Sterility of Peripheral Nerve Block

[ASnaves]

Hello all, I was just trying to find out everyone's thoughts on how they view the sterility of a peripheral nerve block procedure (not catheter). Personally, I treat it as the same sterility of an IV (no mask, regular gloves, tegaderm over the probe, and alcohol prep at needle entry). This is how it was done where I trained and there was a 0% infection rate over several years. Now at the hospital I'm at, they are making a push to have us all do our blocks in a sterile procedure manner minus the gown (sterile gloves, mask, drape, full prep, etc). I was also wondering if any of you knew of any literature about the this topic that I could use to support my stance if need be, thanks.

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[Ashers]

Hello all, I was just trying to find out everyone's thoughts on how they view the sterility of a peripheral nerve block procedure (not catheter). Personally, I treat it as the same sterility of an IV (no mask, regular gloves, tegaderm over the probe, and alcohol prep at needle entry). This is how it was done where I trained and there was a 0% infection rate over several years. Now at the hospital I'm at, they are making a push to have us all do our blocks in a sterile procedure manner minus the gown (sterile gloves, mask, drape, full prep, etc). I was also wondering if any of you knew of any literature about the this topic that I could use to support my stance if need be, thanks.

In residency, we treated single shots as a sterile procedure minus the gowns. In fellowship, we treated it as the same sterility as an IV and called it a "clean" procedure, however, I used sterile gloves for better tactile sensation, and I prep with chloraprep, and I use single use sterile gel packets. I wear a mask and goggles most of the time because I have been sprayed in the face. There are guys in the group who use regular gloves and the non-sterile bottle of gel (sterile packets not with probe covers weren't ordered until I arrived and asked for them). I know of no infections for anyone.

I don't know of literature about this; I'll add that to my list of things to look up.

Edit: Tegaderm on the probe too... except in 1 surgicenter that won't let me, then I chloraprep the probe separately from the block site.

 

[vector2]

We use sterile gloves, hat, mask, chloraprep, teg on probe, no drape, and non-sterile gel. Never heard of an infection from a PNB at our institution.


Infections Associated With Use of Ultrasound Transmission Gel
http://www.medscape.com/viewarticle/774780

 

[Ezekiel2517]

We use sterile gloves, hat, mask, chloraprep, teg on probe, no drape, and non-sterile gel. Never heard of an infection from a PNB at our institution.


Infections Associated With Use of Ultrasound Transmission Gel
http://www.medscape.com/viewarticle/774780

why go thru the trouble of the sterile gloves/hat/mask/chloraprep/tegaderm and then not use sterile gel or lube? makes no sense. the needle and skin are immediately contaminated by the gel

 

[BLADEMDA]

Sterile Gel is essential. Chloraprep, Tegaderm and Sterile Gel.


Contaminated USTG has been associated with outbreaks of infection due to a variety of procedures and microorganisms ( Table 1 ).[1–6] In all circumstances, the outbreaks were aborted after a switch to single-dose sterile gel.

 

[BLADEMDA]

The hands of health care workers are the most common vehicles for the transfer of microorganisms from one patient to another. (27) Studies show that although soap and water may remove bacteria, only alcohol-based antiseptics provide superior disinfection, and solutions of povidone iodine and chlorhexidine possibly provide the most extended antimicrobial activity. (28) Sterile gloves should be used throughout in addition to all other measures discussed. (29) No evidence exists to prove that gowning decreases the incidence of nosocomial infection. (30) One study showed no difference between infection or colonization rates between gowning and not gowning in the pediatric intensive care unit (ICU). (31) Another study showed that use of gowns and gloves was no better than use of gloves alone in preventing rectal colonization of vancomycin-resistant enterococci in the medical ICU. (32) Therefore, although gowning during the performance of PNBs is recommended by some, there is not sufficient evidence that such practice is beneficial in decreasing the incidence of infection. (30)

http://www.nysora.com/regional-anes...009-equipment-for-peripheral-nerve-block.html

 

[ZzzPlz]

In residency, we treated single shots as a sterile procedure minus the gowns. In fellowship, we treated it as the same sterility as an IV and called it a "clean" procedure, however, I used sterile gloves for better tactile sensation, and I prep with chloraprep, and I use single use sterile gel packets. I wear a mask and goggles most of the time because I have been sprayed in the face. There are guys in the group who use regular gloves and the non-sterile bottle of gel (sterile packets not with probe covers weren't ordered until I arrived and asked for them). I know of no infections for anyone.

I don't know of literature about this; I'll add that to my list of things to look up.

Edit: Tegaderm on the probe too... except in 1 surgicenter that won't let me, then I chloraprep the probe separately from the block site.

What on earth sprayed you in the face while doing a PNB?

 

[Ashers]

What on earth sprayed you in the face while doing a PNB?

Local from the needle and syringe for the skin local not being tight enough, and I didn't check it. Happened to me a few times when I didn't get things ready myself -- a nurse and one of my attendings helped me get things ready. So now, I get things ready myself, or I make sure to check and make sure the connections are tight.

