Cleaning your IV site

[Dustdevil]

I'm the one who voted iodine only. Military aid bags include only iodine. It's been more than two decades since I took microbiology, so I'm going to make the mistake of speaking without the benefit of recent research here (which I always caution others not to do). So I certainly do not submit this as authoritative, just historically observational.

The problem with double swabbing is that neither solution is left in place long enough to achieve antimicrobial competency. You may achieve the appearance of "clean" skin, but you won't achieve disinfected skin, which is your ultimate goal. Consequently, unless you are leaving both on long enough to dry, you are being less effective, not more.

Iodine has a better spectral advantage than isopropyl alcohol against pathogenic bacteria. I proved that to myself in the lab, as have others for decades. But both come with potential problems. Iodine sensitivity is not unheard of. And isopropyl alcohol is too flammable for OR use. Electrocautery and a flashpoint of 53f is a very bad mix. Same reason we don't use flammable anaesthetics anymore, even if they are effective. Hell, we used alcohol hand sanitiser gel as a fuel for heating food and drink in Iraq. It burns like crazy.

So, if those are your only two choices, then it is my opinion that iodine is the better way to go, and just hope for no local sensitivity reactions.

As already mentioned, chlorhexadine solutions are quickly starting to spread in non-OR use. This is a good thing, and long overdue. It is a notably superior antimicrobial to both of the previous choices, is not flammable, and has a lower incidence of sensitivity. Unfortunately, this has been a long time coming into common use for several reasons.

A little history: Before chlorhexadine came hexachlorophene. It was a popular OTC skin cleanser in the 60s, used primarily as an anti-acne face scrub, and for bathing children, who are typically germ ridden from normal child behaviour. Problem was that it turned out to be quite neurotoxic, and possibly carcinogenic. I blame it for my short stature [sarcasm]. It was yanked from the shelves, the concentration lowered, and made prescription-only, and few docs would even prescribe it. So then the expensive and bureaucratically hindered process of developing a safe alternative begins.

Sometime in the late 70s, chlorhehadine began showing up in hospitals as Hibiclens. But it was very slow to catch on because of the high price as compared to iodine, the lack of evidence indicating efficacy, and the bad memories left over from the hexachlorophene fiasco. Consequently, chlorhexadine becoming popular and trusted enough to come into enough use to get both literature and price point behind it has taken thirty years. We didn't even have chlorhexadine swabs when I retired three years ago. I expect them to become the solution of choice in the near future. Until then, iodine remains the solution of choice. And using both iodine and alcohol together offers no benefit over the use of any single solution, as well as it doubling the cost of prepping every IV you start.

Edited April 14, 2011 by Dustdevil

[DwayneEMTP]

that was directed at dwayne, not you Ruff

I didn't call you an idiot and didn't claim that alcohol is the bomb as an antiseptic. As usual you are ignoring my post and venting. Stop that. Reread the post and address what it actually says instead of what you wish it said so that you have something to cry about. Then I'll be more than happy to discuss it with you.

I tend to believe that you are probably pretty smart. Just not as smart as YOU think you are. You ignore any question that you don't have an easy, flippant or racial answer to and turn silly questions around to try and make them sound important. No one is fooled. Do you really think that people slam you over, and over, and over for ignoring the pertinent questions and simply continuing to spew nonsense because they have nothing better to do?

And when you put forth anothers work as your own, by not citing your sources, you don't look like an idiot, you look cowardly and morally bankrupt.

Just debate man! It's really not that hard! You can likely do it if you really set you mind to it.

Dwayne

[9OrangeLetters]

Wait, we're supposed to clean IV sites?

I keed...

Chloraprep all the way. I remember hearing somewhere (which means don't quote me on this) that the physical agitation of the skin was effective as well as the actual compound used... that's been rattling around my head for a while but I'm not sure if it's true or even where I got it. I probably heard it on a television commercial for soap for all I can remember...

