Coming clean about chlorhexidine

Introduction

Recent chlorhexidine claims we have dealt with

Alcoholic chlorhexidine is one of many factors in a surgical fire. However, its most notable role is when aqueous chlorhexidine is requested and instead alcoholic chlorhexidine is provided. This confusion typically arises when both solutions being used in the same theatre are the same colour – usually both being pink. If the wrong solution is picked off the shelf to be poured out and the decanting bottle is not properly checked, the indistinguishable solution applied to the patient is not actually what has been requested. This only becomes apparent when there is an unexpected flame with the potential to cause burns to the patient and any staff nearby.

Another cause of an alcoholic chlorhexidine-related fire is when its drying time is insufficient. Alcoholic fumes persist and again form a fuel source where a disastrous outcome can ensue.

Chlorhexidine contact allergy has a prevalence of 0.47-1%^4,5. Patients have suffered cutaneous reactions to anaphylaxis from the application of chlorhexidine even when this has been a documented allergy. Despite the prevalence listed above, many consider chlorhexidine allergy is under-recognised⁶. Chlorhexidine is not a benign product and can cause unbeknown side effects.

Learning points

Chlorhexidine use is susceptible to active (individual) and latent (system) errors. A range of mitigation measures are required to address these.

This encompasses everything from fire awareness and an understanding of the flammability of chlorhexidine (especially when direct diathermy is involved or due to fume accumulation and hence why evaporation is important), to the risks of pooling under drapes, tourniquets, diathermy return plates, near ECG or other electrodes, to the variety of products on the market, how they appear and how they may be indistinguishable.

Like any medicinal product, checks by appropriate staff need to be undertaken on the product and its expiry date.

Where possible, theatres should procure different coloured solutions to help facilitate distinguishing between those that can be of the same colour but different products . Alternatively, a completely different means of delivering one sort of product could be obtained, eg. single use disposable closed applicator system for alcoholic chlorhexidine.

Competent persons should undertake skin preparation. This involves allowing sufficient drying time for the alcohol to evaporate, watching out for pooling, not using excess solution, wiping off any that happens to be in excess, checking areas for excess before applying occlusive dressings, and removing soaked gowns, drapes etc before diathermy.

Like any medicinal product, patients should be asked if they have any allergies to chlorhexidine. These should be appropriately recorded, staff made aware, and alternatives used.

Consider advising patients about the side effects of chlorhexidine prior to use and documenting their acceptance to proceed with it with this knowledge.

Record which type of antiseptic was used, when, where, and by whom, so that if anything untoward arises, an investigation is better facilitated.

Summary

Chlorhexidine use in skin antisepsis is ubiquitous but not without side effects or even disastrous consequences^7-9. Chlorhexidine-related claims seen by Medical Protection are not novel, instead reflecting those seen by others⁹. However, they serve as a reminder of the active and latent errors that can arise even in routine procedures which require many lessons to manage them and promote patient and staff safety.