 

[ZzzPlz]

Local from the needle and syringe for the skin local not being tight enough, and I didn't check it. Happened to me a few times when I didn't get things ready myself -- a nurse and one of my attendings helped me get things ready. So now, I get things ready myself, or I make sure to check and make sure the connections are tight.

Ahh I see. Once I had an attending that was injecting with a 30cc syringe and the syringe itself literally exploded from the side. Never seen anything like it. At least in that situation or the one you described the risk of infection from a shot to the eye is (nearly) zero.

 

[Ashers]

Ahh I see. Once I had an attending that was injecting with a 30cc syringe and the syringe itself literally exploded from the side. Never seen anything like it. At least in that situation or the one you described the risk of infection from a shot to the eye is (nearly) zero.

Very true, but it burns like the dickens when it gets in the eye.

I have never seen a syringe explode!

 

[vector2]

why go thru the trouble of the sterile gloves/hat/mask/chloraprep/tegaderm and then not use sterile gel or lube? makes no sense. the needle and skin are immediately contaminated by the gel

I agree, our policy makes no sense. I think a lot of people are unaware of the infections that have come from supposedly bacteriostatic non-sterile gel.

 

[psychbender]

If you don't coat the patient in gel, and don't stick the needle through gel, you're not going to contaminate anything.

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[soorg]

I spit on the block site, don't get consent, don't do a time-out, and inject with such force that I often rupture nerves. Patients love me.

 

[periopdoc]

Chloraprep, cap (because I'm always wearing one), sterile gloves, probe "condom" and sterile, single use gel. 2nd chloraprep right over the injection site after I have my image lined up.

Overkill, but I don't really care. Medically is no more risky than a PIV, but legally it's probably worth a little extra precaution.

-bsd

 

[BLADEMDA]

Chloraprep, cap (because I'm always wearing one), sterile gloves, probe "condom" and sterile, single use gel. 2nd chloraprep right over the injection site after I have my image lined up.

Overkill, but I don't really care. Medically is no more risky than a PIV, but legally it's probably worth a little extra precaution.

-bsd

For a single shot I use a sterile tegaderm; for catheters I use a condom. I always wear a surgical hat, sterile gloves and use chloraprep. I wipe off any extra sterile gel using the same chloraprep as I used for the prep although I think using a second chloraprep stick is just fine.

 

[pjl]

If you routinely use chloroprep on the probe, you will degrade the probe over time. I guess the 8,500 for a new probe is worth it to them to save the small cost of a tegaderm.

Use a sterile glove if they wont let you use a tegaderm, works just fine.

Poking a bit away from probe site and gel, through a chloroprep field, while wearing sterile gloves always sounded like it should be more than good, but just in case, I use that single use gel to make myself feel better. Catheters are treated with more respect.


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[ZzzPlz]

Anyone else here put on sterile gloves for PNBs and not use sterile technique whatsoever? I don't know wtf is wrong with me. I guess the gloves seem cleaner than box gloves but I'll be damned if I change my gloves if I have to break sterility.

 

[deleted162650]

For SS block: Non-sterile gel on the probe. Obtain U/S image I like. Probe doesn't move from this point forward. Chloroprep in front of probe at puncture site. Needle never passes w/in a couple centimeters of gel, so I'm not worried about it. Seems weird to me to put sterile gel onto non-sterile skin. Sometimes sterile gloves, but only cuz they fit better.

 

[ranvier]

In residency, we did the full monty....just like a line.

In practice, I swipe some chloroprep next to the probe and use a sterile block needle. We don't place catheters. Everything is in long axis so insertion site is a few cm from probe.

 

[psychbender]

My practice is the same as SaltyDog's. I dislike the massive pile of ultrasound goop that some of my partners drop on a random, arbitrary spot on the patient, then slide the probe all over trying to find their landmarks, resulting in a sheet of gel through which they then place a needle. With their practice, I understand why they go full sterile.

 

[BLADEMDA]

https://www.researchgate.net/profil...ogic_Study/links/54e2f5b30cf2edaea09453f2.pdf


http://bmcanesthesiol.biomedcentral.com/articles/10.1186/1471-2253-13-18
"There is no evidence that passing the needle through the studied gels during regional anesthesia procedures is harmful."


I always wipe off any excess U/S gel with the Chloraprep stick. But, it's nice to know a tiny amount isn't neurotoxic.

 

[Neogenesis]

For a single shot I use a sterile tegaderm; for catheters I use a condom. I always wear a surgical hat, sterile gloves and use chloraprep. I wipe off any extra sterile gel using the same chloraprep as I used for the prep although I think using a second chloraprep stick is just fine.

Exactly what I do

 

[ASnaves]

Thanks for all the comments. I agree and do use sterile gel just in case any were to get into the needle site, but otherwise it's like an IV for me. Hopefully I can convince the hospital NOT to make PNB's sterile procedures that a full sterile setup is mandated.

