AnaesthesiaVolume 70, Issue 3 p. 367-368 CorrespondenceFree Access Skin antisepsis guidelines – presentation or concentration? J. A. Hell, J. A. Hell john.hell@uhs.nhs.uk University Hospital, Southampton, UKSearch for more papers by this authorT. D. Madamombe, T. D. Madamombe University Hospital, Southampton, UKSearch for more papers by this authorM. Cordingly, M. Cordingly University Hospital, Southampton, UKSearch for more papers by this authorC. A. Eynon, C. A. Eynon University Hospital, Southampton, UKSearch for more papers by this author J. A. Hell, J. A. Hell john.hell@uhs.nhs.uk University Hospital, Southampton, UKSearch for more papers by this authorT. D. Madamombe, T. D. Madamombe University Hospital, Southampton, UKSearch for more papers by this authorM. Cordingly, M. Cordingly University Hospital, Southampton, UKSearch for more papers by this authorC. A. Eynon, C. A. Eynon University Hospital, Southampton, UKSearch for more papers by this author First published: 11 February 2015 https://doi.org/10.1111/anae.13026Citations: 2 No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat We were interested to read the recent AAGBI guidelines on skin antisepsis for central neuraxial blockade 1. We note the concerns surrounding the use of chlorhexidine in 70% alcohol and its potential to cause adhesive arachnoiditis if injected or allowed to contaminate anything injected into the spinal canal. The letter in response to the recommendation to use 0.5% chlorhexidine in 70% alcohol from West and Pawa appeared sensible and balanced 2: skin antisepsis using a swabstick to apply chlorhexidine in alcohol prevents the solution being injected, so long as it is allowed to dry completely. The only formulation currently available as a swabstick is 2% chorhexidine in 70% alcohol. Therefore, whilst a lower concentration of chlorhexidine may reduce the risk of neurotoxicity, it is not available in the safest form of applicator, and is not likely to be released in that form in the forseeable future. We welcome a full and open discussion about this topic, which affects not just all anaesthetists but anyone that performs neurosurgery, lumbar punctures or spinal drain insertions. We suggest that there are certain core principles that are not in dispute: The technique of skin disinfection must avoid any possibility of chlorhexidine in alcohol's contaminating any fluid that is injected into the spinal canal; The safest current method of applying skin antisepsis is to use a swabstick that can be disposed of immediately after use. This avoids the risk of antiseptic solutions’ being injected, splashed or aerosolised and contaminating the sterile procedure trolley; The lowest concentration of chlorhexidine that achieves the maximal degree of skin disinfection should be employed, provided that it is available in a swabstick; The antiseptic solution applied must be allowed to dry completely and the gloves used for its application changed to a new, dry, sterile pair before the procedure trolley is accessed; Tinted antiseptic solutions allow better identification of the area of skin disinfected. They also ensure that it is immediately obvious if any solution should contaminate any part of the procedure trolley or sterile gloves; Chlorhexidine in alcohol is a more effective skin antiseptic than povidone iodine. As such, it should be the agent of choice. After consulting with the lead neurosurgical, neuroanaesthetic and neurointensive care consultants at our hospital, we have decided to continue using swabsticks containing 2% chlorhexidine in 70% alcohol for skin disinfection. References 1 Association of Anaesthetists of Great Britain and Ireland Obstetric Anaesthetists’ Association Regional Anaesthesia UK Association of Paediatric Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade, 2014. Anaesthesia 2014; 69: 1279– 86. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2West SJ, Pawa A. Continuing to use 2% chlorhexidine applicators. Anaesthesia 2015; 70: 234– 5. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar Citing Literature Volume70, Issue3March 2015Pages 367-368 ReferencesRelatedInformation

inserted. Air was inserted to produce a cuff pressure of 25 cm H2O. The tube was secured at 18 cm at the lips, resulting in easy hand ventilation with bilateral air entry on auscultation, and the patient was put onto the ventilator without problems. The ICU nurse at the bedside noted an audible leak within a few minutes, after the chest X-ray was performed. On examination, air entry remained audible bilaterally, but the tidal volumes had dropped and there was an obvious cuff leak. The cuff was inflated with a further small amount of air, but this did not improve the leak, and the cuff pressure was now measured at over 80 cm H20. The decision was made to replace the ETT. The ETT was railroaded over a bougie and ventilation recommenced without incident. On examination of the original tube the tie was noted to have enclosed the pilot balloon tubing causing a kink at the junction of this tubing and the ETT (see Figure 1). This had prevented effective cuff inflation. When the tie was removed and the kink was relieved the cuff functioned normally. Although this problem was resolved rapidly with reintubation, an ongoing, untreatable leak from cuff inflation failure could have exposed the patient to significant morbidity. Previous case reports describe a similar complication relating to the use of a bite block2 and difficulty in cuff deflation resulting in failed extubation.3 In our Trust, ICU nurses tend to secure and tie tubes once the patient is intubated. We appreciate now that the tying of ETT tubes is a joint responsibility and suggest a quick visual check of the pilot balloon tubing and tie positioning could ensure this particular complication would not be repeated.