Page 1 of 10 NURSING POLICIES, PROCEDURES & PROTOCOLS CENTRAL VENOUS ACCESS DEVICE (CVAD) HEMODIALYSIS CATHETERS: DRESSING CHANGE, INITIATING OR DISCONTINUING AN INFUSION NO.: 00056 (Formerly NSG2146) ISSUED BY: NPPPWG APPROVED BY: Dr. Debra Bournes, Chief Nursing Executive, VP Clinical Programs DATE INITIALLY ISSUED: 2006/12 DATE LAST REVIEWED: 2015/01/20 IMPLEMENTATION DATE: 2015/12/08 CATEGORY: Nursing: Medications & Intravenous POLICY STATEMENT: A Registered Nurse (RN) is responsible for hemodialysis catheter care and maintenance if they have the knowledge, skill and judgment. A RN may perform a dressing change, initiate or discontinue an infusion via the One-Link connector after attending an education session with the Nurse Educator/Delegate. This policy does not encompass care of catheters inserted for the sole purpose of performing apheresis procedures, refer to corporate nursing policy No. 00053. A physician order is required for the maintenance care using the pre-printed Physician s order sheet Anticoagulant Instillation of Hemodialysis/Plasmapheresis Catheters (SPO 147) see Appendix. Hemodialysis catheter access: i. Access only if a One-Link connector is present on the lumen ii. The hemodialysis nurse will add a one link connector to one of the lumens post dialysis for all admitted patients. iii. If a One-Link Connector is not present, or the CVAD is not functioning, notify the hemodialysis unit. o Civic Campus, 14946 o General Campus, 78194 o Riverside Campus, 82799 iv. After hours for admitted patients: o If the hemodialysis unit is not available (closed after hours) the nurse is to contact the hemodialysis unit in the morning (see Nursing Alerts).
v. Exception: Nurses in critical care (i.e. ICU, ER, PACU, Medical Imaging) and nurses working on 7NW (Nephrology Unit), may add a One-Link Connector. The nurse will attend an education session with the Nurse Educator/Delegate prior to assuming this responsibility. Refer to the following policies for other procedures related to hemodialysis catheters: i. No.: 00051: Central Venous Access Device (CVAD): Removal of ii. No.: 00054: Central Venous Access Device (CVAD): Blood Procurement Infection Prevention and Control Hand Hygiene: as per Corporate - Administration # 00233 (Hand Hygiene Products and Materials) and the Policy #00014 (Hand Hygiene Policy) - Before initial patient/patient environment contact - Before an aseptic procedure - After body fluid exposure risk - After patient/patient environment contact Personal Protective Equipment: as per the Infection Prevention and Control Policy # 00023 (Routine Practices) DEFINITIONS: 1. Hemodialysis catheter: a CVAD whose tip is resting in the superior vena cava or its junction with the right atrium. These include percutaneously inserted tunneled or nontunneled catheters in the jugular or rarely the subclavian or femoral vein. i. Non-tunneled hemodialysis catheters: o Used for short term access. o Always sutured in place. ii. Tunneled hemodialysis catheters: o Used for long term access. o o The cuff acts as a barrier to infection and anchors the catheter in place. Are sutured at the time of insertion. Sutures are removed after 14 days by the hemodialysis nurse. 2. 4% sodium citrate dehydrate: an anticoagulant that binds with calcium in the blood, thus interfering with the normal clotting pathway. NURSING ALERTS: 1. Use the hemodialysis catheter for all intravenous (IV) procedures whenever possible to minimize the need to access peripheral veins. This is the patient s lifeline and increased risk of infection occurs with increased manipulation of the CVAD. However, minimize unnecessary manipulation of the hemodialysis line by: i. Performing blood procurement and/or IV medication administration in conjunction with the hemodialysis treatment whenever possible. ii. Limiting access for non-dialysis procedures to twice in a 24 hour period. If more than two procedures are required, obtain a physician s order for an appropriate solution at an infusion rate of 10mL/hr. 2. Hemodialysis catheters are instilled with 4% sodium citrate (with a physician order) but an alternate anticoagulant may be ordered by a physician if required. Page 2 of 10
