Course Access
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Dear Wise Anti-Infection Folk,
When performing vascular access using ultrasound guidance we use standard aseptic technique with 2% chlorhexidine for the skin, and sterile ultrasound probe cover.
Between the skin with dried chlorhexidine, and the probe cover we need an ultrasound conducting medium.
My question relates to what is the best sound conducting medium.
Options are:
1. Sterile ultrasound gel.
Putting the needle through gel into the patient bothers me, and the gel makes things slippery and awkward if needing to advance a wire for the Seldinger technique. Also wiping the gel off afterwards so a dressing will stick removes the chlorhexidine.2. Sterile saline.
Works well, isn’t slippery, but washes away the chlorhexidine.3. More chlorhexidine.
Works well, isn’t slippery, but means we put a needle through wet chlorhexidine into the patient.I anticipate the amount of chlorhexidine introduced if we go through wet chlorhexidine with a needle is miniscule, and this is probably the best option, but seek your advice.
Many thanks in anticipation.
James Rippey
MBBS DDU DCH FACEM
Specialist in Emergency Medicine
Sub specialty Emergency UltrasoundAssociate Professor
University of Western Australia
Sir Charles Gairdner Hospital &
King Edward Memorial Hospital for WomenMessages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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G’day James
Good question! I agree option 3 is best. Skin already nice and
decontaminated after your first application and drying of alcoholic CHG,
another app so you can get the line in and not wiping off all that good
stuff with its residual effect.We use chlorhexidine impregnated CVCs and chlorhex sponge CVC dressings
after all, so a miniscule bit of clorhex (*alcoholic not aqueous, *of
course) shouldn’t do any harm in the bloodstream, and may even cheer folks
up some.I’d rather have a drop of that injected into me than US gel, that’s for
sure…Best regards, Claire
*Professor Claire Rickard RN PhD*
c.rickard@griffith.edu.au | +61 7 3735 6460 | Skype: clairexm1 | Twitter:
IVAD_Research |
http://www.griffith.edu.au/health/centre-health-practice-innovation/research/acute-critical-care/intravascular-devicesIntravascular Access Device Research Group | NHMRC Centre of Research
Excellence in Nursing Interventions | Griffith Health Institute | Visiting
Prince Charles HospitalResearch frequently takes me off campus. Please contact Jenny Chan 3735
5406 *j.chan@griffith.edu.au* or
Jo.Wright@griffith.edu.au 3735 4886 with any urgent enquiries.*It’s nice to be important, but it’s more important to be nice. John Cassis.
*On 7 August 2013 17:57, James Rippey wrote:
> Dear Wise Anti-Infection Folk,
>
> When performing vascular access using ultrasound guidance we use standard
> aseptic technique with 2% chlorhexidine for the skin, and sterile
> ultrasound probe cover.
>
> Between the skin with dried chlorhexidine, and the probe cover we need an
> ultrasound conducting medium.
>
> My question relates to what is the best sound conducting medium.
>
> Options are:
>
> 1. Sterile ultrasound gel.
> Putting the needle through gel into the patient bothers me, and the gel
> makes things slippery and awkward if needing to advance a wire for the
> Seldinger technique. Also wiping the gel off afterwards so a dressing will
> stick removes the chlorhexidine.
>
> 2. Sterile saline.
> Works well, isn’t slippery, but washes away the chlorhexidine.
>
> 3. More chlorhexidine.
> Works well, isn’t slippery, but means we put a needle through wet
> chlorhexidine into the patient.
>
> I anticipate the amount of chlorhexidine introduced if we go through wet
> chlorhexidine with a needle is miniscule, and this is probably the best
> option, but seek your advice.
>
> Many thanks in anticipation.
>
> James Rippey
>
> MBBS DDU DCH FACEM
> Specialist in Emergency Medicine
> Sub specialty Emergency Ultrasound
>
> Associate Professor
> University of Western Australia
> Sir Charles Gairdner Hospital &
> King Edward Memorial Hospital for Women
>
> Messages posted to this list are solely the opinion of the authors, and do
> not represent the opinion of ACIPC.
