Thursday, May 22, 2008

Stepwise Sterility of Central Venous Access

The success of preventing central line infections requires more than a cursory approach to sterility at the bedside, and this is important in the Emergency Department just as much as anywhere else in the hospital. In fact, when I asked a fellow surgical resident how they gown and glove, they said, "the nurses do it for us". In the emergency department, we do not have scrub nurses, and therefore, we must learn how to gown and glove in a sterile fashion. The following sequential approach is recommended when you have time, eg, probably not going to be useful in a code situation, and with all medical procedures, this is not something you should try without appropriate supervision and guidance.

I recommend that you watch the following videos online and try to observe the specific maneuvers which could be eliminated or changed to improve sterility.

If you watch the videos carefully, you will see a few outright violations of sterility, and you will see other maneuvers which are recommended but in fact increase the number of manipulations which increases the chances of transmitting infection.

In the following excellent video by doctors Nicholas Johnson and David Howes, we see a violation of sterility at 07:57 (when placing drape, gloved finger touches the patient's clothes), then at 08:14, the same gloved finger then manipulates the line while attempting to preflush it.

The main idea in doing a procedure to maximize sterility is to minimize physical contact between agents which could transmit infection. So, this means doing the procedure with as few steps as possible. In fact, doing a CLEAN line is faster than doing it in a way that will be dirty, because you eliminate unnecessary maneuvers and demonstrate efficiency of technique. Every movement should be purposeful and crisply and expertly executed.

If you have every worked with tissue culture, cell culture, in a flow hood, in the operating room, you will have learned the microbiologic approach with strict attention to sterility. Pasteur was such an advocate for sterility he wanted people to wash their hands with pure alcohol. In the flow hood, you have access to a flame to sterilize your equipment, and each manipulation is accompanied by a passing of the pipette through the flame. You do not have a flame in the clinical environment, which means you MUST minize contact between objects.

Some of the recommendations below go against what you may have been taught.

get consent.
choose the site. (if there is bad lung, use that side.
avoid pacemaker side)
make sure the patient has no allergies to lidocaine.
choose an assistant and know their name and experience with procedures. tell them what you are going to do.
verify patient identifier, site, side and procedure with your assistant.
ensure monitoring is in place. make sure you can see the monitor.

1.Gather supplies. You will need a mayo stand or bedside table, central line kit, a line dressing kit, a biopatch, a gown kit with gloves inside, and ONE 10 mL saline flush, and gloves if not inside your gown kit. your nurse or assistant should get a CVP pressure monitoring kit and prepare it.

2. Do not open the kit. Leaving the kit open while you are getting ready exposes the kit to the air, and air carries germs. It is important to remember that one of the greatest discoveries in medicine, that of penicillin, was made when a mold drifted from an open window onto a bacteriologic plate, perhaps from the lab below Alexander Fleming's at St. Mary's hospital. Keep the kit closed until the LAST possible minute, right before you are ready to stick the needle. Think about it, why is cell culture done inside a flow hood? To minimize aerosol and droplet spread of infection.

3. Do not flush the line ahead of time. Flushing the line first means you let the saline sit there in the bucket in the tray exposed to air, then you introduce liquid which is a really good vector for infection, then you let the line sit in the tray with the liquid for a while, which means the line is sitting in a wet medium in the tray, which means that anything that fell on the tray is now on the surface of the line... BAD.

4. For the reasons above, DO NOT put saline flush into the TRAY UNTIL the line is inside the patient, and ONLY when you are ready to flush the line. Remember that the flush packaging is dirty, and have your assistant hold it high above the tray and away from any objects, and squirt it into the tray pocket only. I recommend minimizing the amount of fluid, and not putting it into the bucket in the bottom of the line kit as seen in this video.

5. Choose the site and prepare. Move monitor leads, oxygen lines etc out of the way, and have an assistant hold the patient's head if necessary. Put the patient in trendelenburg if they can tolerate it, otherwise you can do this right before you are ready to go, adjust the bed height, put the table with equipment where you want it, have a trash can for waste ready. Remove watch/jewelry. Wash your hands, with soap or surgical scrub, scrub each finger individually, like you were taught in the OR.

