- Email: [email protected]
Hospital Study of a Depilatory Cream for Surgical Patients
HOSPITAL STUDY OF A DEPILATORY CREAM FOR SURGICAL PATIENTS Marie B. Holt, R.N.
Marie Holt is Assistant Director of Nursing Service in charge of Operating Rooms at St. Luke’s Episcopal and Texas Children’s Hospitals, Texas Medical Center, Houston. She is also a strong supporter of AORN and at present is Chairman of both the AORN Story and Public Relations Committees. Early historical references to the removal of hair from the head, face or body, show that for centuries this has been a worldwide practice. Sometimes the removal was dictated by social and religious customs, sometimes by reason of cosmetics. Plucking, singeing, crude ointments and pastes were cited as the means by which depilation was accomplished’, 2. Pumice stone and other abrasives were used. Accounts of shaving appear in Italy as early as 300 B.C.3 In contrast, the origins of the removal of hair as preparation for surgery are obscure. Shaving was probably employed occasionally by the practitioners of the healing arts for a variety of reasons. The presence of hair interfered physically with attempts to close or treat wounds, or to employ topical medi-
66
cation such as poultices in which healing substances were incorporated in paste, wax or resins and applied over inflamed areas. Shaving also helped to exterminate lice and other vermin, a problem which plagued hospitals until a surprisingly recent period and which recurs even today in disaster situations. Even the acceptance in the nineteenth century of the bacterial transmission of infection was not immediately related to the need for aseptic surgical procedures. Antiseptic soaps were used for cleanliness of the genitals prior to delivery in 1916; clipping of the hair was recommended in 1917; and shaving, introduced during the following decade, by 1929 was still not generally practiced? An authoritative pronouncement on the subject appeared in the chapter “Pre-Operative Treatment’’ in the 1927 issue of Lewis’ “Practice of Surgery.” In it, Hughson stated: “The presence of hair is an obvious menace and its proper removal should be a matter of expert attention. This important procedure is too often left in unskilled hand^."^
AORN Journal
Unfortunately, after 35 years, a persistent problem is the inexpertness of hospital personnel in wielding either the straight razor or the safety razor in preparation of the surgical field. Most operating room nurses recall instances in which the surgeon, ready to make an incision, found hair stubble on the skin surface and ordered the shaving procedure repeated under his view. The opposite extreme to inadequate depilation was described by Hughson as “disastrous . . . a field scarred and scratched and possibly bleeding, a condition much worse than the original one of hair.” Many surgeons postpone the operation under these circumstances. A survey of pre-surgical shaving practices undertaken by the School of Nursing of the University of Pennsylvania elicited responses to a questionnaire from 100 hospitals in 45 states and the District of Columbia. The criteria stipulated for a good “prep” were ( 1 ) proper area, (2) elimination of all hair and desquamating epithelium, and (3) no nicks, cuts or scratches of the skin. KeuhnG reported that the hospitals graded the efficiency of shaving procedures in their own institutions as follows: very good, 18.2 per cent; good, 39.4 per cent; satisfactory, 33.3 per cent; and unsatisfactory, 9.1 per cent. The potential for bacterial invasion, wound infection and post-operative morbidity due to inadequate preparation of the surgical field is thus implicit in almost one-tenth of these patients. Regardless of whether this duty is assigned to orderlies, internes, nursing aides or nurses, shaving too often frustrates the recognized objective which has been stated as follows: “The purpose of skin preparation pre-operatively is to render the skin as clean and free of bacteria as possible without causing irritation or damage to the skin, without impairing its natural protective function, and without interfering with subse-
M a r - A p r 1964
quent wound healing.”7 In an era marked by increasing knowledge of the nature of infection and of medication for its control, it was only logical that a technic with such variable results as preoperative shaving would be critically reappraised. One proposal offered as a substitute was the removal of hair from the surgical field by means of a chemical preparation, a depilatory cream. It is this cream, and its use in a general hospital, that is the subject of this report. The formula of the compound, its chemical attack upon the hair structure, and many advantages demonstrated in surgical and obstetrical patients have been described by Prigots, 13 and his associates. The technic for using the depilatory that he detailed9 has been modified in the course of subsequent experience.