i. Each time an access procedure is completed, an anticoagulant must be instilled unless a continuous IV is infusing. ii. The anticoagulant lock solution must be aspirated (5-7 ml) from the catheter lumen before initiation of any procedures (i.e. initiating an IV infusion). iii. The amount of anticoagulation instillation is determined from the lumen volume plus the volume of the One-Link connector. Hemodialysis catheter lumen volumes are identified on the clamps or along the catheter length. If unable to read the volumes, contact the Hemodialysis unit. iv. The hemodialysis nurse will instill the catheter with Alteplase (tpa). This will be identified on the catheter lumen with a pink label. The unit nurse may access the lumen after withdrawing the tpa. 3. Contact the Hemodialysis unit if: i. Unable to aspirate anticoagulant lock solution: o If the nurse is only able to remove some of the citrate and the lumen is not functioning well enough to provide a blood sample, the lumen should be flushed with 20 mls 0.9% sodium chloride and re instill the citrate as per Section D. ii. Signs of infection at insertion site (i.e. purulent drainage). iii. The cuff of the catheter is exposed. iv. Unable to read the volume of the lumen. v. The catheter has been locked with tpa. Note: If the hemodialysis unit is not available (closed after hours) the nurse is to contact the hemodialysis unit in the morning. 4. The turbulent injection technique is used for flushing using a brisk push/pause/push/pause motion on the syringe plunger. 5. Hemodialysis catheter dressing: i. Both the RN and the patient must wear a mask during dressing change. ii. Is changed every 7 days in the hemodialysis unit. o If required to be changed on the inpatient unit/outpatient setting (i.e. no longer occlusive, drainage has accumulated), this can be done as per procedure A below. The dressing will be changed again at the next hemodialysis treatment. iii. Keep the dressing clean, dry and intact; the patient must not shower. iv. Do not place tape on top of transparent dressings. v. Non-Tunneled catheters are sutured at time of insertion. The sutures must be intact at all times. If a suture(s) is missing, the catheter wing must be temporarily secured with a sterile adhesive strip (i.e. Steristrip) until the physician/delegate can replace the suture(s). vi. Tunneled catheters are sutured at the time of insertion (at the wings and just below the clavicle). Sutures are removed on day 14 by the hemodialysis nurse only. 6. The insertion site is assessed every shift, both visually and by palpation through the intact dressing. Obtain a swab for culture and sensitivity if infection is suspected and drainage is present, notify physician and obtain an order prior to sending swab. 7. Cleansing solution: use chlorhexidine gluconate (CHG) 2% in 4% alcohol antiseptic solution or CHG 2% swabsticks, alcohol free. Page 3 of 10
i. Contact time is 2 minutes. ii. Allow skin to fully air dry prior to applying the dressing. If the skin is covered while still moist, a reaction between the cleansing solution and the dressing adhesive can occur and may result in cutaneous reaction. iii. If the patient is allergic to CHG, 10% providone iodine (PI) solution may be substituted. iv. Do not use acetone or any solvent on the hemodialysis catheters. EQUIPMENT: Quantity Product Order # 1 Non-sterile gloves 1 Sterile gloves 2 Masks for nurse & patient 1 Minor dressing tray 213000 2-3 1 1 CHG 2%, alcohol free swabstick OR CHG 2% aqueous solution in 4% alcohol OR Povidone Iodine solution 10% (if allergic to CHG) 230865 230265 230380 1 Sterile adhesive strips (i.e. steristrip) if required 211045 1 1 tape (plastic or paper) 1 Transparent dressing ported 9cm x 12cm (IV 3000) OR Transparent IV advanced securement dressing 8.5cm x11.5 (i.e. 3M TM Tegaderm TM IV advanced securement dressing) if IV 3000 not available OR Gauze dressing 9cmx15cm(i.e. Mepore ) if drainage 210335 230125 210961 1 Swab for culture if required 009410 PROCEDURE: 1. Don mask and mask patient. 2. Open dressing tray and aseptically add equipment. 3. Don non-sterile gloves and remove the dressing from the bottom-up by lifting each side and then stretching it in opposite directions to lift the dressing off, taking care not to dislodge the catheter. 4. Observe alignment of the catheter, condition of the insertion site, the surrounding skin and sutures (if applicable). Obtain swab for culture and sensitivity if there are signs of infection and drainage present. Contact physician for order. 5. Don sterile gloves. SECTION A: DRESSING CHANGE 6. Position first sterile drape approximately 10 cm below the insertion site, overtop of the lumens. Position the second sterile drape along the lateral side of the catheter overlapping the first drape at the bottom. Page 4 of 10
