Povidone-iodine related burns

doi:10.1016/S0305-4179(00)00081-4

Burns

Volume 27, Issue 2, March 2001, Pages 185-188

https://doi.org/10.1016/S0305-4179(00)00081-4 Get rights and content

Abstract

Skin preparation burns associated with chemical agents are uncommon. They occur most frequently in patients placed in the lithotomic position undergoing gynaecologic or urologic operations, the burn being on the buttocks, and in those undergoing orthopaedic operations, the burn being on the extremities and under a tourniquet. The basic mechanism involves irritation coupled with maceration and pressure. If the betadine solution has not been allowed to dry and has been trapped under the body of the patient in a pooled dependent position, such as the buttocks or under a tourniquet, the solution may irritate the skin and result in a skin burn. The irritation coupled with pressure leads to a situation analogous to that seen in the development of an acute accelerated decubitus ulcer; irritation, maceration, friction and pressure compounding each other to result in a skin burn or superficial ulcer in the skin. Our experience with three illustrative patients who presented with various burns following exposure to povidone-iodine (betadine) is described below.

Introduction

An unexpected chemical burn results not only in psychological trauma to the patient and physician but also in prolongation of hospitalisation and in possible disruption of the doctor–patient relationship.

Polyvinylpyrrolidone-iodine (PI), is a widely used antiseptic introduced by Shelanski and Shelanski in 1965 [1]. It is a water-soluble compound that results from the combination of molecular iodine and polyvinylpyrrolidone. The preparations of commercially available PI are povidone-iodine solution, scrub, ointment, tincture and foam; of these, the solution is the most commonly used. The 10% PI solution generally contains 90% water, 8.5% polyvinylpyrrolidone and 1% available iodine and iodide. Chemical burns due to PI, are relatively under-recognised and potentially preventable problems that may be more frequent than believed and often misdiagnosed as electrical burns.

Section snippets

Case 1

A 24-year-old Caucasian male underwent a flexor tendon repair on his right palm. The patient's operation was performed under tourniquet control. The tourniquet cuff used was a standard arm tourniquet and was applied with adequate wool padding. The skin preparation used was a tincture of povidone-iodine with an alcohol content of 70%. The operation lasted for 2 h. When the tourniquet was removed the burn was seen (Fig. 1); the preparation seemed to have run down the patient's arm and had been

Discussion

The pathogenesis of chemical burns resulting from skin preparation agents is different from that of the industrial burn because there is greater time exposure and because the anaesthesia prevents the patient from reacting to the noxious burn stimulus Undoubtedly, maceration, irritation, friction and pressure also contribute. Skin preparation burns are typical in their location. The burn is distributed over in the skin over a bony prominence or point of pressure or is seen underneath an area

Conclusions

To prevent these burns from occurring, the skin must not be abraded excessively before the final skin preparation solution is applied. The agent should not be allowed to pool and become trapped under the tourniquet or the torso of the patient. The agent should be allowed to dry before the patient is draped