PLAN OF STUDY The depilatory compound in question was first introduced to members of the operating room nursing staff of St. Luke’s Episcopal Hospital in March, 1962. Preliminary testing on an informal basis continued for several months, during which there was increasing interest in the new product. I t was then decided that a fully documented clinical study should be undertaken at our hospital and in so planning the views of patients, medical personnel, professional nursing staff and nursing assistants assigned to pre-operative preparation were consulted. It was found that patient acceptance was made easier by the fact that many had had previous experience with some type of cosmetic depilatory and they considered the new method of removing hair more “modern and scientific” than shaving. Medical personnel were basically interested in a safe and adequate preparation of their patients, rather than in a particular technic. Orthopedic surgeons, being acutely aware
67
of complications resulting from improper skin preparation, were among the first to recognize its possibilities and to accept and use the cream at St. Luke’s Hospital. Encouraged by reports of more efficient pre-operative preparation, the professional nursing staff eagerly accepted the opportunity to participate in the clinical study. Nursing assistants were given a thorough orientation in the use of the cream, with instructions demonstrated by an operating room nurse in actual patient situation. With practice they found that a lighter touch and greater gentleness in the handling of the patient was possible with the new procedure. Emphasis was given to close observation of the patient at the time of application, inspection of the site on the following morning, and maintenance of Report Sheet designed for the study. (Fig. 1) In most instances the skin preparation was done in the patient’s room the night before surgery by operating room nursing assistants trained to use the cream in accordance with the method described. INSTRUCTIONS FOR USE OF THE DEPILATORY CREAM The hair removing procedure may be part of the care of the patient the night before surgery, or it may be done immediately prior to surgery in the operating room or in adjacent areas when these are utilized for patient preparation or anesthesia. The proposed surgical field should be adequately
exposed, the patient positioned to provide as much comfort and privacy as possible, and adjustment to bed or table levels taken care of. To protect bed clothing, disposable linen savers should be placed under the area to be prepared, or should be used as draping around the body as required. The use of disposable linen savers and towels in any type of hair removal is good practice in order to keep hair out of the laundry. In some individuals, it may be desirable to cut off long or heavy hair as a preliminary step. This is solely an economy measure, since more of the depilatory is required to saturate a heavy mat of hair. This trimming, however, is not recommended if the patient is prepared in the operating room, as hair particles freed to float in the air are a source of contamination. The collapsible metal tube of the depilatory compound is held over the area from which the hair is to be removed and, with gentle pressure on the tube, the cream flows onto the body surface. A wooden tongue blade or a plastic applicator of similar size and shape should be used to spread a smooth layer, approximately one-quarter of an inch in depth, over the entire operative site. At this point the area is usually left uncovered, if the environment permits. However, if the patient prefers, or if necessary to prevent chilling, disposable towels may be laid carefully over the cream and a
ST. LUKE’S AND TEXAS CHILDREN’S HOSPITALS SKIN PREP INFORMATION
SKIN COND. PREP
AREA
PATIENT NAME
ROOM PREP’ED RAZOR CREAM BEFORE ----
ANY REACTION NOTED
A.M. COMMENTS
__-I
68
AORiV Journal
sheet drawn lightly over the patient. A waiting period of ten minutes is necessary for completion of the chemical action on the hair. During this interval a large basin of warm water is placed near the bed or table. A tongue blade or flat applicator is required also for removal of the cream. When the allotted time has expired the tongue blade should be dipped into the warm water and pressed lightly on the body with a downward movement, until the entire blade is covered with the cream and the embedded hair. It should again be dipped into warm water, using the thumb and index finger to strip the cream from the blade into the water. Then the wet tongue blade should be applied once more to the area on the patient, carrying enough water to soften the compound for the next stroke of removal. The procedure is repetitive - dip blade, remove part of cream, dip blade, remove part