AORN J O U R N A L AUGUST- 1984. VOL 4 0 E

Guest Editorial Benefits of alcohol rediscovered

lcohols have been used as topical an- timicrobials since antiquity. Yet, as A skin disinfectants, particularly prior to

a surgical incision, they lost favor in the half- century from 1930 through 1980. They were replaced by a variety of bactericides, usually gaily colored, and far, far more expensive.

Many of us feel the reason for this was not dissatisfaction, but the fact that no one was actively "selling" alcohol as an antiseptic. Salesmanship, or lack of it. prevailed despite the repeated unreserved advocacy of P B Price, Mor- ton, and a host of others.' In the Federal Register of Jan 6. 1978, the US Food and Drug Adminis- tration (FDA) issued a monograph on Over- thecounter Topical Antimicrobial Drug Prod- ucts. It dismissed alcohol almost without men- tion. except for removal of the tincture of iodine (the only surgical skin preparation that got full approval).2 I shall refer to this later.

Fortunately. in the last year alcohols have again been recommended, and are, at last, being "sold" for skin preparation for surgery.

W History

angensteen has reminded us that "no other antiseptic agents command so great a literature in wound therapy as

do wine and alcohol": both wine orally and the stronger distillates t~pically.~ Galen ( 131-201 AD) recommended the use of alcohol dressings for all wounds. When, in the 13th century, distil- lation was discovered, Aqua Vitae (the water of life). a name given to brandy by the alchemists,

was recommended as wound treatment by Guy de Chauliac (1363). It was later endorsed in medical annals by such greats as Ambroise Pare and Laurenz Heister (although they tempered their faith by also recommending turpentine and other materials on open wounds).

Nelaton in the latter half of the last century recommended alcohol soaks before a surgical incision. His surgical infection rate was so low that in I865 the dressing of wounds with alcohol was called the "ordre du jour." Although there was considerable disagreement about the use of alcohol poured into open wounds, there did not appear to be much question about its use on the intact skin. Those who decried its use did so on the basis that it prevented the fonation of laud- able pus.

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Ethyl and Isopropyl Alcohol

here is no doubt that both ethyl and iso- p p y l alcohol have the attributes of de- T sirable disinfectants. They are bacteri-

cidal rather than bacteriostatic, killing vegetative forms rapidly, and are effective against the pseudomonas and tubemle bacilli. This quality places them in a special class over the other bactericides, according to Spaulding?

Ethyl and isoppyl alcohol are relatively in- expensive (apparently a drawback), readily available, have a cleansing action, are &fatting, and evaporate rapidly. Unfortunately, they are colorless, so the area treated is not delineated. This is easily remedied by the addition of a dye. Alcohols are not sporicidal, at least in the time they are used. Yet, this is not necessarily a draw- back as none of the chemical disinfectants other than iodine are. They do exert a drying action, particularly absolute ethyl alcohol. However, this can be remedied for repeated use, as in hand degerming, by p p e r

A large variety of skin antiseptics have been formulated as alcohol solutions or tinctures. Molinas and Brewer, however, found that the action of the proprietary pparation designated for disinfecting the skin depends on the alcohol solutions in which they are incorporated.6 For example, the addition of chlorhexadine and hexachloraphine to 75% or 95% alcohols did not improve the antibacterial effect.

Mode of Action

W ’hile studies on alcohol have been going on a longer time than with other chemicals, the exact mode of

alcohol’s action is still not completely under- stood. Morton states that the most plausible ex- planation for the antibacterial action is the &- naturing of proteins.’ This process is best accomplished in the presence of some water. This explains why absolute ethyl alcohol is less bactericidal than mixtures containing water. Rice has shown the great value of ethyl alcohol in either a 75% or 95% concentration.* This has been confmed by many authors.

While its bactericidal value is great for vegeta- tive microorganisms, it is not sporicidal. In fact, spores have been reported to be cultund from alcohol preparations. But this is true of all chem- ical disinfectants except iodine, which is the only disinfectant given full approval in the monog- raph written by the FDA.9

When this FDA publication appeared in the Federal Register, the American College of Sur- geons and the Association of Operating Room Nurses both registed a protest that the alcohols were not mentioned. Others may have similarly protested. Possibly, as a rcsult of these ptesta- tions, the FDA four years later published an addendum in the Federal Register entitled “Al- cohol Drug products for Topical Antimicrobial Over-the-Counter Human Use; Establishing a Monograph and Reopening of Administrative Record.”’O

This document discusses all of the alcohols and gives ample references to the many studies attesting to the value of ethyl and isopropyl al- cohol. After this lengthy and scientific review that verifies the superior behavior of these al- cohols, it ends with the almost ludicrous indica- tions that “ethyl alcohol 60-95%, denatured according to the Treasury Department’s regu- lations and 50-91.3%” are indicated for

0 fmt aid to decrease germs in minor cuts and Scrapes

0 decreasing germs on the skin prior to re- moving a splinter or other foreign object preparing of the skin prior to an injection.

