Clinical Skills: Suturing

There are three important aspects to effective suturing: adequate preparation of the patient and their wound, good suturing technique producing well tied knots, and the maintenance of the asceptic non-touch technique throughout the suturing process.

• Put on gloves and gather equipment: suture pack, thick and thin curved needles, sterile 0.9% saline, gauze, lignocaine 1% or 2% (check expiry date of saline and lignocaine with another healthcare professional)
• In the suture pack, you will find:
  • Sterile tray
  • Scissors to cut suture
  • Needle holder to hold the needle during suturing
  • Mayo scissors (scissors with curved edge) - cuts tissue under skin (debridement)
  • Non-toothed forceps to hold suture
  • Toothed forceps to manipulate skin in the wound site
  • N.B..: hold all ringed instruments with your thumb through one arm and you and ring finger (4th finger) through the other

• Return to the patient and ensure they are still happy to continue
• Set up sterile field (open out the blue cloth surrounding the suture pack) on an equipment trolley next to the patient's bed
• Open all sterile equipment into the sterile field, ensuring that your hands and the non-sterile outer packaging of the equipment does not touch the sterile field

• Depth of wound?
• Is there pus or necrosis inside the wound, suggesting infection or devascularisation respectively?
• Is there any surrounding erythema suggestive of cellulitis?
• Are there any foreign objects? E.g. glass, grit, metal? If the object is not small and obviously visible then request a radiograph of the area to ascertain the size and depth of penetration. If foreign objects are found then check that the patient is up-to-date with their tetanus boosters

• Different methods can be used. These include:
  • Using sterile 0.9% saline to soak gauze and carefully wipe area – most commonly used
  • Betadine or chlorhexadine with gauze - may be necessary if the wound recieved exposure to unhygienic materials
  • 0.9% saline irrigation if the wound had heavy visible soiling - this is when a significant volume of saline is used to run over the wound
  • If required can be debrided with 'Mayo scissors', especially if there is clear sign of devascularisation of the wound or significant infection. Speak to your senior if you are not clear on the indications or methods for debriding a wound

• Ask the patient about allergies before you insert anaesthetic. If they had previously reacted to a local anaesthetic with paraesthesia, convulsions, anxiety or cardiac arrythmias then avoid the local anaesthetic
• The maximum dose of lignocaine that can be administered to a patient is 3mg per kg of weight
  • So for a 70kg patient, the maximum dose would equal 70 x 3mg = 210mg lignocaine in 30-40 minutes (it lasts 30-40 minutes)
  • 100% lignocaine would contain 1gram of lignocaine per 1ml of solution
  • If lignocaine is 1%, then there is 10mg in 1ml of solution
  • So, a 70kg patient would be able to receive 21mls of solution
• How to administer the local anaesthetic:
• Check the name, strength and expiry date of the drug with another healthcare professional
• Attach a thick green needle to syringe and fill with the appropriate amount of lignocaine
• Remove thick green needle and attach thin orange needle to the syringe
• Insert needle into the skin around the wound area so that it penetrates into the dermal layer
• First pull back on the syringe to ensure that you haven't penetrated a blood vessel (you will see blood returning into the syringe if you are in a blood vessel). If you penetrated blood vessel then pull the needle out and apply pressure to the area until the bleeding stops
• If you are confident that you are in connective tissue then push the syringe slowly whilst slowly drawing the needle and syringe out of the skin, to 'infiltrate' the local anaesthetic into the area. Do this at various points around the wound
• Wait 5 minutes until the area is anaesthetised (check with the patient whether they can feel a sharp sensation)