A-Lines Sterile

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pie944

pie944

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Do most people place them with sterile gloves, or just use regular gloves without touching the puncture site/catheter tip? I've been at two places, one did the former and the other the latter.
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Regular gloves. I think some put on sterile gloves but only to enhance their palpatory skills.
 
Depends. If there is a good chance that they will need it for more than 24 hours post-op then I wear sterile gloves. Less than 24 hours, I wear whatever gloves are handy. I also use sterile gloves for anyone already in the ICU or on significant immunosuppression.

- pod
 
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periopdoc said:
Depends. If there is a good chance that they will need it for more than 24 hours post-op then I wear sterile gloves. Less than 24 hours, I wear whatever gloves are handy. I also use sterile gloves for anyone already in the ICU or on significant immunosuppression.

- pod
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Do you drape the area too? Or just prep, gloves, go?
 
I always use sterile gloves and make a small field with sterile towels. It's how I was trained, what the CDC guidelines recommend, is cleaner, neater, and not much effort. But, I also admit that when I've stuck an arm many times sterility suffers. Axillary and femorals should have a full body drape since they are central. Oh and I use Chloroprep for everything.
 
+1 on the chloraprep. Don't see the point of the drape for a radial or axillary brachial though.

-pod
 
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Chlorprep and regular gloves for most OR a-lines, sterile gloves outside of the OR, or if I plan on the ICU using it for a while. One hospital at which our residents rotate insists on sterile towels and gloves for all a-lines, so I recently got into the habit of doing it that way, but will probably revert once I get back home.
 
Noyac said:
How many infected A-lines have You guys seen?
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That's one of the reasons I asked the question. None. No one I know has either, but at the same time I've never seen an arterial catheter investigated as the source of unknown bacteremia. The studies I found seem to show arterial catheters have similar rates of colonization when compared to CVC, but lower rates of infection.

I just was curious about what people do because where I did my intern year in the ICU loss of sterility during an arterial line could lead to dirty looks/write ups by an RN. Now, during my residency the only time people consistently throw on sterile gloves is during femoral placement.

In terms of the CDC they state under arterial catheters that:

3. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Category IB
4. During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. Category II

What's funny is if you look at #159 which I assumed was supporting evidence based on the title "Rijnders BJ, Van Wijngaerden E, Wilmer A, Peetermans WE. Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial. Clin Infect Dis 2003; 36:743–8." you find that the first line of the discussion states "In this randomized study, we found no differences in the incidence of AC colonization when the AC was inserted under full SBPs compared with insertion under SOC precautions." They defined SOC as "hand washing, wearing of sterile gloves, and skin disinfection with 0.5% chlorhexidine in 70% alcohol."

So not sure about the draping aspect?

Just was curious how the majority of people practice.
 
My institution "mandates":

--Sterile gloves, drapes/towels, prep, and Biopatch for all A-lines, regardless of the setting it's placed in or pt disposition (most will gown for femorals)
--Stat-locks for all A-lines, IV's, and central lines
--NO sutures for central lines

Yep, pretty reasonable, huh? :rolleyes: It's actually not onerous to do sterile gloves/drape/prep for straightforward radials, though it does take an extra 3-4 minutes. I think I'd want someone to do that if I was the pt.

Sterility certainly suffers when multiple catheters, wires, and proximal arm locations start getting involved, and no one really seems to mind.
 
The only time I've seen data on a-line infection rates that were anywhere near that of central lines, it was in an ad pushing for the use of biopatches for a-lines, and the rate was something like 1.9 per 1000 catheter days (which is high even for central lines in the modern era). I don't use sterile gloves (generally even in the ICU) for a-lines, and the data don't support bio-patch or abx-impregnated catheters for central lines.
 
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fakin' the funk said:
My institution "mandates":

--Sterile gloves, drapes/towels, prep, and Biopatch for all A-lines, regardless of the setting it's placed in or pt disposition (most will gown for femorals)
--Stat-locks for all A-lines, IV's, and central lines
--NO sutures for central lines

Yep, pretty reasonable, huh? :rolleyes: It's actually not onerous to do sterile gloves/drape/prep for straightforward radials, though it does take an extra 3-4 minutes. I think I'd want someone to do that if I was the pt.

Sterility certainly suffers when multiple catheters, wires, and proximal arm locations start getting involved, and no one really seems to mind.
Click to expand...