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Chlorhexidine gluconate (CHG) is one of the most commonly used antiseptic agents for pre-procedural skin preparation and is generally considered safe; however, there are reports that, under certain circumstances, CHG can cause chemical burns. This case report highlights the occurrence and management of a CHG chemical burn in a pediatric patient undergoing upper extremity surgery with a tourniquet despite the use of routine protective measures.
Dermatologic reactions to disinfectant use during the COVID-19 pandemic
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Citation Excerpt :
Topical absorption seems to be time dependent.43 ICD (usually 10% PVP-I) sometimes occurs with chemical burns, pain, blistering lesions, and tissue necrosis.44–49 Such burns, however, are often observed in damaged skin and/or wounds with prolonged exposure.48,50,51
Infection preventive practice of using disinfectants against SARS-CoV-2 has become the new normal due to the COVID-19 pandemic. Although disinfectants may not be applied directly to the human body, it remains at high risk of exposure including close skin contact on disinfected surfaces or during handling. This dermal contact, on a regular basis, can induce hazardous skin reactions like irritation, inflammation, and burning in severe conditions. Disinfectants are germicide chemicals that can penetrate the skin and create skin reactions that are usually regarded as irritant and allergic contact dermatitis. More importantly, disinfectants can react with skin components (proteins and lipids) to facilitate their skin penetration and disrupt the skin barrier function. Whereas the antimicrobial actions of disinfectants are well understood, much less is known regarding their dermatologic reactions, including but not limited to irritation and hypersensitivity. We reviewed the skin reactions created by those disinfectants against SARS-CoV-2 approved by the European Chemical Agency and the US Environmental Protection Agency.
Tourniquet use in orthopaedic surgery
2017, Orthopaedics and Trauma
The application of a tourniquet is a routine adjunct to current orthopaedic surgical practice. It is commonplace for both elective and trauma surgery. This review article seeks to explore the issues surrounding tourniquet and current best practice. The technological evolution in the application of a tourniquet to produce a bloodless field has remained relatively unchanged compared to other more complex advances in modern surgical practice. Despite a tourniquet's relative simplicity, considerable controversy surrounds its exact application; the surgeon constantly seeks a balance between the inevitable morbidity associated with its use versus the advantages conferred by such a device. To trace the history of the tourniquet is of interest and provides a backdrop to understanding the current controversies associated with its use as well as predicting where the next possible evolutions might take place. The tourniquet is often taken for granted, but there is a considerable body of work surrounding its use and safe application. Correct application, training of staff and appropriate use on an individual basis are essential to maximize safety and benefit.
Clinical and forensic signs related to chemical burns: A mechanistic approach
2015, Burns
Citation Excerpt :
Povidone–iodine is an example of an iodophor, a complex of molecular iodine and a solubilizing carrier (polyvinylpyrrolidone), which acts as a reservoir of “free” active iodine that is constantly released and remains in dynamic equilibrium with the complex [131,133]. Povidone–iodine is available in a range of antiseptic formulations (solution, scrub, ointment, tincture, and foam) [134], the aqueous solution being (10% PVP-I) the most commonly used. Although uncommon, iatrogenic chemical burns (Fig. 12) have been reported with povidone–iodine solutions [134,135].
This manuscript highlights and critically analyses clinical and forensic signs related to chemical burns. Signs that may lead to suspicion of a particular chemical are thoroughly discussed regarding its underlying mechanisms. Burns due to sulfuric, hydrofluoric, nitric, hydrochloric (muriatic) and acetic (including derivatives) acids, hydrogen sulphide, sodium (caustic soda) and calcium (cement) hydroxides, paraquat, burns after inflation and rupture of airbags, povidone–iodine, chlorhexidine/alcohol (in preterm infants), laxatives, and vesicants (warfare agents), will be reviewed since these are the most common agents found in daily practice, for which relevant and timed information may be helpful in formulating an emergency treatment protocols and toxicological analysis.
Acute skin lesions after surgical procedures: A clinical approach
2013, Actas Dermo-Sifiliograficas
Citation Excerpt :
Free iodine in the liquid phase has germicidal power and, as it is consumed, more iodine is released from the complex. Free iodine is irritant and, if it remains in liquid phase in contact with the skin for a long period, it can produce severe irritant lesions similar to burns or toxic epidermal necrolysis.14,16,18–20 Four lesion patterns are recognized.
In the hospital setting, dermatologists are often required to evaluate inflammatory skin lesions arising during surgical procedures performed in other departments. These lesions can be of physical or chemical origin. Povidone iodine is the most common reported cause of such lesions. If this antiseptic solution remains in contact with the skin in liquid form for a long period of time, it can give rise to serious irritant contact dermatitis in dependent or occluded areas. Less common causes of skin lesions after surgery include allergic contact dermatitis and burns under the dispersive electrode of the electrosurgical device. Most skin lesions that arise during surgical procedures are due to an incorrect application of antiseptic solutions. Special care must therefore be taken during the use of these solutions and, in particular, they should be allowed to dry.
Dentro del ámbito hospitalario no es infrecuente que los dermatólogos debamos valorar lesiones cutáneas inflamatorias que surgen en intervenciones quirúrgicas realizadas por otros servicios. Estas lesiones pueden ser de causa física o química. La povidona yodada es la causa descrita más frecuentemente de aparición de estas lesiones. Este antiséptico, si permanece en solución en contacto con la piel durante un periodo prolongado, puede ocasionar dermatitis irritativas graves en zonas declives u ocluidas. Otras causas menos frecuentes son dermatitis alérgicas de contacto o quemaduras en el terminal de toma de tierra del bisturí eléctrico. Debido a que la mayor parte de estas lesiones se debe a una aplicación incorrecta del antiséptico, deben extremarse sus normas de uso, especialmente dejándolo secar de forma adecuada.
Aqueous based Povidone-iodine related chemical burn under the tourniquet (a case report) and literature review
2013, Journal of Orthopaedics
Chemical burn under pneumatic tourniquet is an iatrogenic preventable injury and is rarely reported in the literature. The important mechanisms are maceration, irritation, and prolonged use of the tourniquet and pressure. This rare adverse complication occurred in a 35-year old man who underwent anterior cruciate ligament reconstruction of left knee. 5% aqueous based Povidone-Iodine was used as topical antiseptic and partial thickness burn occurred underneath the area of tourniquet application. Previous reports shows that chemical burns are more common in alcohol based Povidone-iodine than aqueous based. Chemical burn develops when Povidone- iodine does not adequately dry, pools beneath a dependent body part during surgery, or is placed under an occlusive device. To reduce the complications like chemical burn, awareness of the risk and the possible pathogenesis as well as the preventive measures is important in surgical practice.

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Case reportPovidone-iodine related burns

Abstract

Introduction

Section snippets

Case 1

Discussion

Conclusions

Am. J. Surg.

Br. J. Plast. Surg.

PVP-iodine, history, toxicity and therapeutic uses

J. Int. Coll. Surg.

Chemical burns and skin preparation solutions

Surg. Gynecol. Obstet.

Chemical burns beneath tourniquet

Br. Med. J.

Chemical burns beneath tourniquet

Br. Med. J.

Case report
Povidone-iodine related burns