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Perioperative management of nail polish, artificial nails and piercings in The Netherlands

A survey study

Bucx, Martin J.L.; Krijtenburg, Piet

European Journal of Anaesthesiology (EJA): March 2016 - Volume 33 - Issue 3 - p 223–224
doi: 10.1097/EJA.0000000000000336

From the Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

Correspondence to Martin J.L. Bucx, Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Internal postal code 717, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands Tel: +31 24 361 45 53; fax: +31 24 361 3585; e-mail:

Published online 11 January 2016


Anaesthetists are increasingly confronted with patients wearing nail polish, artificial nails or piercings.1,2 The presence of any of these during anaesthesia and surgery carries potential risks and may result in complications.1,2 Therefore, in many hospitals, patients are urged to remove nail polish and artificial nails – at least from one or two fingers – as well as all piercings. Unfortunately, removing these may also present problems and often patients can be reluctant to comply with such a request.

Therefore, many anaesthetists are uncertain about how to deal with these patients. Their uncertainty is increased by a scarcity of hard data, major differences in opinion on this topic in the literature,2 and a lack of clear guidelines.

We performed a survey in Dutch hospitals to obtain insight into how these issues are dealt with, focussing on the anaesthesiological aspects.

A questionnaire was sent by e-mail to one selected colleague in each of the 93 hospitals in the Netherlands. If no response was obtained within 2 weeks, a second e-mail was sent. When necessary, a third e-mail was sent or contact was made by telephone.

Complete results were obtained from all eight university hospitals, 69 of 82 general hospitals and two of three specialised hospitals (response rate 84.9%). Forty (50.6%) anaesthetists considered it essential to remove nail polish or artificial nails from at least one or two nails, and 37 (46.8%) indicated they had personally experienced pulse oximetry problems related to nail polish or artificial nails in the past. Tables 1 and 2 summarise data on the preoperative removal of nail polish, artificial nails and piercings.

Table 1

Table 1

Table 2

Table 2

The results of this study indicate that, in the majority of cases, nail polish and artificial nails are removed from at least one or two nails. The most important reason for removing nail polish is its perceived interference with pulse oximetry. Although this was certainly a problem in the past, modern pulse oximeters are considered to be minimally affected by nail polish, although erroneous readings do occur.3 This latter observation was confirmed by almost 50% of anaesthetists in this study, virtually the same proportion who considered not removing nail polish to be poor medical practice. However, the interference with pulse oximetry can be circumvented easily by rotation of the sensor or choosing an alternative measurement site.

Interference with determining capillary refill time might be another reason for removal. However, capillary refill time is influenced by many variables and there is no evidence to justify its use during anaesthesia.4

Perioral piercings have the potential to cause many problems2 and, not surprisingly, almost all tongue piercings and 75% of nose piercings are removed before sedation or general anaesthesia. Removal of perioral piercings is less common when only locoregional techniques are used, and removal of piercings in other areas occurs in less than 50% of patients. To put perioperative problems with piercings into perspective, it is important to realise that only a few airway problems as a result of oral piercings have been described in case reports and the perceived problem of electrosurgery with piercings in general has been eliminated by modern equipment.5

This study confirms major differences in managing the issues/problems of nail polish, artificial nails and piercings as previously described in the literature. When considering only their potential to cause complications, the perioperative removal of these items, especially piercings close to the airway, is to be preferred. However, many patients refuse to follow advice. Their reluctance to comply is often easy to understand, resulting from fear of pain during removal or reinsertion, tract closure or the costs involved. Sometimes the reason is more nebulous; for some these items are part of their identity and removal may cause embarrassment or psychological distress,6 a fact often is not appreciated by medical or nursing personnel.1,7

It is hoped that the results of this study will help anaesthetists to make an informed decision, with respect for the patient's needs,1 but also the results indicate a need for clear guidelines.

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Acknowledgements relating to this article

Assistance with the study: the authors are grateful to all Dutch anaesthetists who participated in this study.

Financial support and sponsorship: none.

Conflicts of interest: none.

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1. Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 2003; 361:1205–1215.
2. Mercier FJ, Bonnet MP. Tattooing and various piercing: anaesthetic considerations. Curr Opin Anaesthesiol 2009; 22:436–441.
3. Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation 2007; 72:82–91.
4. Pickard A, Karlen W, Ansermino JM. Capillary refill time: is it still a useful clinical sign? Anesth Analg 2011; 113:120–123.
5. ECRI Health Devices. Allowing patients to wear jewelry during surgical (and electrosurgical) procedures 1997; 26:441–442.
6. Ferguson H. Body piercing. BMJ 1999; 319:1627–1629.
7. Martino S, Lester D. Perceptions of visible piercings: a pilot study. Psychol Rep 2011; 109:755–758.
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