Perhaps Plutarch was correct: ‘‘The old p v e r b was now made good, the mountain had brought forth a mouse. ’* In other words, the FDA has not mentioned skin preparation for surgery, but con- fmes skin sterilization to miniscule (not even minor) procedures.

I believe that the FDA is grossly over- cautious.

Skin Disinfection Before Surgery

believe three agents, ethyl and isopropyl alcohol and iodine, are still the most effec- I tive skin disinfectants available. As Low-

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AORN J O U R N A L AUGUST 1984, VOL 40. NO?

bury stated, both are rapidly bactericidal toward a wide range of vegetative organisms and have no toxic or sensitizing action on the skin or underlying tissues." I know of no studies con- tradicting this statement.

Recent studies by Geelhoed have again shown that alcohol does its job, although he employed an iodine-impregnated adhesive drape over the alcohol-disinfected skin." I feel certain that the result would have been the same for at least three hours, if he had used a simple adhesive drape, as we have done.I3 Yet I have no quarrel with the use of the iodine-impregnated drape, particularly for long operations.

Ethyl and isopropyl alcohol in a wide latitude of concentrations are effective skin disinfectants preparatory to major surgical intervention, or any other skin disinfection need. They can be effectively used with an adhesive drape.

WILLIAM C BECK, MD, FACS

Notes I , P B Price, "Reevaluation of ethyl alcohol as a

germicide," Archives of S u r g r p 60 (March 1950) 4Y2-502; H E Morton, "Alcohols" in Disiilfrctiotr. Stc~rili:trtiori, mid Prrscrvcrtiorr. ed. S S Block (Philadelphia: Lea & Febiger. 1983) 225-239.

2. US Food and Drug Administration. "Tentative final monograph on over-the-counter antimicrobial drugs," F i d i w l Ri@tiv- (Jan 6. 1978).

3. 0 H Wangansteen, S D Wangansteen, The Rist of Sirrgiyv (Minneapolis: University of Minnesota Press. lY7Y) 312.

4. E H Spaulding. "Chemical disinfection and antisepsis in the hospital, " Jourticil .f Hospitirl RP search Y (February 1972) 5-31.

5 . W C Beck, "Alcohol form as a handwashing substitute," AORN Jourtrol 32 (December 1980)

6. Morton. "Alcohols" chapter, Molinas and

7. Ihid. 228. 8. Rice. "Reevaluation of ethyl alcohol." 492-

502. 9. US Food and Drug Administration. "Tentative

final monograph." 10. US Food and Drug Administration, "Alcohol

drug products for topical antimicrobial over-the- counter human use; establishing a monograph and reopening of administrative record." Federal Reg- ister (May 21, 1982).

1087- 1088.

Brewer quotation, 228.

1 1 . E J L Lowbury et al, *'Methods of disinfection of hands and operation sites." British Mcdiccrl Jour-

12. G Geelhoed, "A comparative study of surgical skin preparation methods, " Surgcn. C,vtrrcolog.v & Obstetrics I57 (September 1983) 265.

13. W C Beck et al. "The incise drape--boon or hazard: An experimental study," The Arneriiwr Sitr-

t l d 2 (August 1964) 531-536.

~sl ' fJ I1 47 (August I98 I ) 343-346.

New Method to Transfuse Oxygen Patients who refuse blood transfusions can still receive transfused oxygen by a new method reported in the June Archives of Surgen.

of California at Irvine, and colleagues used perfluorocarbon infusion (PFC) to treat six severely anemic surgical patients who refused to receive blood products because of religious convictions. While arterial oxygen content did not increase appreciably after PFC infusions, oxygen consumption increased dramatically, the researchers say. PFCs carry oxygen by direct solubility, which results in nearly complete unloading of oxygen at tissue oxygen tensions.

Another benefit of PFC infusion is that in microcirculation. the small particle size of PFCs "may allow the PFC to flow through constricted capillary beds and may improve plasma flow through these vessels as well. "

The researchers emphasize the importance of their findings. "In our anemic patients breathing oxygen, red blood cells transported only 40% of the consumed oxygen, and the PFC transported 22%. while the remaining 38% of consumed oxygen was from oxygen dissolved in the plasma. "

Adverse reactions to the treatment included lowered blood pressure in one patient, an abnomal liver function test result in another, and transient decreases of white blood cell counts following infusion in five of the patients.

Kenneth Waxman, MD, of the University

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