AIM: closing an anaesthetised wound using interrupted sutures using an aseptic technique.
Introduction to patient
- State your name and role and confirm patient’s identity
- State purpose of interaction and gain informed consent
- Check patient’s understanding eg ‘Have you ever had this done before?/ Do you know what this will involve?’
- Explain procedure
- Mention risks: bleeding, infection, pain
Establish site and assess the wound
Screening questions: there are eight…
- How did you acquire the wound?
- Has the wound been x-rayed? What did the x-ray report show?
- Has the wound been cleaned?
- Has the wound been anaesthetised?
- Have you had a tetanus jab?
- Are you allergic to latex?
- Do you have any trouble with needles? You can advise the patient to look away when suturing or distract them with conversation
- Are you on any blood-thinning medication?
- Suture material
- 0.9% Sodium Chloride
- Eye protection
- Clean trolley
- Sterile gloves
- Suture instruments – needle holder, scissors, toothed forceps, dressing forceps.
- Sharps bin
- Wash hands with soap and water, including distal third of forearms
- Clean the trolley and gather equipment.
- Open suture pack correctly using sterile technique and unfold the sterile field
- Check expiry date of appropriate suture material
- Open suture material and sterile gloves onto unfolded sterile field.
- Put on sterile gloves. In the event that you have to prepare the wound yourself:
Administer local anaesthetic (LA)Remove debris with forceps
Clean wound with normal saline or betadine soaked gauze; starting from the wound edges in an outwards motion away from the wound.
Dry with clean gauze
- Check expiry date and dose of LA with another health professional
- Draw up 5ml using 21 gauge needle
- Dispose needle in the sharps bin
- Administer LA with 25 gauge needle
- Lay sterile field with an appropriate window over the wound
- With forceps, press gently on either side of the wound to ensure that the anaesthetic has taken effect (this can take 5-10 minutes), although the patient may feel pressure.
- Grasp needle at 2/3 distance from its tip with needle holder.
- Insert the first suture in the middle of the wound and then continue dividing into equal sections – approximately 5-10mm apart.
- Holding the skin with toothed forceps, pierce the skin at a 90° angle not closer than 5mm from the wound edge, following the curvature line of the needle as it passes through the tissue, into the middle of the wound.
- Remove the needle and remount it in the needle holder before taking a corresponding bite on the other side of the wound. Ensure needle is not touched to avoid needle stick injury, and is handled only by toothed forceps whist repositioning it in the needle holder
- Pull the suture through until a short length remains.
- Tie 3 surgeon’s knots (instrument tie) ensuring that all knots end up on the same side of the wound. Ensure the opposing edges meet well in the middle without excess tension.
- Cut ends of suture to an appropriate length ~5- 10mm
- Dispose of sharps straight away in the sharps bin
- Take note of the number of sutures before applying a non-adherent dressing.
- Explain to patient what you have done
- Instruct the patient appropriately, including precautions and aftercare.
- Keep wound dry- take showers instead of baths and avoid swimming
- Educate patient on signs of infection: hot, pain, redness, swelling around wound site ± fever, pus. Tell them to visit A&E if any of these signs appear.
- Provide clear instructions about the time and place of suture removal
- 7- 14 days for sutures in limbs
- 5 days for suture on the face.
- Clean hands
- Document the procedure in the patient notes including anaesthetic effect, suture material, number of sutures and follow up information given.
- Attend to patient’s comfort throughout the procedure
- Have good eye contact, express concern, and respond to their expressions and body language.
- Engage with patient throughout the procedure- Maintaining a conversation whilst suturing proficiently is worth practicing, this will impress any examiner!