>
> Archive of all messages are available at http://aicalist.org.au/archives- registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
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Hi James,
Good question.
To answer your question about best conducting medium, sterile ultrasound gel is the BEST conducting medium for transmission of image from the skin. It is designed specifically for that purpose.1. I have been using US for VA for almost 10years now and I always use sterile gel – I have not had an issue of the gel smudging the CHG on the skin, as it well dried before I put needle to skin.
A handy tip I perform that you might be interested in trying is once you have located your insertion point for puncture, with the probe in place, gently wipe down the edge of the probe against the skin to remove any excess gel that bulges out from under the probe. This reduces the risk of getting gel in the tip of the needle (which reduces your flashback indicator also).2. Sterile saline isn’t a great conductor for image transmission.
3. Wet CHG is at risk of entering through the puncture site of the skin, and although a very small amount, the risk of CHG reaction is increased.
If the CHG and IPA has completely dried on the skins surface, I find that is not removed when wiping the gel. But I also don’t need a lot of gel usually, just enough to get a clear image of the vessel.
I would send an image, but are unable to do so on this listserver.Alternatively, you could reapply your CHG/IPA after cleaning the area to remove blood/gel, etc and put a fresh layer of CHG prior to the dressing application.
Regards,
Tim.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
Dept ofIntensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 87383603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au—–Original Message—–
Dear Wise Anti-Infection Folk,
When performing vascular access using ultrasound guidance we use standard aseptic technique with 2% chlorhexidine for the skin, and sterile ultrasound probe cover.
Between the skin with dried chlorhexidine, and the probe cover we need an ultrasound conducting medium.
My question relates to what is the best sound conducting medium.
Options are:
1. Sterile ultrasound gel.
Putting the needle through gel into the patient bothers me, and the gel makes things slippery and awkward if needing to advance a wire for the Seldinger technique. Also wiping the gel off afterwards so a dressing will stick removes the chlorhexidine.2. Sterile saline.
Works well, isn’t slippery, but washes away the chlorhexidine.3. More chlorhexidine.
Works well, isn’t slippery, but means we put a needle through wet chlorhexidine into the patient.I anticipate the amount of chlorhexidine introduced if we go through wet chlorhexidine with a needle is miniscule, and this is probably the best option, but seek your advice.
Many thanks in anticipation.
James Rippey
MBBS DDU DCH FACEM
Specialist in Emergency Medicine
Sub specialty Emergency UltrasoundAssociate Professor
University of Western Australia
Sir Charles Gairdner Hospital &
King Edward Memorial Hospital for WomenMessages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
_____________________________________________________________________
This email has been scanned for the Sydney & South Western Sydney Local Health Districts by the MessageLabs Email Security System.
Sydney & South Western Sydney Local Health Districts regularly monitor email and attachments to ensure compliance with the NSW Ministry of Health’s Electronic Messaging Policy._____________________________________________________________________
This email has been scanned for the Sydney & South Western Sydney Local Health Districts by the MessageLabs Email Security System.
Sydney & South Western Sydney Local Health Districts regularly monitor email and attachments to ensure compliance with the NSW Ministry of Health’s Electronic Messaging Policy.Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
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Thank you for your considered opinions regarding the best ultrasound medium.
My final solution:
1. Where there is a controlled situation I will use ultrasound gel but
minimise the quantity, make sure the needle doesn’t go through it, and wipe
it off afterwards with chlorhexidine soaked gauze, letting it dry again
before putting on the final dressing.2. In the critically ill patient (sometimes we are getting central access
whilst CPR is in process) I will use chlorhexidine as the medium. I cannot
afford to have trouble advancing the wire because it has gel on it (or my
gloved fingers) in these situations.All the best
James RippeyOn Thu, Aug 8, 2013 at 7:25 AM, Tim Spencer
wrote:> Hi James,
> Good question.
> To answer your question about best conducting medium, sterile ultrasound
> gel is the BEST conducting medium for transmission of image from the skin.
> It is designed specifically for that purpose.
