MODULE 7 Sutures and Sharps RPN2023.pdf

MODULE 7: Sutures and Sharps Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 174 -182 ORNAC Standards 2023 p. 3-89 Section 4: Biological Hazards p. 4-41 – 4-44...

MODULE 7: Sutures and Sharps Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 174 -182 ORNAC Standards 2023 p. 3-89 Section 4: Biological Hazards p. 4-41 – 4-44 Learning Outcomes Understand the different types, sizes, and strengths of suture material and their application to various surgeries Identify types of surgical needles Understand why needle stick/sharp injuries occur and apply best practices to prevent injuries to the patient, self, and others Definition A suture is a term that is used to describe all materials that are used to repair or re- approximate tissues for the purpose of tissue wound healing. Ligature is also a term used to describe suture. It is essentially a strand of suture that is used to occlude a vessel, tie off a vessel, or isolate a tissue for excision. There are a variety of sutures that are used for ligating, suturing, or closing a wound. Historically, sutures needed to be passed through the eye of the needle by the scrub nurse before suturing or ligating. Today, most of the sutures are swaged, which means that sutures are already attached to the swage of the surgical needles. This has significantly reduced the risk for sharps injury. Furthermore, swaged needles have also reduced the suture loading time of scrub nurses. Characteristics of Suture Material There are several key features to evaluate the properties of sutures. The suture material selected is based on the tissue being sutured, operation, patient condition, risk of infection, postoperative conditions, strand properties, and surgeon’s preferences. Preferred suture characteristics: Sterile All-purpose Composed of material that can be used in any surgical procedure Causes minimal tissue injury or tissue reaction Easy to handle Holds securely when knotted High tensile strength Favourable absorption profile Low reactivity with resistance to infection Module 7: Sutures and Sharps  Suture Size The size of the suture may also be referred to as the diameter or gauge. The suture size is determined by the diameter of the strand. The thicker the suture strand the higher the number on the package. Below is a list specifying the different sizes of sutures from smallest (11/0) to largest (7): Suture Size 11/0 10/0 9/0 8/0 7/0 6/0 5/0 4/0 3/0 2/0 1/0 0 1 2 3 4 5 6 7 Smallest--------------------------------------------------------------------------------------------- Largest Suture Indication Size 11-0, 10-0, Typically used in the most delicate surgeries. Common in both Ophthalmic 9-0, 8-0 surgery and for repairing small damaged nerves often due to lacerations in the hand. 7-0, 6-0 Used for repairing small vessels and arteries or for delicate facial plastic surgery. 5-0, 4-0 Used for larger vessel repair such as an Abdominal Aortic aneurysm or skin closure. 3-0, 2-0 Skin closure when there is a lot of tension on the tissue, closure of muscle layers or repair of bowel in general surgery. 0, 1 For closing of the fascia layer in abdominal surgery, the joint capsule in knee and hip surgery or deep layers in back surgery. 2 For repair of tendons or other high-tension structures in large orthopedic surgeries. The surgeon is responsible for selecting the type and size of the suture. He/She considers the size of the tissue when selecting the suture. It is the responsibility of the perioperative nurse to anticipate the required suture, load its attached needle, and then pass it safely to the surgeon. To effectively do this, the perioperative nurse must be able to read the package of each suture to determine the suture and needle characteristics. Each suture package will specify information about the suture characteristics, such as its size/diameter/gauge, type, length, lot number, colour, and catalog number. The package may even specify if the suture is absorbable, non-absorbable, monofilament, or braided. As mentioned earlier, most sutures are swaged to surgical needles, therefore, the suture package will also include information about the needle characteristics, such as needle length, and point. The needle diagram may also be drawn on the suture package so that the surgical team can see the size of the needle without having to remove the needle from its package. Also, note the expiry or manufactured date of the suture packages. If the manufactured date is indicated on the package, it is implied that the expiry date is 5 years from the manufactured date. Module 7: Sutures and Sharps When a surgeon asks for a suture, there are three components to consider: size, type and needle. Every