of cream. This continues in succession until the area is cleared. The basin with the floating cream and hair is removed for easy disposal as sewage. The operative site is then washed with fresh, warm water applied with a gauze sponge. It may be patted dry or left to be air-dried. This method can also be safely used in body folds, over painful, inflamed areas and around open wounds. Contact with the eyes o r with mucous membranes of the female genitalia should be avoided. I f such contact occurs, the cream should be washed off immediately. Caution is also indicated in scrota1 preparations if the skin appears to be particularly sensitive. DURATION AND SCOPE OF STUDY The study of the depilatory was initiated on January 1, and terminated on August 31, 1963. Although the hospital had some ten months’ prior use of the cream, the results shown in Table I relate only to this latter
Mar-Apr 1964
eight-month period of formal investigation. The depilatory was employed routinely before 1,227 operations, as listed in the table. Both male and female patients were included, their ages ranging from young adults to the very elderly. TABLE 1. PRESURGICAL SKIN PREPARATION WITH A DEPILATORY CREAM
January 1 t o August 31, 1963 NUMBER OPERATIVE PERFORMED PROCEDURE Exploratory Laparotomy 62 Inguinal Herniorrhaphy 72 Genital Procedures (female) 33 10 Genital Procedures (male) Rectal Procedures 2 Abdominal Procedures 251 Head and Neck 55 Amputations & Open Reduction of Fractures 12 Breast 133 Cholecystectomy 52 Thoracic Procedures 196 Appendectomy 15 Gastrectomy 18 46 Lumbar Region & Back AbdominaCPerineal Resection 1 Prostatectomy 1 Hand and Arm 54 Skin Grafting 8 Lower Extremities 188 11 Nephrectomy Shoulder 7 TOTALS
1,227
INCIDENCE OF
SIDE EFFECTS Rash
1
Burning Burning Burning
10 1 1
Pimples
1
Burning
1
Burning RedRash
2 1 20
RESULTS The experience of these tests regarding the efficiency of hair removal with the cream confirmed the reports of previous investigators. The smooth, clean, intact skin of the operative sites met with the unanimous approval of the surgeons. Nurses and “prep” personnel reported that patients generally were pleased with the technic which they found more comfortable and less embarrassing than shaving. There were a few complaints concerning the odor of the compound, or that its application was “messy.” In some classes of patients, the superiority of chemical depilation was especially notable. The apprehension of the aped patient approaching surgery is familiar to hospital
69
personnel. This is often increased with each preparatory step and the appearance and use of the razor adds to their distress. It was found that the ease and gentleness of hair removal with the cream allayed their fears at a critical stage in their care. It was decided that it is a disservice to the aged patient to resort to shaving when this improved technic is available. The pre-operative preparation of mental patients or of those rendered uncooperative or agitated by delirium is an ordeal for both patient and hospital attendant. Shaving under such circumstances may be dangerous and too often results in poor hair removal or a scraped, bleeding skin surface. A few trials with these patients offered convincing evidence of the advantages of chemical depilation. SIDE EFFECTS The incidence of 20 undesirable reactions, detailed in Table I, represents 1.63 per cent of the total number of 1,227 operations. This is dramatically lower than the number of unsatisfactory shaving preps cited by 100 hospitals, which was 9.1 per cent according to Keuhn.B Sixteen of the side effects were complaints of burning when the depilatory was in contact with the skin, although no objective evidence of irritation was detectable. Twelve of these preps were for surgery of the rectum or male genitalia. The skin of these regions, overlying highly vascularized organs without the cushioning of adipose tissue, proved sensitive to the compound. The other four reactions were described as a rash in two patients, slight redness of the skin in one, and pimples in the last. None of the 20 symptoms or complaints reported was so severe as to interfere with either the use of the cream or the scheduled operation. All disappeared, either immediately when the cream was washed off or
70
within a few hours and no special treatment was required for their alleviation. It is felt that this numerically small incidence of side reactions of a temporary character does not detract from an overall gratifying experience with this form of chemical depilation. It is understood that the manufacturer of the cream is revising the formula with the expectation of eliminating all local irritation without impairment of the efficiency of the preparation. The results of these experiments will be awaited with interest.