Biopatch for a-lines? really???? That's crazy. The NNT for that intervention is probably pushing 50K
 
Noyac said:
How many infected A-lines have You guys seen?
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I knew of none until I started looking for them specifically during fellowship. I uncovered 3 or 4 that I would not have known about if I wasn't specifically looking for them (none in my personal patients, just of a-lines placed by the anesthesia department). Of course, that is the same institution where, on more than one occasion, I witnessed residents manipulating the catheter (not the hub, the actual mid-shaft of the catheter) with non-sterile gloves during insertion. :uhno:

I am not a stickler for doing this in a sterile fashion and will use alcohol/ non-sterile gloves if that is what is at hand. It just takes no longer to do it with sterile gloves and chlorhex, so that is what I prefer to do. If it is going to be in for a while, I will take the extra 2-3 min to track down sterile gloves/ chlorhex.

- pod
 
I've put in about 75 this year as an intern, nearly all of them in the ICU. I always use chloraprep and sterile gloves simply because it's what I'm told to do. Call me a conformist. Perhaps at my new location next year it will be different. I've seen many methods but everyone I've asked has never seen an infected a-line.
 
periopdoc said:
I knew of none until I started looking for them specifically during fellowship. I uncovered 3 or 4 that I would not have known about if I wasn't specifically looking for them (none in my personal patients, just of a-lines placed by the anesthesia department).
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Your prudent (as always) post underscores an idea that can lead to complacency - the "fallacy of anecdote" - "I've never seen it, therefore, it doesn't exist". As your post shows, there is the corollary that "things that are not looked for are rarely found".

Where I was a resident (where proman was a fellow), we did the whole shebang in the MICU for A-lines - cap, mask, gown, gloves, operative scrub of the hands, drape. Overkill? I don't know.
 
Apollyon said:
Overkill? I don't know.
Click to expand...

I believe it was a Cochrane Review (for what that's worth) I read awhile back that came down on the side of maximal sterile barriers not to be warranted for a-lines. A review like that is only worth the studies from which it is composed, but people generally take Cochrane at its word.

Of course, now that I tried a brief search for the review, I can't seem to find it, but I did come across this:

http://www.ncbi.nlm.nih.gov/pubmed/12627358
 
Seen one Aline infection. Lady was in ct icu post op with a "therapy" dog. Dog licked her arm and probably other things. Aline got infected. Dog had diarrhea too. She wouldn't do the cabg without the therapy dog. Major administrative nightmare
 
olaf said:
Seen one Aline infection. Lady was in ct icu post op with a "therapy" dog. Dog licked her arm and probably other things. Aline got infected. Dog had diarrhea too. She wouldn't do the cabg without the therapy dog. Major administrative nightmare
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Classic.

We've got nurses standing by with clipboards going through checklists for timeouts, drapes, duration of scrub, sharp counts, mandatory Biopatches, etc for line placement.

But they let dogs into the ICU.
 
periopdoc said:
I uncovered 3 or 4 that I would not have known about if I wasn't specifically looking for them (none in my personal patients, just of a-lines placed by the anesthesia department).
Click to expand...

Yeah it happens, a hospital i rotated at had a run of a few infected a-lines so some people came over to the OR and asked that we go full sterile even though when i asked none of the infected a-lines had been placed in the OR.
 
dhb said:
Yeah it happens, a hospital i rotated at had a run of a few infected a-lines so some people came over to the OR and asked that we go full sterile even though when i asked none of the infected a-lines had been placed in the OR.
Click to expand...

That's how things work where I am now. Some peripherally related, 1:100,000 event occurs and suddenly there is a rushed and poorly thought through universal policy in place. And BTW, it's effective immediately. :rolleyes:
 
IlDestriero said:
That's how things work where I am now. Some peripherally related, 1:100,000 event occurs and suddenly there is a rushed and poorly thought through universal policy in place. And BTW, it's effective immediately. :rolleyes:
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Welcome to the VA. We had a sentinel event involving a surgeon injecting from an unmarked syringe (that happened to contain 5 mL of 1:1000 epi), and the fix was a bar code system for pyxis-loading and a draconian narc waste procedure for the pyxis (nevermind that the epi is neither a narcotic nor stored in the pyxis to begin with).
 
I do 'em like PeriopDoc does.

If it's in the OR and likely just for the case and will likely come out in PACU, I have no problem using alcohol and regular gloves. If the pt. is likely going to the ICU post-op then I do it sterilely. In the OR I don't drape even when doing it sterile, mainly out of convenience. In the ICU I try to maintain sterile technique and I usually drape with sterile towels, mostly to give myself some space to lay stuff down and not make a huge mess on the pt's bed. No mess makes for happier nurses.
 
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cchoukal said:
Welcome to the VA. We had a sentinel event involving a surgeon injecting from an unmarked syringe (that happened to contain 5 mL of 1:1000 epi), and the fix was a bar code system for pyxis-loading and a draconian narc waste procedure for the pyxis (nevermind that the epi is neither a narcotic nor stored in the pyxis to begin with).
Click to expand...

