Use of Povidone I and H2O2 to reduce spinal infections

Comments

1. Dr Senthil Nathan says

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   Dear all,

   My opinion about the use of PI and H2O2 in spinal wounds as per the study may have reduced the infection rate. However the development of infection has many reasons go it as we all know. The use of H2O2 and PI has been shown to have increased the risk of postoperative arachnoiditis and pain over long term. also the incidence of infection in pAtients operated in 2008 needs to looked upon. Just by washing the wound with sterile irrigation will suffice rather than increase the risk of postoperative arachnoiditis.

   Senthil

2. KV Menon Dr says

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   Thanks for bringing my attention to this paper. There are several contentious issues-
   1. H2o2 is tissue toxic, and causes thermal necrosis but I am not aware that it can cause embolisation and has been discontinued by the BNF.
   2. Povidone Iodine has not been recommended for irrigation (except bladder) because it gets inactivated in tissue within seconds (no difference between Betadine and N Saline)
   3. The normal infection rate in spine surgery is very low- therefore to diagnose a positive impact of intervention one needs a huge number of cases whichI am not sure was tested.
   Best Regards

3. admin says

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   What I am really worried is Air embolism due to hydrogen peroxide use.

   the following papers highlight the problem:

   1. http://www.ejbjs.org/cgi/content/extract/86/4/821

   2. http://www.ncbi.nlm.nih.gov/pubmed/10071628

   3. http://bja.oxfordjournals.org/content/88/4/597.full

4. Renjit Kumar, Oncospinal surgeon, AIMS, Kochi says

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   I am not certain about air embolism unless there are open large bore vein in the vicinity. I agree with Dr Menon about the fact that simple things like tissue handling, saline wash and debrima of suspicious muscle before closure is all that is required to reduce SSI. This study is of little value unless the results can be reproduced by an RCT. Cheers

5. admin says

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   Hydrogen peroxide is often used by some surgeons not only in trauma surgery, but even in elective hip arthroplasty. I have put up this paper to get personal experience on usage of hydrogen peroxide. In my hospital, a patient expired 3 years ago during hydrogen peroxide irrigation of a contaminated wound and provisional diagnosis of air embolism was made by our anaesthetist.

6. Dr Amit Bhandarkar says

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   I am totally against this concept

   if you research into the pharma literature- mixture of poviodne iodine and hydrogen peroxide in certain proportions is explosive.

   it is very important to understand that povidone iodine should only be used externally for surgical preparation and it is not meant to be used internally,it is not only cytotoxic but it has systemic absorption and there are many case reports on pubmed warning of blindness to death.

   hydrogen peroxide is a desloughing agent and is totally contraindicated in the surgical wounds- any literature supporting this should be condemned- it is highly cytotoxic and yes it causes thermal necrosis.

   if i have to use any analogy for h202 — if acid has got a bactericidal action it does not mean it is to be used in the surgical wounds

   the side effects of these agents really outweigh any kind of beneficial effects in spine surgery

   but let me draw your attention to one of the articles published in spine journal about
   poviodone iodine from korea ;; — it talks about a bactericidal concentration of iodine that is not cytotoxic can be used in superficial incisions after the fascia is closed followed by irrigation with saline. to use it that way u need to now the physical property of povidone iodine that its cytotoxicity and bacteriocidal activity increases with dilution as more free iodine become available and beyond certain dilutions the bactericidal activity remains and cytotoxicity fades. this dilution is difficult to achieve and it is definitively altered by amount of organic tissue present in the wound. even though authors of this papers too achieved a good infection control rate- it is difficult to make any conclusions as control group is difficult to obtain.

   remarks are welcome

   Amit Bhandarkar
   spine fellow
   UAB Birmingham

7. Dr. Arabind kr' shah says

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   I have been using H2O2 &PI combination for very long time.I have never come across any ill effects.Only thing it should be used carefully.Not only in post operative infections, it works wonder in traumatic lacerated infections also.

8. Dr Niraj B Vasavada, Spine Surgeon, Wochardt Hospitals says

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   I am not aware about surgeons using Povidone Iodine for irrigation of spine surgical wound. But yes, during my fellowships i have seen korean surgeons use diluted H2O2. They use it not to prevent infection. But they use it for its haemostatic properties. Minute oozes can be controlled by irrigation of diluted H2O2 followed by copious irrigation with cold saline. I use it quite frequently at the end of the procedure and haven’t encountered any untoward effects so far. But i havent seen surgeons using it to control infection.