DISCUSSION Any change in hospital routine, especially one that departs from well-established tradition, inevitably meets with a degree of resistance. Some discussion of St. Luke's experience is warranted since it may serve other hospitals undertaking the investigation of this technic or where the decision has been made to replace shaving with other hair removing methods. The success of the clinical evaluation of chemical depilation reported here was due substantially to careful planning of the study and the cooperative attitude of the staff involved at all levels. Demonstrations and conferences soon eliminated most problems. The primary emphasis throughout was on benefit to the patient- on the possibility that a new method would afford greater safety, comfort, privacy and reassurance at the time of pre-surgical preparation, and would enhance a benign post-operative course. Considering the waiting period of ten minutes necessary for action of the compound on the hair, no significant differential was observed in time required for skin preparation with the cream in contrast to shaving. However, it is important that this interval was-for the patient-one of comparative relaxation without the physical and psychological distress associated with shaving.
AORN Journal
In terms of hospital costs - because cost is always a consideration in evaluating a product or a procedure in patient careit has been determined that the cost of using hair remover cream proved to be virtually the same as the cost of shaving. Although self-preparation was not contemplated in the study, the simplicity of the new technic in actual practice suggested that further economies might be effected in hospital time and labor. It would be interesting to determine to what extent patients, not acutely ill, could use the depilatory in preparing themselves for operation. This is rarely possible with a razor. However, just as most patients prefer to wash themselves if they are able to do so, many - if provided with a safe and convenient means -would cheerfully manage the removal of hair from accessible operative sites rather than rely on someone else for this intimate care. The prospective improvement in the chemical formula should be followed by investigation of its use in new aspects of medical practice, as well as by repeated studies in situations where performance thus far might be considered equivocal because of even a minimal occurrence of untoward side effects.
SUMMARY AND CONCLUSION The depilatory cream* which was used prior to 1,227 surgical procedures met the accepted criteria for good pre-operative skin *The product used in this study was Surgexa supplied by Crookes-Barnes Laboratories, Inc., Wayne, N. J.
Mar-Apr 1964
preparation. Although 20 patients had transient dermatological reactions involving the rectal or scrota1 regions, all those concerned considered the overall picture of preliminary skin preparations greatly improved. The time and effort in the investigation of the hair removing product, consultations with the medical staff, planning and execution of the clinical study, and the instruction of prep personnel resulted in a significant contribution to better and safer care of the surgical patients involved. The author gratefully acknowledges her indebtedness to The Medical Research Committee at the St. Luke’s and Texas Children’s Hospitals, f o r their aid in the planning of this investigation and the analysis of our results, and to Rose K . Pizzitola, Operating Room Supervisor, for her assistance in the eficzent execution of the plan.
REFERENCES 1. Yust, W., Encyclopedia Britannica, 14th edition, Chicago, vol. 16, 33, 1949. 2. Ebell, B. (translator), The Papyrus Ebers Levin & Munksgaard, Copenhagen, London: H. Milford, 63:76-80, 1937. and Present, 3. Downing, J. G., Cosmetics-Past J.A.M.A., 103:2089, June 23, 1934. 4. Bethea, Doris Christine, The Effect of the Shave on Infection in Maternity Patients, Nursing Research, 12:2, 103-106, Spring 1963. 5. Hughson, W., Preoperative Treatment, Practice o f Surgery, (Lewis), Hagerstown, Md.: W. F. Prior Co., 1927, Vol. 1, Chap. 12, 15. 6. Keuhn, R. P., Who Should Do the Surgical Prep Shave? The Modern Hospital, 85:81-83, 102-104, Dec. 1955. 7. Knocke, F. J. and Knocke, L. S., Orthopaedic Nursing, Philadelphia: F. A. Davis, Co., 1951, Chap. 10, 279. 8. Prigot, A., Garnes, A. L., and Nwagbo, U., Evaluation of a Chemical Depilatory for Preoperative Preparation of Five Hundred Fifteen Surgical Patients, Am. J . Surg., 104:900-906, Dec. 1962. 9. Prigot, A., and Froix, C. J. L., A Chemical Compound for Hair Removal: Use in Surgical and Obstetrical Patients, Hospital Topics, 41 :103-105, Feb. 1963.