How did that end up?
 
Do you guys suture your a-line catheter in place? We use the a-line arrows which are really nice. Its a all in one needle, guidewire, catheter. They have a grove at the hub to suture the catheter in place.

I've seen some infected skin from poor CVC suture jobs, so I am sure the same would hold true for alines. The suture thread should only contact a sterile drape. Imagine all the crap the thread would pick up before it went in the skin.

When I have to place aline intraop (left arm board, buried under drapes, surgeon's ass covering arm space) sterility usually goes out the window.
 
RxBoy said:
Do you guys suture your a-line catheter in place? We use the a-line arrows which are really nice. Its a all in one needle, guidewire, catheter. They have a grove at the hub to suture the catheter in place.

I've seen some infected skin from poor CVC suture jobs, so I am sure the same would hold true for alines. The suture thread should only contact a sterile drape. Imagine all the crap the thread would pick up before it went in the skin.

When I have to place aline intraop (left arm board, buried under drapes, surgeon's ass covering arm space) sterility usually goes out the window.
Click to expand...

I don't suture a-lines in the OR. I will sometimes suture the ones I place in the unit. The harder it was to place, the more likely I am to suture.
 
At my previous institution, I frequently sutured A-lines that were placed for longer term. At my current institution they don't seem to have so much problem with accidentally pulling a-lines as they did at Da U so I no longer suture them.

-pod
 
Noyac said:
How many infected A-lines have You guys seen?
Click to expand...

Noyac, FTW.

I think arterial pressures are too high to create a sufficient biofilm wihtin the catheter/nidus for infection.

I have seen many kinked, clotted, and whatever else arterial lines, but never an infected one.

I don't think sterile technique for a-lines is evidence-based like central lines. Is it really good practice if you're wasting time prepping, draping, grabbing sterile gloves, and maintaining sterility? Vigilant to those who do, perhaps. Inefficient to those that don't.

In anesthesia, seconds can matter sometimes.

As always, JMO.
 
Ignatius J said:
Noyac, FTW.

I think arterial pressures are too high to create a sufficient biofilm wihtin the catheter/nidus for infection.

I have seen many kinked, clotted, and whatever else arterial lines, but never an infected one.

I don't think sterile technique for a-lines is evidence-based like central lines. Is it really good practice if you're wasting time prepping, draping, grabbing sterile gloves, and maintaining sterility? Vigilant to those who do, perhaps. Inefficient to those that don't.

In anesthesia, seconds can matter sometimes.

As always, JMO.
Click to expand...

Yeah sometimes (rarely) second matters, I would hope everyone modifies their routine practice when that's the case. I know I do. But what's the added time to getting a pack of sterile towels and gloves? About 30 seconds.

But let's look at the CDC guidelines. The use of a cap, mask, sterile gloves and small sterile field is a Category IB recommendation (Category IB is strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice supported by limited evidence).

The risk of infection with arterial lines is lower but not zero (1.7 vs 2.7 per 1,000 catheter days).
Use of full barrier precautions does not reduce the risk of arterial CRBSI.
When using maximum barrier precautions, the risk is 0.41/1000 catheter days.
The risk of arterial CRBSI increases with duration but routine changing does not decrease that risk.

- Martin et al: 11% of dorsalis pedis cannula were colonized with pathogenic bacteria, 9.3% of radial catheters. 4 cases of catheter-related infection. Limitation was the use of betadine instead of Chloraprep.

- Traore et al: 7.4% of radial artery catheters colonized. Used Chloraprep.

- Koh et al.: Colonization of arterial catheters: 15.7 per 1,000 Blood stream infection: 0.92 per 1,000. These rates were not different from central venous lines.

So what conclusions should be drawn?

1) Arterial catheters do get colonized and do cause blood stream infections at the same rate as central venous lines.
2) While the rate of bloodstream infection is low, arterial catheters are still a potential source of sepsis and should be managed the same way as CVC.
3) There's no reason to not place radial artery catheters as the CDC guidelines recommend.
 
proman said:
Yeah sometimes (rarely) second matters, I would hope everyone modifies their routine practice when that's the case. I know I do. But what's the added time to getting a pack of sterile towels and gloves? About 30 seconds.

But let's look at the CDC guidelines. The use of a cap, mask, sterile gloves and small sterile field is a Category IB recommendation (Category IB is strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice supported by limited evidence).