But I digress...

I prefer the chlorapreps to alcohol. One, I think it works slightly better and I like the spongy thing, and two, there never seems to be ENOUGH alcohol on a prep to make me feel comfortable using it as a site prep.

Alcohol is an effective sterilization agent on hard surfaces only when you light it on fire. And as it turns out, I was taught by Nancy Caroline that fire is bad for you. (for the forum purists who are most likely going to be all over me for this, OBVIOUSLY I'm being tongue in cheek)

[Dustdevil]

I remember hearing somewhere (which means don't quote me on this) that the physical agitation of the skin was effective as well as the actual compound used... that's been rattling around my head for a while but I'm not sure if it's true or even where I got it. I probably heard it on a television commercial for soap for all I can remember...

I heard it in nursing school. And RT school. And I taught it in medic school.

We teach you to SCRUB your hands before surgery, not just soak them. So yes, you have a very valid point.

[Doczilla]

Alcohol kills bacteria fairly instantly on contact, but once it has evaporated, there is no persistent antimicrobial effect on the site.

Betadine kills by dessication. It must dry to be effective. But it keeps on killing, which is why we like it for surgical preps.

CHG is kind of the best of both worlds. This has replaced betadine for many procedures such as central lines and blood cultures in my hospital.

We use all 3 as surgical scrubs. All 3 are quite irritating to tissue.

'zilla

[tcripp]

Betadine kills by dessication. It must dry to be effective. But it keeps on killing, which is why we like it for surgical preps.

I've been watching...and I've not seen anyone let the betadine dry yet. And, up until now, that included me.

[1EMT-P]

In the past I've always used Alcohol to clean the skin with, unless I was doing a blood draw for a blood alcohol level or a procedure, but now I use the preps that come in out IV start kits at work.

[Dustdevil]

I've been watching...and I've not seen anyone let the betadine dry yet. And, up until now, that included me.

That's why choices are nice! If you have the time, and/or can visualise your site without a lot of searching, then get the iodine layed down and drying while you get everything set up for your stick. If you're in overdrive mode, scrub it good with alcohol and get after it. But if you have chlorhexadine, you don't have to make that decision.

[croaker260]

That's why choices are nice! If you have the time, and/or can visualise your site without a lot of searching, then get the iodine layed down and drying while you get everything set up for your stick. If you're in overdrive mode, scrub it good with alcohol and get after it. But if you have chlorhexadine, you don't have to make that decision.

Hmm, the little tings you learn, and the little things you overlook when you teach because you "assume: others know it too.

I always used Betadine first then alcohol on the extra grubby homeless population because that was the way I was taught "back" in the day in the army. It was never explained to me then the thought process why.... and while I have heard of letting the betadine dry also, no one could ever tell me "why" for that approach either.

If someone cant tell me the "why" one way is better than the other I tend to be very suspicious of it. But I digress.

I consider myself a very intelligent (if grammatically challenged) Medic with a diverse spectrum of knowledge... so if I am unaware of this than I am sure 75% of the EMS world is as well. I smell a continuing educational article coming on. Of course I may be incontinent again. Damm!

So...just to be clear...Alcohol with scrubing first, THEN Betadine to dry.....then IV stick?

Edited May 10, 2011 by croaker260

[Dustdevil]

So...just to be clear...Alcohol with scrubing first, THEN Betadine to dry.....then IV stick?

If you have the time and circumstances, then yes, that would be the ideal application process. But again, there are a lot of times that you don't have that luxury. And if you're rushing someone to trauma surgery, they're going to be getting a buttload of 3G cephalosporins anyhow. I wouldn't delay their care or transportation waiting for iodine to dry. And again, I expect chlorhexadine to become the standard in the near future.

I think the old technique of iodine followed by alcohol was mostly aesthetically driven. It just seems intuitive to "clean" the iodine off, if you don't understand how they work. Lord knows I did it that way for a very long time.