71
Marie Holt is Assistant Director of Nursing Service in charge of Operating Rooms at St. Luke’s Episcopal and Texas Children’s Hospitals, Texas Medical Center, Houston. She is also a strong supporter of AORN and at present is Chairman of both the AORN Story and Public Relations Committees. Early historical references to the removal of hair from the head, face or body, show that for centuries this has been a worldwide practice. Sometimes the removal was dictated by social and religious customs, sometimes by reason of cosmetics. Plucking, singeing, crude ointments and pastes were cited as the means by which depilation was accomplished’, 2. Pumice stone and other abrasives were used. Accounts of shaving appear in Italy as early as 300 B.C.3 In contrast, the origins of the removal of hair as preparation for surgery are obscure. Shaving was probably employed occasionally by the practitioners of the healing arts for a variety of reasons. The presence of hair interfered physically with attempts to close or treat wounds, or to employ topical medi-
66
cation such as poultices in which healing substances were incorporated in paste, wax or resins and applied over inflamed areas. Shaving also helped to exterminate lice and other vermin, a problem which plagued hospitals until a surprisingly recent period and which recurs even today in disaster situations. Even the acceptance in the nineteenth century of the bacterial transmission of infection was not immediately related to the need for aseptic surgical procedures. Antiseptic soaps were used for cleanliness of the genitals prior to delivery in 1916; clipping of the hair was recommended in 1917; and shaving, introduced during the following decade, by 1929 was still not generally practiced? An authoritative pronouncement on the subject appeared in the chapter “Pre-Operative Treatment’’ in the 1927 issue of Lewis’ “Practice of Surgery.” In it, Hughson stated: “The presence of hair is an obvious menace and its proper removal should be a matter of expert attention. This important procedure is too often left in unskilled hand^."^
AORN Journal
Unfortunately, after 35 years, a persistent problem is the inexpertness of hospital personnel in wielding either the straight razor or the safety razor in preparation of the surgical field. Most operating room nurses recall instances in which the surgeon, ready to make an incision, found hair stubble on the skin surface and ordered the shaving procedure repeated under his view. The opposite extreme to inadequate depilation was described by Hughson as “disastrous . . . a field scarred and scratched and possibly bleeding, a condition much worse than the original one of hair.” Many surgeons postpone the operation under these circumstances. A survey of pre-surgical shaving practices undertaken by the School of Nursing of the University of Pennsylvania elicited responses to a questionnaire from 100 hospitals in 45 states and the District of Columbia. The criteria stipulated for a good “prep” were ( 1 ) proper area, (2) elimination of all hair and desquamating epithelium, and (3) no nicks, cuts or scratches of the skin. KeuhnG reported that the hospitals graded the efficiency of shaving procedures in their own institutions as follows: very good, 18.2 per cent; good, 39.4 per cent; satisfactory, 33.3 per cent; and unsatisfactory, 9.1 per cent. The potential for bacterial invasion, wound infection and post-operative morbidity due to inadequate preparation of the surgical field is thus implicit in almost one-tenth of these patients. Regardless of whether this duty is assigned to orderlies, internes, nursing aides or nurses, shaving too often frustrates the recognized objective which has been stated as follows: “The purpose of skin preparation pre-operatively is to render the skin as clean and free of bacteria as possible without causing irritation or damage to the skin, without impairing its natural protective function, and without interfering with subse-
M a r - A p r 1964
quent wound healing.”7 In an era marked by increasing knowledge of the nature of infection and of medication for its control, it was only logical that a technic with such variable results as preoperative shaving would be critically reappraised. One proposal offered as a substitute was the removal of hair from the surgical field by means of a chemical preparation, a depilatory cream. It is this cream, and its use in a general hospital, that is the subject of this report. The formula of the compound, its chemical attack upon the hair structure, and many advantages demonstrated in surgical and obstetrical patients have been described by Prigots, 13 and his associates. The technic for using the depilatory that he detailed9 has been modified in the course of subsequent experience.
