Accidental Chlorhexidine-alcohol Induced Chemical Burns: Need for Regular Cross-checks in the Perioperative Period

Introduction: Surgical site preparation refers to the preoperative treatment of the intact skin of the patient with the anti-septic solution within the operating room for prevention of surgical site infection.Clinical Experience: Out of 87 surgeries performed, 11 patients; 9 males and 2 female, with no prior history of allergies, developed superficial skin lesions either on the evening of operation or the morning next day.The clinical presentation varied from erythema and superficial desquamation of skin to painful blister formation to sloughing of the whole skin of the genitalia and inner thighs.After ruling out another differential diagnosis, we inferred that 3-4 times concentrated CHG was used in these patients leading to the chemical burns.On Naranjo Adverse Drug Reaction Probability Scale, the probability for chemical burn by CHG was 6. Conclusion:The case reports here described partial-thickness chemical burns in adults after accidental skin preparation with higher than desired concentrations of CHG in alcohol disinfectant.This stresses the need for collective responsibility of the health care team in peri-operative care as well as conduction of regular and thorough audits if any adverse event occurs.