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AAOS Now

Published 5/1/2008
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Gregory P. Nowinski, MD

Don’t shave unless you have to!

Clipping and depilatories are more effective in lowering infection risk

Prepping a patient for surgery frequently involves removing the hair around the surgical site. Studies have shown a direct link between surgical site infections and hair removal, although questions remain about the best method to use.

The Surgical Care Improvement Project (SCIP)—a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications—has developed recommendations for hair removal methods that can help reduce the occurrence of surgical site infections, a complication that develops in 2 percent to 5 percent of operated patients each year. These recommendations are listed in Table 1.

What’s the best method?
Appropriate removal of hair does help prevent surgical site infections. Shaving has traditionally been the most common method used to prepare the skin before surgery. But the best method of removing hair is debatable.

Razors can rapidly remove hair from the surgical field, but may result in small cuts and abrasions. This minor skin damage can provide an area where bacteria flora can multiply and potentially infect the surgical incision site.

An alternative to using razors is powered surgical clippers. Clippers mechanically trim the hair close to the skin, effectively removing it from the field, and avoid the skin trauma caused by the sharp blade of a razor. A study of open heart surgery patients showed a significant decrease in deep infections in individuals whose hair was removed by clippers compared to those whose hair removal was done with a razor. Reviews of other randomized controlled trials have confirmed this finding. When hair needs to be removed, it should be clipped instead of shaved.

Using depilatories—creams that remove the hair from the surgical site via a chemical, rather than a mechanical, action—may be even more effective in lowering infection rates. Although depilatory creams are easy to apply and avoid mechanical trauma to the skin, they are costly and may generate a sensitivity reaction at the surgical site.

When’s the best time?
Timing of hair removal may also have an effect on infection rates. At least one study comparing infection rates when patients were shaved the night before surgery versus the day of surgery showed that preparing the skin closer to the time of surgery resulted in significantly lower infection rates, although this has not been confirmed.

Is it even necessary?
In some cases, leaving the hair intact at the surgical site may be the best option. A prospective randomized study in spinal surgery patients demonstrated lower infection rates in unshaved patients than in shaved patients.

The Centers for Disease Control and Prevention recommends that hair should not be removed from the surgical site unless it is necessary to facilitate the surgical procedure. Unless you need to remove hair from the surgical area to see what you’re doing, the best course of action may be to leave it alone.

Other ways to reduce surgical site infections
Surgical site infections remain a major source of postoperative morbidity in patients undergoing orthopaedic surgery. These complications can clearly compromise patient outcomes and also increase the cost of healthcare delivery. Payors and consumers looking for measures of quality of care are increasingly monitoring compliance by healthcare workers and hospitals with the evidence-based practice guidelines developed by SCIP.

Several measures have been established to decrease the number of surgical site infections. Current performance measures for surgical site infection prevention include the following:

  • appropriate timing, selection, and duration of prophylactic antibiotics
  • glucose management
  • maintenance of normothermia
  • employment of appropriate hair removal methods

A collaborative effort of 56 hospitals involving more than 35,000 cases found that surgical infections decreased (27 percent reduction rate) as compliance with infection prevention practices increased.

Gregory P. Nowinski, MD, is in private practice in Troy, Mich. He can be reached at gnowinski@comcast.net

References

  1. Dellinger EP, Hausmann SM, Bratzler DW, Johnson RM, Daniel DM, Bunt KM, Sugarman JR: Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190:9-15.
  2. Sellick JA, Stelmach M, Mylotte JM. Surveillance of surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1991; 12:591-596.
  3. Niel-Weise BS, Wille JC, van den Broek PJ. Hair removal policies in clean surgery: systematic review of randomized, controlled trials. Infect Control Hosp Epidemiol 2005;26:923-928.
  4. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251-254
  5. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris, MJ. The influence of hair removal methods on wound infections. Arch Surg 1983;118:347-352
  6. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews 2006:3:1-35
  7. Celik SE, Kara A: Does shaving the incision site increase the infection rate after spinal surgery? Spine 2007;32:1575-1577.
  8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247-278.