PLAN OF STUDY The depilatory compound in question was first introduced to members of the operating room nursing staff of St. Luke’s Episcopal Hospital in March, 1962. Preliminary testing on an informal basis continued for several months, during which there was increasing interest in the new product. I t was then decided that a fully documented clinical study should be undertaken at our hospital and in so planning the views of patients, medical personnel, professional nursing staff and nursing assistants assigned to pre-operative preparation were consulted. It was found that patient acceptance was made easier by the fact that many had had previous experience with some type of cosmetic depilatory and they considered the new method of removing hair more “modern and scientific” than shaving. Medical personnel were basically interested in a safe and adequate preparation of their patients, rather than in a particular technic. Orthopedic surgeons, being acutely aware
67
of complications resulting from improper skin preparation, were among the first to recognize its possibilities and to accept and use the cream at St. Luke’s Hospital. Encouraged by reports of more efficient pre-operative preparation, the professional nursing staff eagerly accepted the opportunity to participate in the clinical study. Nursing assistants were given a thorough orientation in the use of the cream, with instructions demonstrated by an operating room nurse in actual patient situation. With practice they found that a lighter touch and greater gentleness in the handling of the patient was possible with the new procedure. Emphasis was given to close observation of the patient at the time of application, inspection of the site on the following morning, and maintenance of Report Sheet designed for the study. (Fig. 1) In most instances the skin preparation was done in the patient’s room the night before surgery by operating room nursing assistants trained to use the cream in accordance with the method described. INSTRUCTIONS FOR USE OF THE DEPILATORY CREAM The hair removing procedure may be part of the care of the patient the night before surgery, or it may be done immediately prior to surgery in the operating room or in adjacent areas when these are utilized for patient preparation or anesthesia. The proposed surgical field should be adequately
exposed, the patient positioned to provide as much comfort and privacy as possible, and adjustment to bed or table levels taken care of. To protect bed clothing, disposable linen savers should be placed under the area to be prepared, or should be used as draping around the body as required. The use of disposable linen savers and towels in any type of hair removal is good practice in order to keep hair out of the laundry. In some individuals, it may be desirable to cut off long or heavy hair as a preliminary step. This is solely an economy measure, since more of the depilatory is required to saturate a heavy mat of hair. This trimming, however, is not recommended if the patient is prepared in the operating room, as hair particles freed to float in the air are a source of contamination. The collapsible metal tube of the depilatory compound is held over the area from which the hair is to be removed and, with gentle pressure on the tube, the cream flows onto the body surface. A wooden tongue blade or a plastic applicator of similar size and shape should be used to spread a smooth layer, approximately one-quarter of an inch in depth, over the entire operative site. At this point the area is usually left uncovered, if the environment permits. However, if the patient prefers, or if necessary to prevent chilling, disposable towels may be laid carefully over the cream and a
ST. LUKE’S AND TEXAS CHILDREN’S HOSPITALS SKIN PREP INFORMATION
SKIN COND. PREP
AREA
PATIENT NAME
ROOM PREP’ED RAZOR CREAM BEFORE ----
ANY REACTION NOTED
A.M. COMMENTS
__-I
68
AORiV Journal
sheet drawn lightly over the patient. A waiting period of ten minutes is necessary for completion of the chemical action on the hair. During this interval a large basin of warm water is placed near the bed or table. A tongue blade or flat applicator is required also for removal of the cream. When the allotted time has expired the tongue blade should be dipped into the warm water and pressed lightly on the body with a downward movement, until the entire blade is covered with the cream and the embedded hair. It should again be dipped into warm water, using the thumb and index finger to strip the cream from the blade into the water. Then the wet tongue blade should be applied once more to the area on the patient, carrying enough water to soften the compound for the next stroke of removal. The procedure is repetitive - dip blade, remove part of cream, dip blade, remove part