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CHAPTER (4): POVIDONE-IODINE PLEURODESIS INTRODUCTION Povidone-iodine (PVP-I) is a stable chemical complex of polyvinylpyrrolidone (Povidone, PVP) and elemental

iodine. It contains from 9.0% to 12.0% available iodine, calculated on a dry basis. This unique complex was discovered at the Industrial Toxicology Laboratories in Philadelphia by H. A. Shelanski and M. V. Shelanski. They carried out tests in vitro to demonstrate anti-bacterial activity, and found that the complex was less toxic than tincture of iodine in mice. Human clinical trials showed the product to be superior to other iodine formulations. It was first sold in 1955, and has since become the universally preferred iodine antiseptic. (Walter Sneader 2005)

HISTORICAL VIEW First discovered in its elemental form by Courtois in 1812, iodine has been used as a topical antiseptic since the mid-1800s. Of all the chemical species found in solutions studied, free molecular iodine or free iodine is the only species with a concentration proven to correlate with bactericidal activity. Whereas free iodine correlates with bactericidal activity, total iodine correlates with a given formulations capacity to kill bacteria. (Gottardi W. 2001) Povidone Iodine or polyvinyl pyrrolidone-iodine, commonly abbreviated as PVP-I was discovered by American scientists H. A. Shelanski and M. V. Shelanski. PVPI was introduced to the pharmaceutical market as an antiseptic agent in the 1950s and is found to be more effective than other iodine formulations and was less toxic.. (Eugene SB, Harry GB. 1998)

PVP-I is completely soluble in cold and mild-warm water, ethyl alcohol, isopropyl alcohol, polyethylene glycol, and glycerol. Its stability in solution is much greater than that of tincture of iodine or Lugol's solution. Free iodine, slowly liberated from the poviodine -iodine (PVP-I) complex in solution, kills eukaryotic or prokaryotic cells through iodination of lipids and oxidation of cytoplasmic and membrane compounds. This agent exhibits a broad range of microbicidal activity against bacteria, fungi, protozoa, and viruses. Slow release of iodine from the PVPI complex in solution minimizes iodine toxicity towards mammalian cells.

US ES i. As Skin Disinfectant: The patients skin is a major source of pathogens that cause infection. Traditional aqueous-based iodophors, such as povidone -iodine, are one of the few products that can be safely used on mucous membrane surfaces.6 PVP -I as 10% solution(1% available iodine) is widely used for skin disinfection and 7.5% PVP -Iodine solution (0.75% available iodine) is used for wound cleansing. The resultant broad spectrum of antimicrobial activity is well documented and its efficacy, particularly in relation to resistant micro-organisms such as methicillin-resistant Staphylococcus aureus, has been shown. (Durani P, Leaper D. 2008) ii. Pre-Operative skin preparation: Procedural and surgical site infections create difficult and complex clinical scenarios. A source for pathogens is often thought to be the

skin surface, making skin preparation at the time of the procedure critical. The most common skin preparation agents used today include products containing iodophors. PVP Iodine products have been widely used for pre -operative skin preparation and in various surgical procedures and shown to significantly lo wer subsequent infection rates. In the aqueous form, most commercially available iodophors require a 2 -step application in a scrub-and-paint technique, and their activity is limited by the amount of time the agent is in contact with the skin. (Micah L Hemani, 2009) iii. Topical Application: PVP-I in the form of ointments, sprays, lotions is used to prevent microbial contamination of wounds, ulcers, burns etc. PVP-Iodine effectively controls bacterial growth and protects the developing epithelium. Unlike man y antibiotic agents it has the added advantage in that its continued use does not result in the gene ration of resistant organisms. (Povidone Iodine, 2011) iv. Pleurodesis: It is used in pleurodesis (fusion of the pleura because of incessant pleural effusions). For this purpose, povidone -iodine is equally effective and safe as talc, and may be preferred because of easy availability and low cost. (Das SK, Saha SK, 2008) DOSAGE AND EFFICACY The pleurodesis solution, containing a mixture of 20 ml of 10% iodopovidone (Betadine Aqueous paint) and 30 ml normal saline, used to be injected into the pleural cavity through the chest tube. Some difficulty was experienced in the form of increased resistance while injecting the total volume of fluid in the patients with recurrent pneumothorax. It is possible that patients with pneumothorax require lower amounts of the sclerosing agent for pleurodesis. (Dey A, Bhuniya S, 2010) A mixture of 20 mL of 10% topical solution of Povidone -iodine and 30 mL of normal saline and 2 mg/kg lidocaine 2% was Instilled into the pleural cavity through

thoracostomy tube and then, the tube was clamped for 6 hours. The position of these patients was changed within 6 hours by the medical staff to circulate the mixture. After pleurodesis, all patients were assessed via chest X -ray (CXR) after 1 week, 1 and 3 months. (Godazandeh G, 2013)

ADVERSE EFFECTS The only significant side effect of iodopovidone was the occurrence of chest pain. Only two studies have systematically assessed the occurrence of chest pain. Hypotension was reported in two studies and was found associated with chest pain and is likely to be vasovagal in origin. However, iodine can cause severe allergic reactions, especially in patients with allergic diathesis, and thus one should be prepared to deal with this emergency. Iodine may also precipitate thyrotoxicosis in patients with subclinical hyperthyroidism (Jod-Basedow effect). However, in a study with 12 patients, no alteration in thyroid function was noted. There were no deaths or ARDS associated with this agent. There is also a single report of visual loss associated with iodopovidone pleurodesis. (Ritesh Agarwal, et al.; 2012) Many studies have demonstrated that the significant side effects of povidone -iodine are the occurrence of the chest pain, postoperative visu al loss and thyroiditis. However patients on the povidone-iodine group reported higher scores of dyspnea in one month follow up. (Wagenfeld L, Zeitz O, 2007)