Lecithin5

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I did an sdn search, but didn't find a good thread for my question... I've seen a wide spectrum for sterile technique for aline placement, from simple alcohol swab to full blown sterile technique.
1- for the times you're using ultrasound, what is you're sterile technique? Sterile sleeve probe cover? No probe cover at all, perhaps a quick wipe of the probe plus sterile gel? Etc
2- for non-ultrasound alines?

I'm sure they're going to be a lot of different styles, but are all of you comfortable justifying your technique (ie a less sterile one) should an infectious complication occur?
 

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I did an sdn search, but didn't find a good thread for my question... I've seen a wide spectrum for sterile technique for aline placement, from simple alcohol swab to full blown sterile technique.
1- for the times you're using ultrasound, what is you're sterile technique? Sterile sleeve probe cover? No probe cover at all, perhaps a quick wipe of the probe plus sterile gel? Etc
2- for non-ultrasound alines?

I'm sure they're going to be a lot of different styles, but are all of you comfortable justifying your technique (ie a less sterile one) should an infectious complication occur?
The veins take the blood directly to the heart, without even going through tissues, and still we don't see endocarditis or bacteremia from clean peripheral IV placements.There is no logic behind doing clean IV placements but sterile A-lines. It only becomes arguable for A-lines that are supposed to stay in there for longer than the usual IV.

IMO, what keeps an a-line clean and safe is not initial sterility, it's proper post-insertion care, e.g. when drawing blood, as in "no blood left behind", gloves, alcohol wipes etc. I have witnessed improper care for all kinds of lines, from nurses and/or anesthesia providers, on so many occasions that it would take a lot to convince me that A-line insertion sterility will change much in outcomes.
 
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G-Man82

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I'll do sterile arterial lines for brachial and femoral a-lines only. I also tend to use longer (12 cm) catheters at those sites, and chances are if going those routes, they're probably going to stay in longer.

For a radial arterial line, both blind or ultrasound? Gloves, alcohol wipe, and go.


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periopdoc

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Depends on how long it's going to be in, and the immune status of the patient. For all my heart patients, I use sterile gloves, and chlorhexidine prep. No probe cover if I use ultrasound. For patients who need it just for the surgery, alcohol and non-sterile gloves. If the patient is severely immunocompromised, I'll add a drape and probe cover.

I won't touch the catheter or the wire with non-sterile gloves, but I have seen it done more times than I care to remember.

It's not so much the risk of infection vs the risk of PIV infection as it is the fact that, right or wrong, PIV infections are more or less ignored while a-line infections will result in a huge QA/QI investigative process.

That being said, I've never had an infection on one of my a-lines, so the process may not be as bad as I envision.
 

periopdoc

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As above, for the longer catheters, I use a drape when I place those.
 
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algosdoc

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Depends on the urgency of placement and the hospital. If I am desperate due to the patient crashing, it is alcohol hard wipe x 2 then go. Some hospitals use a chloroprep skin prep then wait 3 minutes. Others, alcohol or betadine is ok then insert. As far as US covers, none of the hospitals I am at employ them for anesthesia blocks or alines.
 
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BLADEMDA

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Chloraprep and Sterile Gloves for arterial line insertion. If I use U/S I typically place a tegaderm over the probe and use sterile jelly. Is any of this necessary? Well, it is what I would want for my family members or myself and it certainly makes more sense than not being able to wear a fancy scrub cap or forced to put on a jacket over my scrubs.
 

BLADEMDA

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The superiority of chlorhexidine over povidone iodine has been linked to quick bactericidal activity, poor inactivation by blood and other protein-rich biomaterials present on skin, and long-term antimicrobial suppressive activity. These findings have led the Centers for Disease Control and Prevention (CDC) to include in their 2011 recommendations [7] the use of alcoholic chlorhexidine at a concentration >0.5% as a first-line antiseptic in catheter care

Comparison of four skin preparation strategies to prevent catheter-related infection in intensive care unit (CLEAN trial): a study protocol for a randomized controlled trial
 

BLADEMDA

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A-Lines Sterile

Read post number 39. The bottom line is that wearing sterile gloves and using chloraprep doesn't add even 5 seconds to the procedural time.
 
