2.2 Sterile Technique & Universal Precautions

Sterile Technique & Universal Precautions

Quick Answer: Cardiac catheterization requires surgical aseptic technique for vascular access and device delivery, combined with Standard Precautions that treat all blood and body fluids as potentially infectious. The RCIS who scrubs maintains the sterile field above waist level; circulating team members never break the sterile barrier without explicit need and proper technique.

Sterile technique and infection prevention are tested throughout the RCIS exam under pre-procedural and radiation-safety categories. A single break in asepsis can convert an elective diagnostic case into a bloodstream infection, endocarditis, or surgical site infection requiring weeks of IV antibiotics. The RCIS must internalize both surgical asepsis (protecting the sterile field) and Standard Precautions (protecting personnel from bloodborne pathogens) — they operate simultaneously but serve different purposes.

Principles of Surgical Asepsis

Surgical asepsis aims to exclude all microorganisms from the operative field. In the cath lab, the "operative field" encompasses the puncture site, guidewire path, and any intravascular device being introduced.

Core sterile-field rules:

1. Only sterile items enter the sterile field. Packages are opened using aseptic technique; the inner wrapper is presented to the scrub person without touching the contents.
2. Sterile field is above waist level (or above the lower table edge) and within the scrubbed person's line of sight.
3. Hands remain above the waist after gloving; arms are never folded behind the back or tucked at the sides below the sterile drape edge.
4. Face the sterile field when moving — turning your back to the field risks contamination from non-sterile clothing or room air currents.
5. Sterile-to-sterile contact only. A sterile item that touches a non-sterile object becomes contaminated.
6. Edges of wrapped supplies are non-sterile. The 1-inch border of opened drapes and the outer packaging flap are considered unsterile.
7. If in doubt, throw it out. Questionable sterility is treated as contamination.

Surgical Hand Scrub, Gowning & Gloving

Hand hygiene is the single most effective infection-prevention measure. The RCIS performing the scrub role completes a surgical hand antisepsis before every case.

Surgical scrub steps:

After scrubbing, the technologist dons a sterile gown without touching the outer surface, then applies sterile gloves using the closed or open gloving method. Glove size must fit snugly — too-large gloves tear on equipment; too-small gloves restrict dexterity and may split at the thumb web.

Gown sterility zones:

• Sterile: Front from chest to the level of the sterile field, sleeves to 2 inches above the elbow.
• Non-sterile: Back of gown (cannot be turned around), neckline, shoulders, belt tie in the back, and any area below the table edge.

Draping the Patient

Patient draping creates the sterile barrier between the non-sterile environment and the vascular access site.

Draping principles for cardiac catheterization:

• The access site (radial, femoral, or alternative) is prepped with antiseptic (CHG-based solutions preferred for skin antisepsis; allow adequate dry time per manufacturer instructions).
• Sterile drapes are placed and NOT moved once positioned. Repositioning a drape whose underside has contacted the table edge, floor, or non-sterile equipment contaminates the field.
• If a drape is breached or suspected contaminated, cover with an additional sterile drape or remove and re-prep the site — never simply pull the drape back into place.
• Fenestrated drapes align the opening over the access site; the fenestration edge is sterile only if it has not been touched by non-sterile skin or equipment.
• For radial access, a radial board and arm drape are added; the hand may be wrapped in a sterile towel or placed in a sterile drape pouch.

Hair at the puncture site is clipped (not shaved) if needed — shaving causes micro-abrasions that increase infection risk. Beards and body hair near the field are covered with adhesive incise drapes when institutional policy requires.

Strike-Through & Moisture Contamination

Strike-through occurs when moisture (blood, saline, perspiration) penetrates a sterile barrier material, wicking bacteria from the non-sterile side to the sterile side. This is a heavily tested RCIS concept.

Antibiotic prophylaxis (e.g., cefazolin before device implantation) does not replace sterile technique — it supplements asepsis for certain high-risk procedures but never justifies a sloppy field.

Standard (Universal) Precautions

Standard Precautions — formerly called Universal Precautions — require treating all blood, body fluids, secretions, and excretions (except sweat) as potentially infectious for bloodborne pathogens including HIV, hepatitis B (HBV), and hepatitis C (HCV).

Standard Precautions in the cath lab:

• Hand hygiene before and after every patient contact, after removing gloves, and after touching potentially contaminated surfaces.
• Gloves for all contact with blood, body fluids, mucous membranes, and non-intact skin. Change gloves between tasks on the same patient if contamination occurs.
• Gown or apron when splashes or sprays of blood or body fluids are anticipated.
• Mask, eye protection, or face shield during procedures that may generate splashes (vascular access, sheath removal with spurting).
• Needle-safe devices and no recapping of used needles — dispose directly in a sharps container.
• Respiratory hygiene/cough etiquette for patients with respiratory symptoms.

These precautions apply to every team member — the circulating RCIS, the monitoring nurse, the physician, and housekeeping — not only the scrubbed person. A circulating technologist who handles blood-soaked dressings without gloves violates Standard Precautions even though they are not at the sterile field.

Exposure Management

Despite best practices, needlestick and blood-splash exposures occur in cath labs. Immediate response follows institutional post-exposure protocol:

1. Wash needlestick wounds with soap and water; flush mucous membranes with water or saline.
2. Report to occupational health immediately — do not delay for serology results.
3. Source patient testing (if consented) for HBV, HCV, and HIV guides prophylaxis decisions.
4. HBV vaccination status is verified; non-immune personnel may receive HBIG and vaccine.
5. HIV post-exposure prophylaxis (PEP) is initiated within hours when the source is HIV-positive or unknown high-risk.

The RCIS maintains current BLS/ACLS certification and participates in annual bloodborne-pathogen training as required by OSHA 29 CFR 1910.1030.