Simple Lacerations - Sterile of Nonsterile Technique?

[cbrsmurf]

So I will be getting back in the urgent and emergent care business again after a few years of not doing it.  In reviewing some of the literature, it appears that there is good evidence that repair of simple lacs with nonsterile gloves do not cause more infections than with with sterile gloves.  Same for tap water rinses vs saline rinses.  

 

So what's everyone doing these days?

[Boatswain2PA]

Nonsterile, with glove change between cleaning/irrigation & draping.

[sk732]

Nonsterile, with glove change between cleaning/irrigation & draping.

 

I usually use plain gloves too...for some things I'll use sterile ones, if doing a lot of exploration, a lot of debridement/wound edge clean up and such.

 

SK

[Katera]

Man, you gotta be kidding me.  With all the MRSA and other infectious bugs running around?  Sterile technique from start to finish.  If someone came at me with gloves pulled off the wall to fix a lac I had in an UC clinic I would stop them dead in their tracks.  The simple fact is, anything we can do to reduce infections we should do.  Plus, you would be thrown out of a lot of the UC's I work at if you tried to suture a lac un-sterile.

[d2305]

I wonder how sterile the Pakistan instruments are? 

[Reality Check 2]

I use sterile technique for procedures - PERIOD.

Good form, good habit.

 

Now if I could only teach the MAs to NOT dab with unsterile gauze while I am excising or sewing. They sneak up on me sometimes and I am unprepared and cannot yell at anyone in front of the patient.

 

Spent so many years in the OR that sterile fields, technique and diligence are drilled into my brain.

[Boatswain2PA]

Man, you gotta be kidding me. With all the MRSA and other infectious bugs running around? Sterile technique from start to finish. If someone came at me with gloves pulled off the wall to fix a lac I had in an UC clinic I would stop them dead in their tracks. The simple fact is, anything we can do to reduce infections we should do. Plus, you would be thrown out of a lot of the UC's I work at if you tried to suture a lac un-sterile.

Got any evidence that the $40 bottle of sterile water and $60 sterile gloves reduce infections? Of course, UC will charge $80/$100 for those, so of course they do sterile for everything.

 

Do you give abx for simple lacerations too?

 

Pretty sure there is good evidence that clean technique has same infection rate as sterile.

[JustinPA]

https://www.ncbi.nlm.nih.gov/pubmed/14985664

 

"Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial.

Abstract

STUDY OBJECTIVE:

Although sterile technique for laceration management continues to be recommended, studies supporting this practice are lacking. Using clean nonsterile gloves rather than individually packaged sterile gloves for uncomplicated wound repair in the emergency department may result in cost and time savings. This study is designed to determine whether the rate of infection after repair of uncomplicated lacerations in immunocompetent patients is comparable using clean nonsterile gloves versus sterile gloves.

METHODS:

A prospective multicenter trial enrolled 816 individuals who were randomized to have their wounds repaired by using sterile or clean nonsterile gloves. The attending physician or resident completed a checklist describing patient, wound, and management characteristics. The patients were provided with a questionnaire to be completed by the physician who removed their sutures at the prescribed time and indicated the presence or absence of infection. When follow-up forms were not returned, a telephone call was made to the patient to determine whether he or she had experienced any wound complications.

RESULTS:

Follow-up was obtained for 98% of the sterile gloves group and 96.6% of the clean gloves group. There was no statistically significant difference in the incidence of infection between the 2 groups. The infection rate in the sterile gloves group was 6.1% (95% confidence interval [CI] 3.8% to 8.4%) and was 4.4% in the clean gloves group (95% CI 2.4% to 6.4%). The relative risk of infection was 1.37 (95% CI 0.75 to 2.52).

CONCLUSION:

This study demonstrated that there is no clinically important difference in infection rates between using clean nonsterile gloves and sterile gloves during the repair of uncomplicated traumatic lacerations."

 

 

I use nonsterile gloves for simple laceration repairs.  

[camoman1234]

I work FM (buying out the practice currently) and use to work UC for a couple years. I always used un-sterile for simple lacs, same as the 3 doctors in UC. There is no evidence for using sterile tech. and it cost more money for the same outcome...When you own your practice you look at cost, when you work at a big institution, then you don't care if you waste money. But for me, my patients come first then money, still there is no reason to cost the system/me more money to use sterile draps/glove/gauze/H2O for the SAME EBM outcomes. Just because you can do something doesn't mean you should.  

[SHU-CH]

I'd wait until some big name (ACEP or the like) publicly blesses non-sterile as acceptable. This might make good economic and scientific sense, but when someone gets infected a lawyer will have a field day. You will be like the first person off the landing craft at Normandy.

[JMann]

Discussed this in journal club at my residency a while back. Consensus was as noted in the article above. Practice wise, most staff at my place don't use sterile, but some will in instances of the non-simple lacs or immunocompromised folks. Irrigation and cleaning is more important by far!

[newton9686]

Theres no clinical evidence to suggest sterile technique offers any improvement over non-sterile. That being said, you have to know your audience. If your patient is a CNA, RN or office manager you use sterile technique. If they say anything about using sterile gloves, you use sterile gloves. However, your average joe, physician or PA, I would use non-sterile. Its all about knowing your audience and who to put the show on for. 

[GetMeOuttaThisMess]

Question of the day. For abscesses, can one infect pus? Discuss....

[camoman1234]

Theres no clinical evidence to suggest sterile technique offers any improvement over non-sterile. That being said, you have to know your audience. If your patient is a CNA, RN or office manager you use sterile technique. If they say anything about using sterile gloves, you use sterile gloves. However, your average joe, physician or PA, I would use non-sterile. Its all about knowing your audience and who to put the show on for. 