 

[Pinkegg]

On a related note, what do people think about A lines? I always used chloroprep and sterile gloves but I've seen people who do normal globes and alcohol wipe.

 

[BLADEMDA]

On a related note, what do people think about A lines? I always used chloroprep and sterile gloves but I've seen people who do normal globes and alcohol wipe.

Best practice includes sterile prep with chloraprep and of course, sterile gloves.

http://forums.studentdoctor.net/threads/a-lines-sterile.905461/


http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf (page 18)


Recommendations from the recent CDC/HICPAC guideline for prevention of intravascular-catheter-related infection29 are summarized in Table V. Arterial catheters should be placed by trained personnel, using an aseptic technique and cutaneous antisepsis, preferably with >0.5% chlorhexidine. Sterile gloves and a sterile fenestrated drape are recommended for insertion of peripheral arterial catheters, and maximal barrier precautions for central (femoral or axililary) arterial catheters; a prospective randomized trial failed to show benefit with the use of maximal barrier precautions for insertion of peripheral arterial catheters, but was underpowered to extend this finding to central arterial catheters.30

https://www.medicine.wisc.edu/sites...elated_bloodstream_infections_Maki_Safdar.pdf

 

[BLADEMDA]

Crit Care Med. 2014 Jun;42(6):1334-9. doi: 10.1097/CCM.0000000000000166.
Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis.
O'Horo JC1, Maki DG, Krupp AE, Safdar N.



So what did they find? Well, after reviewing almost 50 studies, the authors concluded that a-lines are an under recognized and significantsource of CRBSIs. Here is the breakdown:

• Incidence: In systematically cultured arterial catheters, the infection rate was 1.6 infections/1,000 catheter days which is similar to what has been reported for infections associated with short-term CVC’s.
• Location: Femoral a-lines are more likely than radial a-lines to be a source of a CRBSI. Femoral a-line CRBSIs occurred in 1.5% of all catheters (95% CI, 0.8–2.2%), which is higher than radial CRBSI, with a relative risk of infection 1.94 times greater than those placed at the radial site.
• Technique: Only one study specifically evaluated the impact of full barrier precautions versus using sterile gloves only for peripheral a-lines, and it did not find any significant difference in BSI. No study has evaluated the impact of maximal barrier precautions for femoral, axillary, and brachial arterial catheters.
• Dressing: The risk of infection was significantly decreased with the use of chlorhexidine-impregnated dressings (ex: BioPatch)

http://maryland.ccproject.com/2014/01/25/line-significant-source-blood-stream-infections/​

 

[fakin' the funk]

To my knowledge -- and I combed Pubmed a couple years ago -- there has never been a case report of a soft tissue infection following a SINGLE SHOT peripheral nerve block. The reports that I could find were in continuous catheters.

Accordingly, I do the minimum that is "culturally acceptable" at my institution, which is pretty much as Salty described his. (We do all our blocks in the OR, so hat and mask are pretty much a given).

If you Chloraprep the puncture site, never have either your skin wheal needle or block needle touch anything except prepped skin, the thing ought to be as clean as a "max barrier" procedure.

Sterile gel is unnecessary, no matter how many abstracts Blade posts.

 

[IlDestriero]

We are sterile - the gown, +/- drape/towels. Same for Aline, CL gets the full monte.


--
Il Destriero

 

[OB1🤙]

For me, radial a-lines are no different than PIVs. Regular gloves. I do chloraprep though.

Any other a-line gets sterile gloves and mini drape.

 

[BLADEMDA]

Acceptable vs Good practice vs Best practice. I think putting on sterile gloves and using sterile gel doesn't create any negatives or add any time to perform the task. As such, I prefer to use sterile gloves, Chloraprep and sterile gel whenever possible.

I can see how adding the gown and large drape makes a simple procedure more labor intensive (best practice) while not adding much in terms of safety. Still, I can understand if someone decides to go that route. But, using "good practice" doesn't require any more time or effort to do the procedure.

 

[Skip2myLou]

chloroprep, sterile gel , sterile teggy/ cover , sterile gloves ... no mask , no towels ...


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[Ignatius J]

To my knowledge -- and I combed Pubmed a couple years ago -- there has never been a case report of a soft tissue infection following a SINGLE SHOT peripheral nerve block. The reports that I could find were in continuous catheters.

Accordingly, I do the minimum that is "culturally acceptable" at my institution, which is pretty much as Salty described his. (We do all our blocks in the OR, so hat and mask are pretty much a given).

If you Chloraprep the puncture site, never have either your skin wheal needle or block needle touch anything except prepped skin, the thing ought to be as clean as a "max barrier" procedure.

Sterile gel is unnecessary, no matter how many abstracts Blade posts.

Good info. Thanks.

I do aseptic technique and have never had any issues. I am careful not to let the needle touch anything other than the cholera-prep and that's about it.