perioperative nurse must be able to read a suture package and decipher its characteristics. This is an important perioperative nursing skill. Types of Suture Material Suture materials are classified under absorbable or non-absorbable, which are further subdivided into braided or monofilament. A monofilament suture has one single strand. A braided suture has multiple fibers rendered into one single thread. Sutures have different absorption times, which affect the strength of the tissue closure and healing. It is important to note that one suture material may have two different names, and may vary with each manufacturer. Two of the prominent manufacturers of sutures in Canada are Covidien and Ethicon. Each manufacturer will have a different name for the same suture material. For example, Ethicon manufactures the suture named Vicryl. Covidien manufactures the same suture material, but they call the suture Polysorb. Perioperative nurses must be familiar with both names of the same suture material because individuals may use the names interchangeably to describe the same suture material. Absorbable Sutures Absorbable sutures are defined as flexible and sterile strands prepared from collagen derived from healthy mammals or synthetic polymer. These sutures can be absorbed by living mammalian tissue. The most common absorbable sutures are surgical gut (Chromic) and glycolic acid polymers (Vicryl, Polysorb, Dexon). Chromic and Plain Gut are natural bovine-based suture instilled with alcohol to provide maximal pliability. Once removed from the package, this suture must be used immediately. Vicryl/Polysorb Dexon Synthetic, braided Synthetic, braided Tensile strength sufficient for wound Low reactivity approximation Excellent knot security Low reactivity Coated to reduce tissue drag Excellent knot security Coated to reduce tissue drag Monocryl/Biosyn Maxon/PDS Synthetic, monofilament Synthetic, monofilament Low reactivity Low reactivity Good knot security Good knot security Excellent tissue passage Excellent tissue passage Module 7: Sutures and Sharps  Caprosyn Synthetic, monofilament Excellent knot security Excellent tissue passage Excellent replacement for gut products Ideal for most OB/GYN and urologic procedures Nonabsorbable Sutures Nonabsorbable sutures are material strands that resist enzymatic digestion in tissues of living animals. The suture material is not metabolized by the body. Nonabsorbable sutures are encapsulated. The tissues around the strands are walled off during wound healing. The most common non-absorbable sutures are silk (Sofsilk), nylon (Monosof), polypropylene (Prolene/Surgipro), and stainless steel wires. Non-absorbable sutures are commonly used for skin closure because they can be removed after a few weeks. Non-absorbable sutures are also used for repair of tissues where absorbable sutures are inadequate, such as vessels and heart valves. Non-absorbable sutures are needed for these tissues because the healing time is longer than 3 weeks. Non-absorbable sutures are contraindicated in some circumstances, such as the urinary tract due to high risk for stone formation. Sofsilk Stainless Steel Natural source, braided Monofilament Wax-coated Excellent tissue passage High reactivity - not used in areas of Required modified knot infection Extremely strong Excellent knot security Poor tissue passage Nurolon/Surgilon Mersilene, Ethibond/Ticron Monofilament Braided Good tissue passage Good Tissue passage Lower reactivity Low reactivity Excellent knot security Extremely strong Excellent knot security Module 7: Sutures and Sharps  Prolene/Surgipro Synthetic, monofilament Low reactivity Extremely strong Poor knot security Suture Needles To understand the characteristics of suture needles, you must first be familiar with the needle anatomy. The needle point is the sharpest end of the needle. The swage, also known as the eye, is the end of the needle where the needle and suture meet. The needle body is the shaft of the needle in between the point and swage. The eye of a suture needle can be classified under one of three categories: eyed needle, French eyed needle, and or swaged/eyeless needle. Eyed and French eyed needles are free needles that do not have sutures attached to the swage, therefore, the scrub nurse must thread the suture through the needle eye before suturing. Swaged or eyeless needles are needles that are already connected to the suture material, therefore, suture threading is not required. Swaged sutures are less traumatic to tissues, when compared to eyed needles. Swaged needles are commonly used in surgery today due to its ease of use and sharps safety element. The point or tip of a suture needle determines how the needle pierces