The risk of infection with arterial lines is lower but not zero (1.7 vs 2.7 per 1,000 catheter days).
Use of full barrier precautions does not reduce the risk of arterial CRBSI.
When using maximum barrier precautions, the risk is 0.41/1000 catheter days.
The risk of arterial CRBSI increases with duration but routine changing does not decrease that risk.

- Martin et al: 11% of dorsalis pedis cannula were colonized with pathogenic bacteria, 9.3% of radial catheters. 4 cases of catheter-related infection. Limitation was the use of betadine instead of Chloraprep.

- Traore et al: 7.4% of radial artery catheters colonized. Used Chloraprep.

- Koh et al.: Colonization of arterial catheters: 15.7 per 1,000 Blood stream infection: 0.92 per 1,000. These rates were not different from central venous lines.

So what conclusions should be drawn?

1) Arterial catheters do get colonized and do cause blood stream infections at the same rate as central venous lines.
2) While the rate of bloodstream infection is low, arterial catheters are still a potential source of sepsis and should be managed the same way as CVC.
3) There's no reason to not place radial artery catheters as the CDC guidelines recommend.
Click to expand...

Arterial catheters cause infections at the same rate as central lines? Do you have these studies. That is very hard to believe.
 
sterile gloves, chloraprep, small drapped area and tegaderm. I like using sterile gloves cause they fit better. Chloraprep is nice cause I can see where I've cleaned. I drape mainly to prevent spillage of blood b/c I always go through and through (even w/arrows)
 
Ignatius J said:
Arterial catheters cause infections at the same rate as central lines? Do you have these studies. That is very hard to believe.
Click to expand...

Full citations are in the CDC guideline document, I've named the first author from the references. It's a good read on how to prevent catheter related blood stream infections from arterial, venous and peripheral catheters. It's at
www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
 
A radial A line is comparable to a peripheral IV and actually has a lower risk of infection.
So, it requires the same level of sterility a peripheral IV requires regardless of what the the nurses, CDC geeks, administrators, Jacho... might think.
But you do what they tell you to do because you need to keep your job not because they are right.
 
I had a pt. in the ICU earlier this year that was the usual player (IDDM, HTN, PAD, ESRD s/p renal transplant now back on HD, CAD s/p 4 vessel CABG so she can get relisted for another kidney) PEA arrest several days after her CABG. She was next to impossible to get lines in (including a-line). Finally got brachial a-line with U/S and left it in for 25+ days (through sepsis and all) and it never got infected and site always looked fine. This changed my perception of attendings telling us to change lines "because it's been in too long". Just food for thought.
 
TrustMe said:
I had a pt. in the ICU earlier this year that was the usual player (IDDM, HTN, PAD, ESRD s/p renal transplant now back on HD, CAD s/p 4 vessel CABG so she can get relisted for another kidney) PEA arrest several days after her CABG. She was next to impossible to get lines in (including a-line). Finally got brachial a-line with U/S and left it in for 25+ days (through sepsis and all) and it never got infected and site always looked fine. This changed my perception of attendings telling us to change lines "because it's been in too long". Just food for thought.
Click to expand...

You can add to that:

1) Suturing arterial lines
2) Routine central line change q7 days or whatever
3) Rewiring central lines of any kind
4) Peripherals need to be changed every 3 days
 
pie944 said:
Only suture femoral arterial lines, radial/brachial spray/Tegaderm.
Click to expand...

I see brachial artery access being used more and more frequently at other institutions. I head from someone applying for a CT fellowship that at CC, fellows shoot for the brachial aline first. I always thought brachials were taboo. Ive seen many dusky hands in the ICU but I've seen it with axillary and radials as well.

Whats it like at other institutions?
 
RxBoy said:
I see brachial artery access being used more and more frequently at other institutions. I head from someone applying for a CT fellowship that at CC, fellows shoot for the brachial aline first. I always thought brachials were taboo. Ive seen many dusky hands in the ICU but I've seen it with axillary and radials as well.

Whats it like at other institutions?
Click to expand...

Brachials are standard for cardiac at CCF and were at Case when I was there. Must be a Cleveland thing. I never saw them before I came here. There was a large series that did not show increased complications with the brachial route, but I would be reluctant to go there unless I had exhausted other sites.
 
I think for cardiac cases, brachial a-lines (or axillary if needed) give a much better estimation of central aortic pressures than radial a-lines. Especially when on high dose vasopressors or inotropes. I have taken care of multiple pt's whose brachial or axillary pressure reading was markedly higher than their radial a-line reading even when not on vasopressors. I don't always trust radial pressures as much in severe vasculopathic pt's. Not to say that I don't put in radial a-lines on them, but if something doesn't seem right I have a lower tolerance to start checking other sites for BP confirmation.
 
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