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BLADEMDA

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When inserting an arterial catheter:

Perform hand hygiene with an alcohol based hand rub before inserting an IV device or having contact with the IV dressing, site, device or attachments
Prep skin at insertion site with an alcohol/chlorhexidine solution (70% alcohol, >0.5% chlorhexidine), such as ChloraPrep.

The Center for Disease Control (CDC) says this type of solution is best for site preparation and care. Follow these steps: – Perform a 30 second back and forth scrub and then air dry – Perform a two-minute back and forth scrub and then air dry for moist sites, such as the groin – Use tincture of iodine, an iodophor, and/or 70% alcohol as alternatives if there is a contraindication to chlorhexidine (i.e., patient sensitivity, device manufacturer recommendations, neonates)

Use maximal sterile barriers for all arterial line insertions – Maximal sterile barriers include cap, mask, sterile gown, sterile gloves and a full body sterile drape. For radial artery line insertions, a smaller drape may be used. – All teammates directly assisting in the catheter insertion procedure are to use maximal sterile barriers (cap, mask, sterile gown and sterile gloves)
 

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I treat radial alines like a PIV. Clean gloves, chloraprep (and let it dry). Don't touch the part entering the patient's skin obviously.

Brachial or femoral, then sterile gloves and some sterile towels to drape.

I u/s all my radial a-lines in the heart room (since the u/s is sitting there anyway, and then I can put the line higher up the forearm where it won't be positional), and for this I just put a little tegaderm over a pre-gooped probe (I use the hockey stick), then I'll use another splash of chloraprep as the ultrasound medium. No need to open sterile goop.

It should be noted that putting the tegaderm over the probe doesn't protect the patient- it protects the probe. Chloraprep will reliably degrade ultrasound probes over time. The Teggie prevents this.
 
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When inserting an arterial catheter:

Perform hand hygiene with an alcohol based hand rub before inserting an IV device or having contact with the IV dressing, site, device or attachments
Prep skin at insertion site with an alcohol/chlorhexidine solution (70% alcohol, >0.5% chlorhexidine), such as ChloraPrep.

The Center for Disease Control (CDC) says this type of solution is best for site preparation and care. Follow these steps: – Perform a 30 second back and forth scrub and then air dry – Perform a two-minute back and forth scrub and then air dry for moist sites, such as the groin – Use tincture of iodine, an iodophor, and/or 70% alcohol as alternatives if there is a contraindication to chlorhexidine (i.e., patient sensitivity, device manufacturer recommendations, neonates)

Use maximal sterile barriers for all arterial line insertions – Maximal sterile barriers include cap, mask, sterile gown, sterile gloves and a full body sterile drape. For radial artery line insertions, a smaller drape may be used. – All teammates directly assisting in the catheter insertion procedure are to use maximal sterile barriers (cap, mask, sterile gown and sterile gloves)
I use sterile gloves and chloraprep for radial a-lines, but I am not convinced it is based on sound medical reasoning, unless you are doing the same for all peripheral IV sites.
 

algosdoc

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I agree. I also am convinced the CDC recommendations are based primarily on the tacit supposition that all doctors are idiots incapable of coherent thought when inserting lines. Their recommendations for sterility are frequently based on case reports of infection and ignore large bodies of medical evidence demonstrating that it makes no difference if one wears a mask or hat. As for chloraprep- the package insert states 3 minutes minimal to dry on hairless skin and much longer on hairy skin prior to initiation of procedure. Anything less than that and in case of infection, legally you are toast. And don't forget to add the 30 sec-2 min recommended scrub time according to the CDC. Therefore in a hurried situation chloraprep is not indicated- it is for the leisurely anesthesiologist that has at least 3.5-7 min to wait for the prep to dry before placing lines. Oh, and don't forget the full body drape and sterile gowns necessary for line placement according to the CDC. Definitely adds more than 5 seconds to the procedure, and if you don't do everything the CDC recommends, you might as well do none of it. In court, one omission is all it takes, when you decide to fashion your life around clinical recommendations of the non-clinical epidemiologists of the CDC.
 

