"K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations
I. CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS
GUIDELINE 3. CANNULATION OF FISTULAE AND GRAFTS AND ACCESSION OF HEMODIALYSIS CATHETERS AND PORT CATHETER SYSTEMS
The use of aseptic technique and appropriate cannulation methods, the timing of fistula and graft cannulation, and early evaluation of immature fistulae are all factors that may prevent morbidity and may prolong the survival of permanent dialysis accesses.
3.1 Aseptic techniques:
3.1.1 For all vascular accesses, aseptic technique should be used for all cannulation and catheter accession procedures. (See Table 2.) (A)
3.2 Maturation and cannulation of fistulae:
3.2.1 A primary fistula should be mature, ready for cannulation with minimal risk for infiltration, and able to deliver the prescribed blood flow throughout the dialysis procedure. (See Table 3.) (B)
3.2.2 Fistulae are more likely to be useable when they meet the Rule of 6s characteristics: flow greater than 600 mL/min, diameter at least 0.6 cm, no more than 0.6 cm deep, and discernible margins. (B)
3.2.3 Fistula hand-arm exercise should be performed. (B)
3.2.4 If a fistula fails to mature by 6 weeks, a fistulogram or other imaging study should be obtained to determine the cause of the problem. (B)
3.3 Cannulation of AVGs:
Grafts generally should not be cannulated for at least 2 weeks after placement and not until swelling has subsided so that palpation of the course of the graft can be performed. The composite PU graft should not be cannulated for at least 24 hours after placement and not until swelling has subsided so that palpation of the course of the graft can be performed. Rotation of cannulation sites is needed to avoid pseudoaneurysm formation. (See Table 4.) (B)
3.4 Dialysis catheters and port catheter systems:
Infection-control measures that should be used for all HD catheters and port catheter systems include the following:
3.4.1 The catheter exit site or port cannulation site should be examined for proper position of the catheter/port catheter system and absence of infection by experienced personnel at each HD session before opening and accessing the catheter/port catheter system. (B)
3.4.2 Changing the catheter exit-site dressing at each HD treatment, using either a transparent dressing or gauze and tape. (A)
3.4.3 Using aseptic technique to prevent contamination of the catheter or port catheter system, including the use of a surgical mask for staff and patient and clean gloves for all catheter or port catheter system connect, disconnect, and dressing procedures. (A)
There is considerable evidence that the use of maximal sterile precautions, as opposed to clean aseptic technique, for cannulation of AV accesses and catheter accession is both impractical and unnecessary.222-225 However, the importance of strict dialysis precautions226 and aseptic technique222 cannot be overemphasized in the prevention and minimization of all access infection.227 Despite the general acceptance of the importance of standard precautions for hand washing and glove changes, these simple acts to minimize transmission of disease frequently are skipped. An audit in a selection of Spanish HD units examined opportunities to wear gloves and wash hands per the standard preventive guidelines (high-risk activities of connection, disconnection, and contact between patients during dialysis). Gloves were worn by only 19% and hands were washed after patient contact on only 32% of all occasions.228 Mandatory hand washing before patient contact occurred only 3% of the time. A decade later, wearing of gloves improved to 92%, but the practice of hand washing before or after these patient-oriented procedures remained low at 36% after and 14% before such activities.229 Greater adherence was found in acute than in long-term HD units. A greater patient-nurse ratio independently influenced hand-washing rates. With the increasing microbial resistance to mainstream antibiotics,230 infection prevention must be considered the first rule of vascular access maintenance.231 Data from prospective studies in both Canada and the United States clearly show that great variability exists between centers in infection rates, indicating the need to have not only a national registry, but also a local (ie, in-center) infection surveillance program.232-234 Increased awareness at the individual center level is key to stemming access infection and its extreme consequences, such as endocarditis and metastatic infections (eg, spinal abscesses), conditions that are disabling at best, sometimes fatal, and prohibitively costly to treat.235,236
In the effort to prevent infection, it is not only staff that must be vigilant to potential breaks in technique and the need for the appropriate use of masks. Patients also must be taught that lapses in their use of masks and poor personal hygiene are known to increase their risk for infection. Patients with type 2 diabetes are at increased risk for nasal staphylococcal carriage and catheter-related bacteremia (CRB) as a result.237,238"
The guidelines should also be used as guideline for home hemodialysis patients as well. Practice patterns between the US and other countries can vary widely, but the use of a mask for the patient and caregiver at home is an essential part of proper infection control when using a hemodialysis catheter. The cleaning agents used also vary by country- the key is to follow the manufactory’s Instructions For Use (IFU’s) carefully to ensure the proper action of the agent to kill bacteria. Touch contamination of the lumens must taught and reinforced regularly since most infections are not form the exit site/tunnel track, but from the lumens of the catheter being touch contaminated with a direct blood access to the blood steam and the heart.
As a member of the K/DOQI Vascular Access Guideline Work Group for the 1997, 2000 and 2006 versions- we did not address home hemodialysis as a separate issue because the Guidelines are anticipated to cover all hemodialysis vascular access patients with the same level of care regardless of the treatment venue.