SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: HEMODIALYSIS TEMPORARY CATHETER (INSERTION, DRESSING CHANGE, REMOVAL, MEDICATION AND BLOOD DRAWS, DISCONTINUATION OF MEDS AND IV FLUIDS) Nursing DATE: REVIEWED: PAGES: 07/82 2/18 1 of 7 RESPONSIBILITY: Staff RN, RN-Hemodialysis PURPOSE: DEFINITIONS: KNOWLEDGE BASE: To provide a temporary access for the hemodialysis treatment and as a means for emergent vascular access. Skin prep: The site will be thoroughly cleansed with chlorhexidine/alcohol skin prep. Use repeated back-and-forth strokes of the applicator for approximately 30 seconds. Completely wet the treatment area with antiseptic. Allow the area to air dry for approximately 30 seconds. Do not blot or wipe away. Temporary catheters have a blue port and a red port. In order to maintain the patency of these lumens for dialysis, the blue and the red port are not routinely utilized as intravenous devices. However, with an MD order from the Nephrologist, the blue port may be used for intravenous access in cases where there are no other options for IV access. If the blue port can t be accessed then the red port may be accessed for urgent needs only and there must be an order from the Nephrologist. NOTE: In an emergent situation, a Hemodialysis catheter may be used to administer medications while the notification of the Nephrologist is pending. Some temporary hemodialysis catheters have a third port that is a pigtail off of the blue port. If the catheter has a third lumen (pigtail), it may NOT be used as a central line without a Nephrologist order. PROCEDURE: INSERTION: NOTE: Central line insertion is a sterile task and is to be completed by a physician or a specially trained health professional. The nurse may assist the physician. NOTE: Items for insertion are in the Central Line Insertion Cart which is available in Central Services. The items on the Central Line Insertion Cart includes the following: 1. Catheter insertion tray
2. Maximum barrier pack bundle/ mask 3. Chlorhexidine swabs (4) 4. Chlorhexidine skin prep 5. Sterile gloves 6. TEGO connectors 7. BioPatch 8. 12 ml syringes (2) 9. Sorbaview dressing 10. White Curo caps (2) 11. Green Curo cap (1) for pigtail only PAGE: 2 of 7 A time-out will be performed as per the SMH Policy (01.PAT.18) Correct Patient, Procedure, and Site Verification. A consent is needed. 1. Follow time out procedures. Nursing should use the Central Line Insertion checklist. 2. Using sterile technique, the physician will prep the left or right subclavian, femoral area, or internal jugular area using the skin prep method. 3. Physician may or may not inject 1% Lidocaine for local anesthesia (included in insertion tray). 4. The introducer will be used by the physician to locate the vein. The guidewire will be placed through the introducer and the introducer removed. The blade may be used to enlarge the entry site at the skin. The dialysis catheter will then be advanced over the guidewire and the guidewire removed. 5. The catheter will be sutured for security, using 2-0 silk (or 2-0 nylon). 6. Catheter will be irrigated with 10 ml normal saline through each port. No blood should be visible. Plastic clamps on the catheter must be clamped. Place a BioPatch around the line. If the catheter has a third lumen (pigtail), it may NOT be used as a central line without a nephrologist order. If a physician order is obtained for use as a central line, flush with 10 ml Normal Saline. May use a connector on this lumen only with a Green Curos cap. 7. TEGO connectors will be fitted to the catheter s adapter sites along with White Curos caps. Refer to the nursing procedure TEGO Connector Cap. 8. Apply sterile Sorbaview dressing over the insertion site.
Label dressing with date and initials. PAGE: 3 of 7 9. Obtain STAT x-ray to confirm proper placement of subclavian catheter tip and to rule-out pneumothorax, upon order from physician. 10. Watch for any untoward effects such as: *Occurrence of subcutaneous emphysema *Respiratory distress, e.g., SOB, dyspnea *Absence of breath sounds *Hematoma and/or bleeding at insertion site *Notify MD immediately of any of above. DRESSING CHANGE: 1. Equipment needed: Central line dressing change kit BioPatch Sorbaview dressing 2. Dressing will be changed if soiled, wet, or non-occlusive. Otherwise, it will be changed in the dialysis unit every 7 days at treatment time to reduce risk of contamination. 3. Strict aseptic technique should be maintained. 4. Don mask. Perform hand hygiene. Don exam gloves. 5. Remove tape and dressing. 6. Perform hand hygiene. Assemble supplies. Apply sterile gloves and clean entire insertion area using chlorhexidine. Allow area to air dry. 7. Place a BioPatch around the line. 8. Apply sterile Sorbaview dressing over insertion site. 9. Label dressing with date. REMOVAL OF CATHETER:
PAGE: 4 of 7 NOTE: Verify the type of catheter PRIOR to removing it. Only a temporary catheter may be removed by the nurse. All tunneled catheters will be removed by the physician. If unsure of catheter type, contact a Hemodialysis RN or PICC RN. 1. Equipment: a. Sterile gloves and non-sterile gloves b. Suture Removal Set c. 2% chlorhexidine skin prep d. 4 x 4 s and 2x2 s e. Tape f. Transparent dressing g. Sterile plastic container (optional) 2. If applicable, check PT/INR prior to removal. Notify physician of any abnormalities. 3. Place the patient in a supine position. 4. Perform hand hygiene 5. Remove the dressing with non-sterile gloves. 6. Remove gloves and again perform hand hygiene. 7. Don sterile gloves. Cleanse the site using chlorexidine. 8. Remove sutures with sterile scissors and tweezers. 9. Ask patient to take a deep breath and hold it or ask him to bear down. While applying direct pressure to site with a sterile 4 X 4, remove catheter. Then have patient breathe normally after removal. 10. Keep the catheter tip sterile. If a the line is to be cultured, place the catheter tip in a sterile specimen container, label appropriately and send to the laboratory with a requisition. 11. Apply pressure to the site for at least five minutes or until bleeding stops. 12. Apply dressing/band-aid over site. NOTE: Watch for any untoward effects such as: *Occurrence of subcutaneous emphysema *Respiratory distress such as shortness of breath or dyspnea *Absence of breath sounds *Hematoma and/or bleeding at insertion site.
