Nurses Can Protect Patients From Neurotoxicity During Lumbar Puncture Procedures

Chlorhexidine gluconate (CHG) solution has been considered the broad-spectrum germicide (https://rapm.bmj.com/content/31/4/311) effective against most nosocomial yeasts and gram-positive and -negative bacteria. It’s available as 2% or 5% CHG in 70% isopropyl alcohol and is used as an antiseptic for skin preparation and central venous catheter dressings. Oncology nurses may use it to prepare skin for therapeutic or diagnostic lumbar puncture procedures, including spinal anesthesia, intrathecal administration of chemotherapy or antibiotics, and contrast media for myelography or for cisternography. Concerns have emerged for CHG’s use as an antiseptic solution used for cleaning skin prior to any neuraxial procedures (spinal or epidural) because studies have reported neurotoxicity and neurological complication (https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.12844) after cleaning with CHG 2% or 5%, despite the evidence-based recommendations that CHG is the superior aseptic solution.

In 2008, the U.S. Food and Drug Administration (FDA) issued a product label warning against the use of CHG (https://www.accessdata.fda.gov/drugsatfda_docs/nda/2018/208288Orig1s000MedR.pdf) for “lumbar puncture or in contact with the meninges’’ because of the lack of clinical safety evidence and testing for the use of CHG for skin antisepsis before lumbar puncture. Although there is minimal percutaneous penetration of CHG as it adheres to the stratum corneum—which increases its length of action—it could potentially put patient at risk (https://academic.oup.com/bja/article/103/3/456/245003) for neurological complication.

Using CHG Versus Povidone Iodine

CHG has a faster onset and longer duration of action than povidone iodine. It retains its efficacy (https://onlinelibrary.wiley.com/doi/full/10.1111/anae.12844) and is associated with a lower incidence of skin reactions (https://rapm.bmj.com/content/31/4/311) than povidone iodine as well. To date, CHG is considered to be safer for lumber puncture (https://rapm.bmj.com/content/37/2/139) or any procedures involving the spine or neuraxis. However, the manufacturer recommends letting it dry completely (https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/21555Orig1s024lbl.pdf) before surgical procedures not involving the lumbar neuraxis (spinal and epidurals). One study showed that drying time for CHG (https://academic.oup.com/bja/article/103/3/456/245003) could reach up to three minutes and 15 seconds and that patient characteristics, environmental factors, and application methods could influence drying time.

One study recommended to use alcohol and a disinfectant (https://rapm.bmj.com/content/37/2/139) such as povidone iodine on the overlying skin for lumbar puncture-related procedures. Allow the antiseptic to dry completely before beginning the procedure.

How to Address Safety Concerns With CHG

When preparing a patient for intrathecal procedures, nurses should consider all the facts for patient safety:

• Review the package insert alert information with the team.
• Adhere to outlined FDA recommendations and product label warnings against the use of CHG for lumbar puncture or in contact with the meninges.
• Ensure nurses receive proper training and education and are aware of the potential complication of the using CHG as antiseptic for lumbar neuraxis-related procedures.
• Routinely check that up-to-date, evidence-based procedures are documented and followed.
• Prevent CHG from reaching the cerebrospinal fluid.

• Keep CHG away from other drugs and equipment.
• Allow the solution to completely dry prior to beginning procedures.

Nurses are the first line of safety for their patients. Understanding the potential hazards and best practices for effective, safe care is vital to successful patient outcomes. Work together with your team to stay up to date with the latest evidence in practice, and reinforce a culture of safety (https://voice.ons.org/topic/safety) and accountability in your institution.