Avoiding the Hazards
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Enhancing the Safety of Medical Suction Through Innovative Technology Patricia Carroll, RN,BC, CEN, RRT, MS Abstract: Medical suctioning is essential for patient care. However, few clinicians receive training on the principles of physics that govern the safe use of medical suction. While all eight manufacturers of vacuum regulators sold in North America require occlusion of the tube before setting or changing vacuum levels, anecdotal evidence reveals that clinicians are not aware of this requirement or skip this step when pressed for time. This white paper summarizes the physics relating to medical suction, the consequences of damaged mucosa, the risks to patient safety when suction levels are not properly set and regulated, and technology advances that enhance patient safety. Medical suction is an essential part of clinical practice. Since the 1920s, it has been used to empty the stomach, and in the 1950s, airway suction levels were first regulated for safety. Today, medical suction is used for newly born babies and seniors, and in patients weighing between 500 grams and 500 pounds. Medical suction clears the airway, empties the stomach, decompresses the chest, and keeps the operative field clear. It is essential that clinicians have reliable equipment that is accurate and easy to use. Why a Safety Mindset is Important The current focus on patient safety extends to suction procedures and routines. When suction pressures are too high, mucosal damage occurs, both in the airway1 and in the stomach. If too much negative pressure is applied through a chest tube, lung tissue can be drawn into the eyelets of the thoracic catheter2. Researchers are examining the connection between airway mucosal damage and ventilator-associated pneumonia. In pediatrics, airway suction catheters are inserted to a pre-measured length that avoids letting the suction catheter come in contact with the tracheal mucosa distal to the endotracheal tube3. Mucosal damage can also be mitigated with appropriate suction techniques, and every effort should be made to reduce this insult to the immune system of patients who are already compromised. Damaged airway mucosa releases nutrients that support bacterial growth4, and P. aeruginosa and other organisms are drawn to damaged epithelium5, 6. Mucosal damage in the stomach can result in bleeding and anemia as well as formation of scar tissue. secretions are removed from the patient. Ideally, clinicians need the best flow rate out of a vacuum system at the lowest negative pressure. Three main factors affect the flow rate of a suction system: • The amount of negative pressure (vacuum) • The resistance of the suction system • The viscosity of the matter being removed The negative pressure used establishes the pressure gradient that will move air, fluid, or secretions. Material will move from an area of higher pressure in the patient to an area of lower pressure in the suction apparatus. The resistance of the system is determined primarily by the most narrow part of the system — typically, a tubing connector — but the length of tubing in the system can increase resistance as well. Watery fluids such as blood will move through the suction system much more quickly than thick substances such as sputum. At one time, it was thought that instilling normal saline into an artificial airway would thin secretions, enhancing the flow of secretions out of the airway. However, research shows no thinning occurs and that patients’ oxygenation drops with saline installation. Thus, the practice should be abandoned7, 8. Increasing the internal diameter of suction tubing or catheters will increase flow better than increasing the negative pressure or shortening the length of the tube. However, in most clinical applications the size of the patient will be the key factor determining the size of the catheter that can be safely used. Researchers at the Madigan Army Medical Center explored factors affecting evacuation of the oropharynx for emergency airway management. They tested three substances — 90 mL of water, activated charcoal, and Progresso vegetable soup — with three different suction systems, progressing from a standard 0.25-inch internal diameter to a 0.625-inch internal diameter at its most restrictive point. All systems evacuated water in three seconds. The larger diameter tubing removed the soup 10 seconds faster and the charcoal mixture 40 seconds faster than the traditional systems. The researchers note that this advantage in removing particulate material can speed airway management and reduce the risk or minimize the complications from aspiration9, 10, 11. Video 1: Clinical Animation Video “Avoiding the Hazards of Inadvertent Administration of High Suction Pressures” Physics of Suction Flow rate is the term used to describe how fast air, fluid, or Vacuum regulators are ever-present in the hospital setting. Clinicians use them daily and may not be as attentive to this Reference Neonatal Intensive Care, May-June 2008 Issue, Article: Enhancing the safety of Medical Suction Through Innovative Technology, by Patricia Carroll, RN, BC, CEN, RRT, MS Video 2: Clinical Video “Understanding the Hazards of Tracheal Oversuctioning” The Principles of Vacuum and Clinical Application in the Hospital Environment Safe Suction Advisory Care ProgramTM A comprehensive analysis and educational program created for clinicians, physicians, quality managers and hospital staff. Medical Leadership Education In-Service Training Patient Safety Clinical Audits Inventory Assessment Reference Information 1. Excerpt from American Association of Respiratory Care® 2010 published Guidelines Endotracheal Suctioning of Mechanically Ventilated Patients with Artificial Airways; Section 2.3 Smeltzer, Suzanne, Brenda Bare, Janice Hinkle, and Kerry Cheever. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing: 12th edition (2009), page 1022. Prevention of Endotracheal Suctioning-induced Alveolar De-recruitment in Acute Lung Injury; Salvatore M. Maggiore, Francois Lellouche, Jerome Pigeot, Solenne Taille, Nicolas Deye, Xavier Durrmeyer, Jean-Christophe Richard, Jordi Mancebo, Francois Lemaire, Laurent Brochard. Published in Feb. 2003 American Journal of Respiratory and Critical Care Medicine. Ohio Medical Corporation®, 1111 Lakeside Drive, Gurnee, IL 60031 1.866.549.6446 | www.ohiomedical.com 255489 (Rev.5) 01/2015 Ohio Medical Corporation is a registered trademark and Push-to-Set and Safe Suction Advisory Care Program are trademarks of Ohio Medical Corporation. American Association for Respiratory Care is a registered trademark of American Association for Respiratory Care. © Copyright 2015. All Rights Reserved. This document contains information that is proprietary and confidential to Ohio Medical Corporation. Use of this information is under license from Ohio Medical Corporation. Any use other than that authorized by Ohio Medical Corporation is prohibited. Avoiding the Hazards of Inadvertent Administration