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Side question. Those who are strictly fee for service. Do u use ultrasound routinely for A lines? Figure 1-2 extra billing units for ultrasound use.

Lots of my friends who do spine cases routinely put a lines in for all their cases with ultrasound. Every billable unit matters.
 

Ezekiel2517

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Spit and rub, Eldridge.
 

Ezekiel2517

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Side question. Those who are strictly fee for service. Do u use ultrasound routinely for A lines? Figure 1-2 extra billing units for ultrasound use.

Lots of my friends who do spine cases routinely put a lines in for all their cases with ultrasound. Every billable unit matters.
I know folks that do, but I don't. In our practice, we'd have a lot of pissed off surgeons if they saw us routinely putting in art lines for their routine spine cases in otherwise healthy patients
 

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Side question. Those who are strictly fee for service. Do u use ultrasound routinely for A lines? Figure 1-2 extra billing units for ultrasound use.

Lots of my friends who do spine cases routinely put a lines in for all their cases with ultrasound. Every billable unit matters.
Our billers told us that most payers don't pay for USG for Aline's.
 
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BLADEMDA

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I agree. I also am convinced the CDC recommendations are based primarily on the tacit supposition that all doctors are idiots incapable of coherent thought when inserting lines. Their recommendations for sterility are frequently based on case reports of infection and ignore large bodies of medical evidence demonstrating that it makes no difference if one wears a mask or hat. As for chloraprep- the package insert states 3 minutes minimal to dry on hairless skin and much longer on hairy skin prior to initiation of procedure. Anything less than that and in case of infection, legally you are toast. And don't forget to add the 30 sec-2 min recommended scrub time according to the CDC. Therefore in a hurried situation chloraprep is not indicated- it is for the leisurely anesthesiologist that has at least 3.5-7 min to wait for the prep to dry before placing lines. Oh, and don't forget the full body drape and sterile gowns necessary for line placement according to the CDC. Definitely adds more than 5 seconds to the procedure, and if you don't do everything the CDC recommends, you might as well do none of it. In court, one omission is all it takes, when you decide to fashion your life around clinical recommendations of the non-clinical epidemiologists of the CDC.
I always add a dose of common sense to any recommendation especially the CDC. The way I see it sterile gloves and using a chloraprep doesn't require me to do anything out of the ordinary to place an arterial line. I can still do it quickly and efficiently on par with those who use non sterile gloves and spit to sterilize the field.

I'm really not concerned about the "court" as much as simply doing the right thing especially when it doesn't add any time or cost to the procedure (maybe a dollar or two at most).
 
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drmwvr

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Most A-lines come out before discharge to the ward. If they are to stay in longer, I'm more "careful". Otherwise, they're a PIV.
 

algosdoc

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Since most of these I place in the OR, I do the same. Already wearing a mask and hat, chloraprep is fine unless they have zero blood pressure, like I ran into 4 days ago, then alcohol is just grand with non-sterile gloves. Usually I wear sterile gloves, never drape an A-line, and never wear the total body suit required by the CDC. I also don't shower with Hibiclens and triple distilled water, ozonate my house, or vaporize my epidermis with a xenon flash lamp (just in case I might have to start an art line that morning)
 

pjl

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Side question. Those who are strictly fee for service. Do u use ultrasound routinely for A lines? Figure 1-2 extra billing units for ultrasound use.

Lots of my friends who do spine cases routinely put a lines in for all their cases with ultrasound. Every billable unit matters.
I do nothing purely to upgrade my billings.
Life is plenty good without it, and I am happy when I look in the mirror. Others may be happier looking in a gold plated mirror though, so to each their own.


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