6. Clean the IJ and subclavian site so you can switch if necessary. Open the central line dressing pack or just get some chlorhexidine (since this is all you want). Clean the site with alcohol swabs first, let it evaporate, then once over with chlorhexidine. Remember if you use iodine it has to be dry to work. Take the top of the central line kit off only, but do not take the packing out and do not unfold it.

7. Get yourself sterile. You will be able to tell if someone used the right technique by looking at them in the final outfit. Watch this video and observe that the gloves come up the wrists and cover the gown's collared sleeve.

Put your cap and mask on. If you have big hair, tie it off so it is under the cap. Get your gown on. Have an assistant tie your gown, remember which part you grab while you spin.
Notice that in this video

at 1:12, the operator allows the nonsterile portion to snap over the wrist. This is NOT the appropriate technique when you are wearing a gown.

To appropriately place the gloves while wearing the gown, you must use the "closed technique" . You must study this technique carefully.

Grab the sterile gloves package with the gown sterilely through the gown sleeve, open the package, spread it out so it is a sterile field.

If your sterile gloves pack is not in the gown kit and you prefer to use a specific size, have an assistant sterilely drop the inside of the gloves package onto the gown pack field. The closed technique means you pick up the base of either folded glove with one hand, pick it up high off the field so the glove is not flopping around on a dirty surface, put your fingers through, open them inside the glove, putting the fingers aligned in each finger hole and the fingers through the finger parts since you need them for the next step, but DO NOT pull the double folded portion of the glove over the gown.

If you have BIG HANDS, your hands may get stuck inside the gown sleeve while doing the closed technique. If this is a problem, you can go partially closed, by inserting your fingers so the tip of the gown sleeve is precisely at the crease of your thumb so your fingers stick outside the gown and the elastic part of the sleeve is covering the thenar and hypothenar eminence/half of your hand.

In this way, you can use your fingers to pick up the base of the glove, pull it over the other hand's gown sleeve, but leave the folded part of the glove folded since you now DEFINITELY have a nonsterile portion on the gown sleeve, where your finger touched the outside of the gown sleeve at the point at which your opposing finger picked up the base of the glove, this spot will be covered after you put on the other glove.

Now, use the gloved hand to pick up the other glove by hooking under the folded surface of the glove and inserting your other hand into the glove, now you can bring the glove entirely around the gown sleeve, so that there is overlap of about 2-3 inches of the glove over the gown sleeve.

With this gloved hand, now hook UNDER the folded glove on the first hand. It is important to hook UNDER, since you touched the folded part of the glove before. Bring the folded part of the first glove up over rest of the gown sleeve, ensuring overlap. Be careful NOT to touch the gown with your gloved hand since there is a spot of dirtiness on it from where you put the glove on at the first step.

Note in this video, at 00:10, the operator touches the finger to the nonsterile folded inside of the glove and allows it to snap to his wrist, this is incorrect, he then touches this dirty zone at 00:40 when he readjusts, violating sterility of the right hand.

The operator should have gently dragged the nonsterile portion up the left wrist, and then hooked over from the sterile inside with the sterile right hand to cover this contaminated spot.

Now you are sterile.

8. Now that you are sterile, you may use your sterile fingers to unfold the contents of the central line kit. Remembering that you are sterile, take the chloroprep that comes in the kit, and now do a second cleaning of the site. Your site should already be free of obstructions and have been cleaned first. in this second cleaning, start in the middle of the site and spread outwards in progressively larger circles. Put the prep thing in the trash which you have placed nearby so the nurse or anyone who is watching is happy. Don't throw it on the floor, or just anywhere, they will think you are careless and a slob, and they will think you have not taken pains to be sterile.

9. Finish unfolding the kit. Get the drape. The drape has a white absorbable side and a blue nonabsorbent side. the main thing is that you want the absorbent side to be UP, so that if there is blood, it will be absorbed and not dripping and running everywhere. Now, take your drape and put it over your site. Remember that in any sterile field, you assume that only the central portion is sterile. You must confine yourself to working in the middle. In your brain, subtract about 6 inches to a foot (20 cm) from the edge of the field and do not touch anything in this border zone.

