Suction Equipment Shortage in a Patient with CRAB
You are the senior respiratory therapist on the 12-bed adult ICU at a MOH hospital in Kuwait. Bed 7 has a 62-year-old man intubated for 9 days after aspiration pneumonia. He is colonised with carbapenem-resistant Acinetobacter baumannii from a tracheal aspirate taken 48 hours ago, and contact precautions are posted. He has copious thick secretions, and the team wants chest physiotherapy and suctioning every 2 hours. The unit has only two closed suction systems left; one was opened yesterday and stored beside the bed without a cap, and the other is unopened. A new assistant asks whether they can rinse the used catheter with tap water and reuse it for the next shift because the central store is closed until morning. The patient's SpO2 is 94% on FiO2 0.40, PEEP 8, and secretions are visible at the tube connector. The nurse is busy with a new admission.
1. What immediate actions should you take regarding the suction equipment and infection prevention, and why?
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- Do not rinse or reuse the opened catheter. Tap water is not sterile, and CRAB survives well in water and biofilm; rinsing would contaminate the catheter and the patient's airway. The opened, uncapped system stored beside the bed must be treated as contaminated because its inner lumen has been exposed to the bed space.
- Use the unopened closed suction system for this patient. If that is not available, use a sterile, single-use open suction catheter with sterile gloves and a sterile field. Never share a suction catheter between patients.
- Perform hand hygiene and don contact-precaution PPE (gloves, gown, eye protection, and mask per MOH policy) before entering. Keep the door closed and limit staff traffic.
- Escalate the stock shortage immediately to the charge nurse and infection control; request emergency stock from the central store or another unit. Do not wait until morning.
- Reason: the safest option is the one that protects the artificial airway from environmental organisms; convenience and cost do not justify reusing a contaminated airway device.
2. How would you balance effective secretion clearance with limiting aerosol and staff exposure?
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- Pre-oxygenate with 100% oxygen for 30–60 seconds before suctioning, and suction only when clinically indicated (visible secretions, rising peak pressures, desaturation, or coarse breath sounds), not purely by the clock.
- Prefer the closed suction system to reduce aerosol generation and staff exposure. If open suction is required, use a sterile single-use catheter and keep the number of staff in the room to the minimum needed.
- Use a fit-checked N95 respirator if the procedure is likely to generate aerosols, in addition to contact-precaution PPE. Keep the door closed and avoid unnecessary entry during and after the procedure.
- Limit each suction pass to 10–15 seconds, allow recovery between passes, and monitor SpO2, heart rate, and secretions. Stop if SpO2 falls significantly below baseline or if the patient becomes unstable.
- Avoid saline instillation unless specifically ordered; it does not reliably thin secretions and can increase contamination of the lower airway.
3. What should be documented and communicated at handover?
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- Document the date and time, type of suction system used, whether the opened system was discarded, and the reason for any deviation from the usual stock.
- Record suction frequency, secretion amount and character, patient tolerance, SpO2 before and after, any desaturation, and the IPC measures used.
- Document the equipment shortage and who was notified (charge nurse, infection control, store). If the shortage created a patient-safety risk, file an incident report through the hospital quality system.
- At handover, state clearly: contact precautions for CRAB, the suction plan, the remaining stock, the need for morning replacement, and any pending infection-control review. This ensures the next shift does not improvise unsafe reuse.