   Furthermore, I do agree with Dr. Menon that as such infection rate in spine is very low. And i think irrigation with plenty of saline at the end of procedure is sufficient enough to prevent colonization of pathogens, same way we orthopodes do in Open fractures.

9. Dr George Thomas, Editor Indian Journal of Medical Ethics says

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   Dear Hitesh,

   As we all know, infection control involves a lot of factors. we also know that hydrogen peroxide has no effect on infection and is a drying agent which releases oxygen derived free radicals which are bad for tissue healing. We use hydrogen peroxide to dry the bone before cementation taking care to not allow it to spill on the soft tissues as much as is possible. Povidone -Iodine is an effective antiseptic but can cause anaphylaxis rarely if applied directly to raw wounds.
   The article is a retrospective analysis with all the problems associated with such a trial design. I would consider it Level IV. I would be reluctant ever to use this protocol because of the problems with hydrogen peroxide and povidone-iodine.This article will not change my practice in any way.

10. Siddharth Joglekar, Orthopedic Oncology Fellow Mayo Clinic Rochester, MN says

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    The opinions presented by all the authors are very useful to understand this issue.
    Infection risk is approximately 2.2% in the the setting of prophylactic antibiotics. In this situation large numbers are needed to prove the effectiveness of any infection control measure. Unless a power analysis is performed and followed up with a well designed randomized controlled trial (in short in the absence of good evidence) it will be hard to justify the use of any chemical or measure that has been associated with reports of toxicity or adverse reactions.

    The only RCT on the use of povidone iodine is published by Cheng and Chang from Taipei and they have concluded that PI is useful however there are a few serious questions regarding the study:
    1. No power analysis was performed prior to study
    2. Antibiotic protocol may be considered excessive by current standards
    3.An infection rate of zero in the PI group in 208 cases is highly questionable. Anybody doing spine surgery will find this infection rate curiously low!
    4. Inclusion exclusion criteria not clearly defined
    5. Same study published in two different journals (unethical and undermines credibility)
    6. Randomization technique not completely acceptable
    7. Single blinded without any independent observers

11. bimal says

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    dear hitesh,

    i could only go through the abstract of the study…in my opinion this study is not properly evidenced for it to be taken very seriously..i mean to consider something like using peroxide in wounds…single center level 3 evidence, i guess. isn’t it?..personally i have reservations about using peroxide in any surgical wound and i am not convinced about superiority of povidone iodine above say, normal slaine (especially in closed wounds)..havign said that i am not aware of any specific situations in spine …what s ur take on this..

    regards,
    bimal

12. Vinod Naneria, Consultant, Indore says

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    The present article has re-established the importance of “wound irrigation” before closure of surgical wound. Irrigation of the surgical wound certainly reduce the load of contaminating bacteria in the wound. Lot many things are being used for irrigation from plain saline, and Chlorhexidine, to triple antibiotic solution (Polymixin + Basitracin + Neomycin). This study has confirmed the advantage of H2O2 and Povidone Iodine 10% irrigation in reducing the infection rate to Zero in 490 spinal surgeries done in year 2009 compared to 7 deep wound infections in 460 surgeries done at the same setup with same team in the year 2008. The authors need complements for proposing a systematic method of use of irrigating solution including the quantity of Iodine and H2O2 with water and the exact duration of exposure to soft tissue.
    However there are some drawbacks. The study has not compared with irrigation using plain saline/ chlorhexidene/and other antibiotic solutions. The infection rate as such is high in cases of spinal fusion with instrumentation and more so with the use of BMP for acceleration in fusion. The deep infection occurred in 2008 were cases of spinal fusion following laminectomy or instrumentation.

    A detailed investigation as to the cause of infection in these cases should have been included in the study in order to pinpoint the reduction in the infection is solely due to Povidone Iodine and H2O2, and there was no other deviation from the standard practice of routine spinal surgery.
    Authors agreed that improvement in the surgical technique and improved precautions also helped in reduction of infection rate. Use of oral antibiotics for 7 days in post operative period in the current study is not supported by the world literature.