In this video demonstrating ultrasound guidance at 3:53, the hand of the operator is very close to the edge of the sterile drape. Note also at 3:39 in the same video that the sleeve covering the probe touches outside the drape, then at 3:59, the sleeve is draped across the sterile field, at 4:09, the left hand of the operator is pressed against the edge of the sterile field. Be careful when adding steps to minimize unneccessary contacts. Multiple manipulations decreases sterility.

10. Now that your drape is ready, and you are in place, make sure you can see the monitor and your assistant can see the patient. Pick up the lidocaine. You are going to give a medicine, ask your assistant to read the container label to ensure it has not expired- (how long has that kit been sitting on the shelf?). Verify the patient has no allergies to lidocaine. If the lidocaine is in a vial, take a 4X4 or other sterile gauze to hold over the vial while you crack the vial (you do not want to get cut by the sharp edges of the vial, this has happened to me, it means you have to get gloved up again. Draw out some lidocaine. Administer the lidocaine and probe towards the clavicle in the subclavicular space if doing a subclavian, always aspirating before injecting. If you are using the seeker technique to identify the IJ, remember that you do not want to inject lidocaine into an artery if you can avoid it.

11. Now you are ready to insert the needle into the subclavian. Do not take the wire feeder or the dilator or anything out of the kit. With your nondominant hand, stabilize the chest, identify the sternal notch, and hold the chest wall down. Move the bevel so that it is aligned with the numbers, and maintain appropriate bevel orientation (bevel edge to the feet in a subclavian so that the wire goes down and not up. Insert the needle. When you have flashback, take the syringe off the needle, and stabilize the position of the needle, so that it does not move out of the vessel. Pick up the wire feeder from the kit, and advance the wire. It is not necessary to touch the wire feeder against the needle hub, doing so puts force on the needle and can move it out of the vessel. Simply advance the wire into the needle hub without touching the wire feeder against the needle hub.

12. Keep your eye on the monitor while advancing the wire. Dispose of the wire feeder. Slide the needle off the wire and put it in the sharps pincushion. Maintain the wire in the air, and control it. Do not let the wire touch, drag or flop on the drape or skin. Remember that the skin around the puncture site is technically not 100% sterile. Keep the wire high in the air. Get a sterile 4X4 and place it at the puncture site so that the leading edge of the wire rests on the 4X4 and not on the drape or the skin. In this video , at 5:45, notice the blood is oozing everywhere, this could be prevented by a gauze pad.

13. Take the scalpel and orient it parallel to the wire. Go along the wire, and insert the scalpel into the puncture site, slightly dilating the site. See it here at 6:30 in the video . Slide the dilator over the wire. Dilate. Take the dilator off, place it in the tray.

14. Pick up the central line. Do not flush it. With economy of motion, slide the line over the wire, taking it directly in a straight movement from the tray to the wire. Do not let the line drag on the skin, keep the line in the air while you insert it over the wire. Advance the line until the wire comes through the brown port. Insert the line to the desired depth. Watch the monitor. Notice in this In this video , at 6:24, the end of the wire is flopping all over the edge of the drape. Maintain control of the end of your wire and keep it high and away from the skin and edge of drape.

15. Take the wire out, it is wet and bloody, dispose of it. Now your line is in, there is a piece of gauze where you had it before to stop oozing from the site. Do not be concerned that you have not flushed the line. Put the caps on the port sites.

16. Take the biopatch and place it blue side up, put the bridge holder on the line.

17. You may now get an assistant to sterilely place 10 mL of flush on your tray, being sure to squirt the liquid only, and NEVER allow the nonsterile flush container onto your sterile field. Take a sterile syringe and draw up the flush. From the ports, aspirate air and blood from the line, holding the syringe higher than the line, then flush each line.

16. Suture the line to the skin, in three positions.

17. Place the dressing on the line, label it as per hospital protocol.

18. You may now ask your assistant to connect the line to a CVP monitor and confirm waveform and pressure. Doing so at this stage will confirm you are not in an artery.

19. Clean up and dispose of sharps, wash your hands, get a chest x ray and write a procedure note, always note the cvp pressure. Come back and tell your patient how things went, or if you got phone consent, call whoever consented and tell them how things went.

1 comment:

S. said...

Nice that your sterile gown sleeves are modeled after black sweatshirts. Much more cozy... wink.