through the tissue. There are different types of needle points, such as taper, cutting, and blunt. A taper needle is round with a point. A cutting needle is round with sharp triangular edges along the needle. Cutting needles are used for tough and dense tissue, such as skin. A blunt needle is indicated for biopsy of organs and other delicate tissues, such as liver, that may be torn if penetrated by a sharp cutting needle. The body or shaft of a suture needle may be round, flat, or triangular. The needle may also be curved or straight. The body gradually tapers to a point. There are variations in needle lengths. The surgeon selects the needle length based on the width and size of the tissue of interest. The surgeon’s needle selection is determined by the tissue type, suture material, and intended action Module 7: Sutures and Sharps  with the suture needle. Threading Free Needles Sutures may also be threaded through the eye of free needles, which are needles that are unattached to any suture material. Eyed needles (also known as closed eyed needles) and French eyed needles (also known as spring eyed needles) are the two types of free needles. Although swaged needles are universally used, free needles are still available in ORs. Loading a Suture As with any surgical instruments and items, the suture and needle must be assessed for its completeness and functionality before use. Is it complete? Is it functional? Is there a knot in the suture? Is the needle tip bent? Does the needle have the correct point (taper or cutting)? Some sutures, such as Prolene/Surgipro, PDS/Maxon, or Monosof, require manual straightening by the scrub nurse due to the strand’s high memory. To manually straighten the suture, the scrub nurse’s one hand grasps the suture 1-2 inches distal to the needle, while the other hand pulls gently on the other end of the strand. Avoid running gloved hands along the suture because this action can cause fraying. Loading a needle on the needle driver is a skill that requires continuous practice to master. To load the suture needle, the scrub nurse clamps the needle driver onto 1/3 of the distance distal from the needle swage/eye. The needle is placed 1/8 inch distal from the needle driver tip to facilitate tissue suturing. Avoid touching the point of the needle with your gloved hand to prevent injury. Ensure that the thread does not fall below the level of the surgical field. Always pass a forcep to the surgeon’s non-dominant hand if s/he is suturing. Have your straight mayo scissors ready for cutting the suture after the knots are completed. Upon return of the suture needle, ensure that the needle is guarded by the surgeon to prevent sharps injury. Ensure that you place the used needle in the needle counter upon its retrieval. Sharps Safety Needle stick injury from suture needles is one of the most common sharps injuries in the OR. Suture needle injuries often occur when loading or removing needles from needle drivers. There is also a risk for injury when surgical personnel pass sharps directly from one hand to another. Needle stick injuries may occur while the surgeon is suturing towards the direction of the assistant. If needles are left on the operative field, there is a higher potential for needle stick injuries. Every perioperative nurse must develop sharps safety awareness and practices to prevent injuries to patients, themselves, and others. This prevents transmission of blood borne infection Module 7: Sutures and Sharps  between patients and healthcare providers. Listed are some of the sharp safety principles: Neutral Zone/hand free method: Avoid direct hand-to-hand passing of sharp items. Application of no-touch passing involves passing of sutures or blades onto a neutral zone (i.e. Kidney basin with towel), instead of passing directly into another’s hand, or placing directly on the mayo stand closest to the surgeon. Place one sharp item on this neutral zone. Verbalize every time you place a sharp item on the neutral zone. ORNAC recommends safety engineered devises (safety needle). Activate the safety mechanism immediately after use and do not recap used needles unless you use the one-handed technique or a recapping device. Ensure that every suture needle that is returned to you is guarded by the surgeon. Use blunt needles when possible. Use a puncture proof container for containment. Keep sharp and blunt instruments separated. Put blades on and take off using another instrument, such as a needle driver. Be aware of where all your sharp items are located at all times. By applying two sterile surgical gloves, the scrubbed personnel have an additional barrier against sharps injuries. Module 7: Sutures and Sharps Module 7: Sutures and Sharps