaphyIococcus aureus variety aIbus. These positive cultures, however, were obtained during the phase of this study when the Iesser concentration of the iodine complex was utiIized. Following the increase to 0.75 per cent avaiIabIe iodine, there were no positive cuItures.
Despite its antibacteria efficiency, the use of tincture of iodine for preoperative preparation of body surfaces and other surgica1 purposes is disadvantageous because of topica and systemic reactions, often of a serious nature. In bacteriologica studies, anima1 experiments and extensive clinica tria1, an iodophor, iodine in a stabIe organic compIex, demonstrated proIonged germicida1 action without the danger of cutaneous burns, irritation and aIIergic manifestations, and there was no interference with wound heaIing.
Prigot and Rot Its use on the surgica1 service incIuded the cIeansing of Iacerations prior to suturing in IOO operations, the preparation of the body surface for surgery, 127 operations, and as a preoperative scrub for the hands of the surgeons in 2,958 operations. We found the aIky1 ary1 poIyether aIcoho1
ester iodine complex an exceIIent antiseptic for surgica1 practice.
Acknowledgment: We gratefuIIy acknowIedge the assistance of Mr. EIIis Patrick in the tabuIation and anaIysis of the records of 2,800 patients in this investigation.