Dressings for tunneled dialysis catheters

I like to get a concensus from other home hemodialysis nurses on what their method of changing tunneled catheter sites- what they use as a cleaning agent, gauze or no gauze @ site, transparent drsg-yes or no, and how often if the patient is doing daily hemodialysis.

"K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations
2006 Updates
Vascular Access



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.

I am very familiar w/ the KDOQI guidelines. I find it interesting no one has responded to me except yourself, a member of the Vascular Access Guideline Work Group, even after 56 views of this posting.

Hi Jonesy. I actually pointed a number of folks to your posting in an effort to get others to answer, but you’ve seen how much luck we’ve had! We truly appreciate professionals posting, and hope to boost professional traffic. My guess is that some folks don’t have Internet at work and don’t think to check once they get home (or don’t want to deal with work issues then), and others may be afraid that someone will know who they are and they’ll get in trouble–even though they don’t have to register or use a real name. Please do keep trying, though.

I am not a professional but I am proud I have this post to read.

There are now over 150 views of this thread. It’s very possible that many of those reading it are patients who want to know more about ways to care for their catheter. As you see, patients and professionals post to each other’s message boards.

In our in-ctr unit, we had always utilized sterile dressing changes with sterile 2x2, Antibiotic oint, betadine swabs, and a tegaderm (unless allergy present). After the KDOQI was released we found it very hard to go with just a “gauze & tape”. Many patients found it “hard to believe” that a gauze/tape or just a bandaid would be clean. Studies show that infection rates did not increase with the non-sterile dressings.

I just read your posting and would be happy to reply. In our home program we teach the same catheter care that the patients receive in-center. I have the patient and family member/care giver mask, glove and gown. They are taught strict aseptic technique when preforming any care on the catheter including changing gloves and washing hands. Infection rates in general appear less in the home setting due to the limited care givers and personal care, attention and devotion they have.

We clean the site with betadine, unless allergic, apply ointment, and dress with a breathable dressing. They are instructed to remove the dressing for showers, etc. and redress for security/comfort.

My concern is that do we have to close the clamp of a permanet hemodialysis catheter? What i observe is that after many months, there is a permanent kink on the plastic tube where we close the clamp. Is it ok to just close the cap and leave the clamp open to prevent this. I believe that the clamp is there for the actual dialysis sessions.