PAGE: 5 of 7 PROCEDURE TO ADMINISTER MEDICATION OR BLOOD DRAW : (requires a Nephrologist order to use the blue port. An order from a nephrologist is also needed to use the pigtail) 1. Equipment: a. Sterile gloves/mask b. 1 12 ml syringe with 10mL Normal Saline c. Alcohol swabs d. Medication/IV Fluid e. Curos cap (white) f. Curos cap (green) for pigtail blood draw or medication administration 2. Assure blue port is clamped and TEGO connector is securely in place. 3. Perform hand hygiene. Don sterile gloves. 4. Clean TEGO with an alcohol swab for 15 seconds. (If White Curos cap in place, remove cap.) 5. Connect 12 ml syringe and withdraw 3 ml s of blood. Clamp line, discard syringe. Clean connection with an alcohol swab for 15 seconds. 6. Draw specimens. 7. If only blood drawn, Clean connection with an alcohol swab for 15 seconds. Flush line with 10 ml of Normal Saline and re-clamp blue port. Attach a new White Curos cap. 8. If giving medications, remove syringe and attach IV or medication. 9. Open clamp to infuse medication or IV. 10. If catheter has a third port (pigtail), it may be used as a central line. Add a connector to end of pigtail. Pigtail may NOT be used as a central line without a nephrologist order. Flush with 10 ml normal saline and attach a new Green Curos cap. PROCEDURE TO DISCONTINUE MEDICATION OR IV FLUIDS: 1. Equipment: a. Sterile masks (2) and gloves
PAGE: 6 of 7 b. Sterile towel c. 1 12 ml syringe with 10 ml Normal Saline d. 2 10 ml syringe e. 1 sterile luer cap f. Alcohol swabs g. 2 TEGO connectors h. 2- white and/or green Curos cap 2. Place mask on patient and on self. 3. Perform hand hygiene and don sterile gloves. Discontinue the medication. 4. Clean port vigorously with alcohol for 15 seconds and attach a sterile syringe. (If White Curos cap in place, remove cap.) 5. Unclamp catheter and aspirate 5 ml blood. 6. Clamp catheter immediately and screw rotating collar of the TEGO cap onto the CVC port. 7. Discard aspirate. 8. Clean connection with an alcohol swab for 15 seconds. 9. Attach 10 ml normal saline syringe, unclamp catheter; flush; and then re-clamp catheter attach a new white Curos cap. 10. If catheter has a third port (pigtail), treat it the same as a central line. Pigtail may NOT be used as a central line without a nephrologist order. Add a connector to end of pigtail. Flush with 10 ml normal saline and attach a new green Curos cap. DOCUMENTATION: Nursing Reassessment: Document the time and the specific information pertinent to each procedure performed. Include patient education and the patient s response to teaching and/or procedures. Document any untoward effects and action taken.
PAGE: 7 of 7 REFERENCES: SMH Policy. (01.PAT.18) Correct Patient, Procedure, and Site Verification. SMH: Author. SMH Nursing Procedure. Use of the TEGO Connector Caps on External Access of Hemodialysis Catheter (dhd20). SMH: Author. Lippincott Nursing Procedures. 7th edition. (2015) (pp. 145-154). Lippincott, Williams & Wilkins. Philadelphia: PA. REVIEWING AUTHOR(S): Jordan Solich, BSN, RN, Nurse in Professional Development 7WT Kelly Comingore, RN, BSN, CCRN, NPD, Hemo Jackie Bland, BSN, RN-BC, 7WT APPROVAL: Clinical Practice Council 2/1/18