of cream. This continues in succession until the area is cleared. The basin with the floating cream and hair is removed for easy disposal as sewage. The operative site is then washed with fresh, warm water applied with a gauze sponge. It may be patted dry or left to be air-dried. This method can also be safely used in body folds, over painful, inflamed areas and around open wounds. Contact with the eyes o r with mucous membranes of the female genitalia should be avoided. I f such contact occurs, the cream should be washed off immediately. Caution is also indicated in scrota1 preparations if the skin appears to be particularly sensitive. DURATION AND SCOPE OF STUDY The study of the depilatory was initiated on January 1, and terminated on August 31, 1963. Although the hospital had some ten months’ prior use of the cream, the results shown in Table I relate only to this latter
Mar-Apr 1964
eight-month period of formal investigation. The depilatory was employed routinely before 1,227 operations, as listed in the table. Both male and female patients were included, their ages ranging from young adults to the very elderly. TABLE 1. PRESURGICAL SKIN PREPARATION WITH A DEPILATORY CREAM
January 1 t o August 31, 1963 NUMBER OPERATIVE PERFORMED PROCEDURE Exploratory Laparotomy 62 Inguinal Herniorrhaphy 72 Genital Procedures (female) 33 10 Genital Procedures (male) Rectal Procedures 2 Abdominal Procedures 251 Head and Neck 55 Amputations & Open Reduction of Fractures 12 Breast 133 Cholecystectomy 52 Thoracic Procedures 196 Appendectomy 15 Gastrectomy 18 46 Lumbar Region & Back AbdominaCPerineal Resection 1 Prostatectomy 1 Hand and Arm 54 Skin Grafting 8 Lower Extremities 188 11 Nephrectomy Shoulder 7 TOTALS
1,227
INCIDENCE OF
SIDE EFFECTS Rash
1
Burning Burning Burning
10 1 1
Pimples
1
Burning
1
Burning RedRash
2 1 20
RESULTS The experience of these tests regarding the efficiency of hair removal with the cream confirmed the reports of previous investigators. The smooth, clean, intact skin of the operative sites met with the unanimous approval of the surgeons. Nurses and “prep” personnel reported that patients generally were pleased with the technic which they found more comfortable and less embarrassing than shaving. There were a few complaints concerning the odor of the compound, or that its application was “messy.” In some classes of patients, the superiority of chemical depilation was especially notable. The apprehension of the aped patient approaching surgery is familiar to hospital
69
personnel. This is often increased with each preparatory step and the appearance and use of the razor adds to their distress. It was found that the ease and gentleness of hair removal with the cream allayed their fears at a critical stage in their care. It was decided that it is a disservice to the aged patient to resort to shaving when this improved technic is available. The pre-operative preparation of mental patients or of those rendered uncooperative or agitated by delirium is an ordeal for both patient and hospital attendant. Shaving under such circumstances may be dangerous and too often results in poor hair removal or a scraped, bleeding skin surface. A few trials with these patients offered convincing evidence of the advantages of chemical depilation. SIDE EFFECTS The incidence of 20 undesirable reactions, detailed in Table I, represents 1.63 per cent of the total number of 1,227 operations. This is dramatically lower than the number of unsatisfactory shaving preps cited by 100 hospitals, which was 9.1 per cent according to Keuhn.B Sixteen of the side effects were complaints of burning when the depilatory was in contact with the skin, although no objective evidence of irritation was detectable. Twelve of these preps were for surgery of the rectum or male genitalia. The skin of these regions, overlying highly vascularized organs without the cushioning of adipose tissue, proved sensitive to the compound. The other four reactions were described as a rash in two patients, slight redness of the skin in one, and pimples in the last. None of the 20 symptoms or complaints reported was so severe as to interfere with either the use of the cream or the scheduled operation. All disappeared, either immediately when the cream was washed off or
70
within a few hours and no special treatment was required for their alleviation. It is felt that this numerically small incidence of side reactions of a temporary character does not detract from an overall gratifying experience with this form of chemical depilation. It is understood that the manufacturer of the cream is revising the formula with the expectation of eliminating all local irritation without impairment of the efficiency of the preparation. The results of these experiments will be awaited with interest.