Your comment is VERY concerning.... you should practice medicine by EBM and by experience. You should be confident in your skills and knowledge such as if you were suturing a CNA, RN, office manager you have proof to back up your claims/technique/etc. I respectfully would reconsider your thought processes and how you manage your patients with "appearances." To me this is alarming and not good patient care, right or wrong (about the sterile vs non-sterile technique), your thought process is what is alarming and how you "change" the way you practice medicine is scary. Suturing is done the same way by me every time, if you are a CEO or a homeless man, if it is a simple lac, you get cleaned, irrigated, and sutured up in a non-sterile way, end of story. 

[ventana]

newton9686, on 15 May 2017 - 2:18 PM, said:

Theres no clinical evidence to suggest sterile technique offers any improvement over non-sterile. That being said, you have to know your audience. If your patient is a CNA, RN or office manager you use sterile technique. If they say anything about using sterile gloves, you use sterile gloves. However, your average joe, physician or PA, I would use non-sterile. Its all about knowing your audience and who to put the show on for. 

Your comment is VERY concerning.... you should practice medicine by EBM and by experience. You should be confident in your skills and knowledge such as if you were suturing a CNA, RN, office manager you have proof to back up your claims/technique/etc. I respectfully would reconsider your thought processes and how you manage your patients with "appearances." To me this is alarming and not good patient care, right or wrong (about the sterile vs non-sterile technique), your thought process is what is alarming and how you "change" the way you practice medicine is scary. Suturing is done the same way by me every time, if you are a CEO or a homeless man, if it is a simple lac, you get cleaned, irrigated, and sutured up in a non-sterile way, end of story. 

 

---------------------------------------------------

 

 

^^^^  I "could" make the argument that this is the ART of medicine......

[sk732]

Question of the day. For abscesses, can one infect pus? Discuss....

 

I do use a sterile knife...but they're disposable and packaged that way and I'm not overly interested on pulling out my Gerber from my pocket and getting MRSA all over it and putting it back in my pocket.  The packing gauze too is sterile...as is usually the gauze I'm sopping the mess up with, since our multipacks are all sterile..

 

I can't say there needs to be STERILE vice CLEAN instruments for when you're deloculating the mess either - you're still spreading crud around, so unless it's not an MRSA abscess and you've just grabbed some Kelly that's just been left lying around and wiped down a bit, then you might inoculate MRSA or worse into the pus...especially if you do a shyte job irrigating everything out afterwards.

 

To answer the question, I think there is a theoretical potential to infect the pus if you do a poor job of things...or if you're just stupid and uncaring.  Hope there aren't too many/any here that fit into the last two categories...

 

SK

[d2305]

How many use a new bottle of iodoform gauze for each I&d? I got stuck with being an infection control officer a while back.

[sk732]

And I says "Pardon??!!"  Scandalous doing that...​as he runs off to check the Infection Nazi Manual.

 

SK

[RuralER/Ortho]

..... devils advocate incoming..... who doesn't pack <5 cm abscesses? Who doesn't worry about copiously irrigating every spec of pus out of there?

 

Sorry for the somewhat of a thread derail

[camoman1234]

Ventana, I am sure you could come up with some clever points, but this is not how I was trained nor think. So I refuse to use this in my daily practice as I care for all my patients the same and not based off who they are or what they do... I won't ever understand that way of thinking, but your more than free too.

[tunafish]

Man, you gotta be kidding me.  With all the MRSA and other infectious bugs running around?  Sterile technique from start to finish.  If someone came at me with gloves pulled off the wall to fix a lac I had in an UC clinic I would stop them dead in their tracks.  The simple fact is, anything we can do to reduce infections we should do.  Plus, you would be thrown out of a lot of the UC's I work at if you tried to suture a lac un-sterile.

 

Yeah, they come with their lac covered with a kitchen towel or a random paper napkin. the cut was over a dirty object and sterile gloves would make all the difference... give me a break

[Boatswain2PA]

I don't pack abscesses. Ever.

 

If they are in folds/etc that will close up anyway I will put in a loop of drain to keep open.

[newton9686]

Camoman you can practice medicine however you want. And if you would rather "educate" patients that doesn't want to be educated, you can. However I would not rather waste my time "educating" AND likely waste my time when they file a complaint with the company MBA anyways. I don't know about you, but I need all the time I can get to find and treat sick people. I can't afford to waste time on things that don't matter like sterile versus non-sterile technique for simple lacerations when BOTH provide equal results.

[camoman1234]

Camoman you can practice medicine however you want. And if you would rather "educate" patients that doesn't want to be educated, you can. However I would not rather waste my time "educating" AND likely waste my time when they file a complaint with the company MBA anyways. I don't know about you, but I need all the time I can get to find and treat sick people. I can't afford to waste time on things that don't matter like sterile versus non-sterile technique for simple lacerations when BOTH provide equal results.

I only educate if they question me, which has yet to occur. I have my own practice so no worries about the company MBA, but if I had to talk with one I have valid claims and would tell them that I am saving them $$$ by not doing a sterile field for a simple lac as the results are the same. I am sure that MBA would be very happy :) I am not hear to argue a point, but you said it yourself that BOTH provide equal results, just one cost more $$$. I do not want to pass that extra $$$ to my patients. I love educating my patients as that is the basis of medicine. Education is power and at my clinic I get great results with education. BTW I see 21-23 patients per 8 hour shift so my time is just as limited as yours with the education. 

[TheDude]

What's yall's thoughts on simple head lacs that only need a few staples (1-5)?  Sterile or "non-sterile" but clean?  Obviously with no intent to cause more harm and do it as clean as possible (removing gross contaminants, etc...)