Sterilization of Injection Site for Spinal Anesthesia
For spinal anesthesia, the lumbar injection site must be prepared with alcoholic chlorhexidine gluconate solution (preferably chlorhexidine 2% with 70% isopropyl alcohol), allowed to dry completely, and performed under maximal barrier precautions including full hand washing, sterile gloves and gown, cap, mask covering both mouth and nose, and large sterile drape. 1
Antiseptic Solution Selection and Application
Use chlorhexidine with alcohol as the first-line antiseptic agent for skin preparation prior to spinal anesthesia. 1, 2 The American Society of Anesthesiologists specifically recommends chlorhexidine with alcohol as the preferred solution. 1, 2
Apply the antiseptic liberally to the surgical site and allow adequate drying time before needle insertion. 1, 3 This drying period is critical—the antiseptic must be allowed to dry completely to achieve maximum antimicrobial efficacy. 1
When chlorhexidine is unavailable, use povidone-iodine with alcohol rather than povidone-iodine alone. 1 Alcoholic povidone-iodine solution is an acceptable alternative. 1
Use individual single-use packets of antiseptic preparation rather than multi-use bottles to minimize contamination risk. 1
Research demonstrates that both chlorhexidine-based and iodine-based preparations with alcohol are equally effective at eradicating common bacterial pathogens from the lumbar spine skin when properly applied. 4
Maximal Barrier Precautions Protocol
Spinal anesthesia requires full aseptic technique with maximal barrier precautions—this is non-negotiable even for single-shot spinals. 1 While many practitioners historically used less stringent precautions for single-injection techniques, current guidelines emphasize that penetration of central neural spaces mandates complete sterile technique. 1
Hand Hygiene
- Perform full surgical hand washing with antimicrobial soap before the procedure. 1
- Remove all jewelry (rings, watches) before hand washing. 1
- Hand hygiene is the single most critical infection control measure. 5
Personal Protective Equipment
- Wear sterile gloves for the procedure. 1
- Wear a sterile gown in addition to gloves. 1
- Wear a cap covering all hair. 1
- Wear a mask covering both mouth and nose. 1 Consider changing the mask before each new case. 1
Patient Draping
- Use a large sterile drape to create an adequate sterile field around the injection site. 1
Critical Pitfalls to Avoid
Do not proceed with needle insertion before the antiseptic has completely dried. 1 Premature insertion while the skin is still wet significantly reduces antimicrobial efficacy and increases infection risk.
Do not use reduced aseptic precautions for "simple" single-shot spinals. 1 The risk of serious infectious complications including meningitis and epidural abscess mandates full sterile technique regardless of whether a catheter will be placed.
Do not skip hand washing even when using sterile gloves. 1 Gloves can have microscopic defects, and proper hand hygiene remains essential.
Special Considerations for High-Risk Patients
For immunocompromised patients, maximal barrier precautions are absolutely required for all invasive procedures. 1, 5 These vulnerable patients face substantially higher infection risk and require meticulous technique.
For known or suspected bacteremic patients, administer preprocedure antibiotic therapy before performing spinal anesthesia. 1 However, recognize that infectious complications can still occur despite antibiotic prophylaxis. 1
Avoid lumbar puncture entirely in patients with known epidural abscess. 1 This represents an absolute contraindication.
Environmental Factors
The operating theater location does not inherently reduce infection risk—the level of barrier protection determines safety, not the surrounding environment. 1 Proper sterile technique is equally critical whether the procedure occurs in the operating room, labor suite, or other location.