DISCUSSION Any change in hospital routine, especially one that departs from well-established tradition, inevitably meets with a degree of resistance. Some discussion of St. Luke's experience is warranted since it may serve other hospitals undertaking the investigation of this technic or where the decision has been made to replace shaving with other hair removing methods. The success of the clinical evaluation of chemical depilation reported here was due substantially to careful planning of the study and the cooperative attitude of the staff involved at all levels. Demonstrations and conferences soon eliminated most problems. The primary emphasis throughout was on benefit to the patient- on the possibility that a new method would afford greater safety, comfort, privacy and reassurance at the time of pre-surgical preparation, and would enhance a benign post-operative course. Considering the waiting period of ten minutes necessary for action of the compound on the hair, no significant differential was observed in time required for skin preparation with the cream in contrast to shaving. However, it is important that this interval was-for the patient-one of comparative relaxation without the physical and psychological distress associated with shaving.
AORN Journal
In terms of hospital costs - because cost is always a consideration in evaluating a product or a procedure in patient careit has been determined that the cost of using hair remover cream proved to be virtually the same as the cost of shaving. Although self-preparation was not contemplated in the study, the simplicity of the new technic in actual practice suggested that further economies might be effected in hospital time and labor. It would be interesting to determine to what extent patients, not acutely ill, could use the depilatory in preparing themselves for operation. This is rarely possible with a razor. However, just as most patients prefer to wash themselves if they are able to do so, many - if provided with a safe and convenient means -would cheerfully manage the removal of hair from accessible operative sites rather than rely on someone else for this intimate care. The prospective improvement in the chemical formula should be followed by investigation of its use in new aspects of medical practice, as well as by repeated studies in situations where performance thus far might be considered equivocal because of even a minimal occurrence of untoward side effects.
SUMMARY AND CONCLUSION The depilatory cream* which was used prior to 1,227 surgical procedures met the accepted criteria for good pre-operative skin *The product used in this study was Surgexa supplied by Crookes-Barnes Laboratories, Inc., Wayne, N. J.
Mar-Apr 1964
preparation. Although 20 patients had transient dermatological reactions involving the rectal or scrota1 regions, all those concerned considered the overall picture of preliminary skin preparations greatly improved. The time and effort in the investigation of the hair removing product, consultations with the medical staff, planning and execution of the clinical study, and the instruction of prep personnel resulted in a significant contribution to better and safer care of the surgical patients involved. The author gratefully acknowledges her indebtedness to The Medical Research Committee at the St. Luke’s and Texas Children’s Hospitals, f o r their aid in the planning of this investigation and the analysis of our results, and to Rose K . Pizzitola, Operating Room Supervisor, for her assistance in the eficzent execution of the plan.
REFERENCES 1. Yust, W., Encyclopedia Britannica, 14th edition, Chicago, vol. 16, 33, 1949. 2. Ebell, B. (translator), The Papyrus Ebers Levin & Munksgaard, Copenhagen, London: H. Milford, 63:76-80, 1937. and Present, 3. Downing, J. G., Cosmetics-Past J.A.M.A., 103:2089, June 23, 1934. 4. Bethea, Doris Christine, The Effect of the Shave on Infection in Maternity Patients, Nursing Research, 12:2, 103-106, Spring 1963. 5. Hughson, W., Preoperative Treatment, Practice o f Surgery, (Lewis), Hagerstown, Md.: W. F. Prior Co., 1927, Vol. 1, Chap. 12, 15. 6. Keuhn, R. P., Who Should Do the Surgical Prep Shave? The Modern Hospital, 85:81-83, 102-104, Dec. 1955. 7. Knocke, F. J. and Knocke, L. S., Orthopaedic Nursing, Philadelphia: F. A. Davis, Co., 1951, Chap. 10, 279. 8. Prigot, A., Garnes, A. L., and Nwagbo, U., Evaluation of a Chemical Depilatory for Preoperative Preparation of Five Hundred Fifteen Surgical Patients, Am. J . Surg., 104:900-906, Dec. 1962. 9. Prigot, A., and Froix, C. J. L., A Chemical Compound for Hair Removal: Use in Surgical and Obstetrical Patients, Hospital Topics, 41 :103-105, Feb. 1963.
71