>
> 1. I have been using US for VA for almost 10years now and I always use
> sterile gel – I have not had an issue of the gel smudging the CHG on the
> skin, as it well dried before I put needle to skin.
> A handy tip I perform that you might be interested in trying is once you
> have located your insertion point for puncture, with the probe in place,
> gently wipe down the edge of the probe against the skin to remove any
> excess gel that bulges out from under the probe. This reduces the risk of
> getting gel in the tip of the needle (which reduces your flashback
> indicator also).
>
> 2. Sterile saline isn’t a great conductor for image transmission.
>
> 3. Wet CHG is at risk of entering through the puncture site of the skin,
> and although a very small amount, the risk of CHG reaction is increased.
>
> If the CHG and IPA has completely dried on the skins surface, I find that
> is not removed when wiping the gel. But I also don’t need a lot of gel
> usually, just enough to get a clear image of the vessel.
> I would send an image, but are unable to do so on this listserver.
>
> Alternatively, you could reapply your CHG/IPA after cleaning the area to
> remove blood/gel, etc and put a fresh layer of CHG prior to the dressing
> application.
>
> Regards,
> Tim.
>
> Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
> Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
> Service
> Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine
> | University of NSW
> Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
> Elizabeth Street, Liverpool, 2170, NSW, Australia
> Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
> Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On
> Behalf Of James Rippey
> Sent: Wednesday, 7 August 2013 5:58 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Ultrasound guided vascular access question
>
> Dear Wise Anti-Infection Folk,
>
> When performing vascular access using ultrasound guidance we use standard
> aseptic technique with 2% chlorhexidine for the skin, and sterile
> ultrasound probe cover.
>
> Between the skin with dried chlorhexidine, and the probe cover we need an
> ultrasound conducting medium.
>
> My question relates to what is the best sound conducting medium.
>
> Options are:
>
> 1. Sterile ultrasound gel.
> Putting the needle through gel into the patient bothers me, and the gel
> makes things slippery and awkward if needing to advance a wire for the
> Seldinger technique. Also wiping the gel off afterwards so a dressing will
> stick removes the chlorhexidine.
>
> 2. Sterile saline.
> Works well, isn’t slippery, but washes away the chlorhexidine.
>
> 3. More chlorhexidine.
> Works well, isn’t slippery, but means we put a needle through wet
> chlorhexidine into the patient.
>
> I anticipate the amount of chlorhexidine introduced if we go through wet
> chlorhexidine with a needle is miniscule, and this is probably the best
> option, but seek your advice.
>
> Many thanks in anticipation.
>
> James Rippey
>
> MBBS DDU DCH FACEM
> Specialist in Emergency Medicine
> Sub specialty Emergency Ultrasound
>
> Associate Professor
> University of Western Australia
> Sir Charles Gairdner Hospital &
> King Edward Memorial Hospital for Women
>
> Messages posted to this list are solely the opinion of the authors, and do
> not represent the opinion of ACIPC.
>
> Archive of all messages are available at http://aicalist.org.au/archives- registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>
> _____________________________________________________________________
> This email has been scanned for the Sydney & South Western Sydney Local
> Health Districts by the MessageLabs Email Security System.
> Sydney & South Western Sydney Local Health Districts regularly monitor
> email and attachments to ensure compliance with the NSW Ministry of
> Health’s Electronic Messaging Policy.
>
> _____________________________________________________________________
> This email has been scanned for the Sydney & South Western Sydney Local
> Health Districts by the MessageLabs Email Security System.
> Sydney & South Western Sydney Local Health Districts regularly monitor
> email and attachments to ensure compliance with the NSW Ministry of
> Health’s Electronic Messaging Policy.
>
> Messages posted to this list are solely the opinion of the authors, and do
> not represent the opinion of ACIPC.
>
> Archive of all messages are available at http://aicalist.org.au/archives- registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>—
*Associate Professor James Rippey*University of Western Australia
Sir Charles Gairdner Hospital
King Edward Memorial Hospital for WomenMobile 0400990186
Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
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