7. Starting at the insertion site, scrub the skin with the swabstick. Use a circular scrubbing motion and move from the insertion site, outwards. Repeat as required, using a new swabstick each time. Ensure that the entire area under the dressing is cleansed. Allow the skin to fully air dry. 8. Using a fresh swabstick, clean the catheter including the white hub. Allow the catheter to fully air dry. 9. Ensure the catheter is lying in its natural position to avoid kinks and stress at the exit site. For jugular and subclavian sites, turn the patient s head away from the CVAD to extend the neck. 10. Apply the transparent (or gauze) dressing. The dressing must cover at least 2.5 cm (1 inch) around the insertion site: i. Place the transparent dressing so that the base of the ported dressing covers the white portion of the catheter where the 2 lumens join (see figure 1 for IV 3000 dressing and figure 2 for 3M TM Tegaderm TM IV advanced securement dressing). Ensure the tails of the dressing touch behind the lumens. Place the dated adhesive date strip (provided with dressing) over the keyhole where lumens exit. Figure 1: IV 3000 Transparent Dressing Figure 2: 3M TM Tegaderm TM IV advanced securement dressing Ensure base of ported dressing covers the white portion of the catheter where the lumens join 11. Lumen(s) securement: i. Capped lumens: Wrap 10 cm x 10 cm gauze around the lumens of the catheter and secure it with tape. If needed, tape the wrapped lumens to the skin, ensuring the catheter lies in a natural position, with no kinks. ii. Lumen attached to a continuous infusion: loop the catheter and attached IV tubing lying below the dressing and secure them to the skin with a piece of tape. Page 5 of 10
SECTION B: CHANGING/ADDING THE ONE-LINK CONNECTOR (CRITICAL CARE AREAS AND 7NW ONLY) EQUIPMENT: Quantity Product Order # 2 Masks for patient and nurse 1 Sterile gloves 1 One-Link Connector 120617 1 Pre-filled 0.9% sodium chloride syringe (for priming) 1 Minor dressing tray 213000 1-2 CHG 2% alcohol free swabstick 230865 PROCEDURE: 1. Ensure the catheter lumens are clamped. 2. Don mask and mask patient. 3. Open dressing tray and aseptically add equipment. 4. Prime the One-Link Connector within its package, maintaining sterility, with pre-filled 0.9% Sodium Chloride syringe. Disconnect syringe and aseptically add One-Link connector to sterile tray. 5. Don sterile gloves. 6. Position a sterile drape distal to the catheter lumens. 7. Select the lumen to be used for IV access or blood procurement. Select the distal lumen (blue) first. Lift the hemodialysis catheter lumen using sterile 10cm x 10cm gauze. 8. Using a CHG swabstick, scrub the connection for 30 seconds 9. Allow to air dry. 10. Remove the cap with sterile 10cm x 10cm gauze and discard. Cleanse the lumen threads with a new CHG swabstick and allow to air dry. Avoid dripping solution into the lumen. 11. Attach the primed One-Link Connector. Follow Section C for initiating an IV infusion OR Policy No. 00054 CVAD: Blood Procurement as required. SECTION C: INITIATING AN IV INFUSION EQUIPMENT: Quantity Product Order # 1 BD 10mL Syringe; Luer-Lok identified for discard 140515 2 Non-sterile 10mL pre-filled 0.9% sodium chloride syringe 140530 3 Alcohol swabs 1 Sterile 10cm x 10cm gauze 210565 Page 6 of 10
PROCEDURE: 1. Prepare IV infusion 2. Pick up the catheter end and scrub the One-Link Connector with an alcohol swab for 15-30 seconds. Allow to air dry. 3. Place cleansed One-Link Connector on a sterile 10cm x 10cm gauze. 4. Attach an empty 10mL Luer-Lok syringe to the One-Link Connector. 5. To remove the anticoagulant, unclamp the catheter lumen and pull back to the 1mL mark and stop while maintaining suction. 6. When blood return is visible, continue to aspirate to 5-7mL. Discard syringe. 7. Scrub the One-Link Connector with an alcohol swab for 15-30 seconds. Allow to air dry. 8. Flush with two 10mL pre-filled 0.9% sodium chloride syringes using turbulent injection technique. Ensure no blood is visible in the connector prior to connecting the IV. 9. Connect IV infusion tubing directly to the One-Link Connector. \ SECTION D: DISCONTINUING AN IV INFUSION EQUIPMENT: Quantity Product Order # 2 Non-sterile 10mL pre-filled 0.9% sodium chloride syringes 140530 3 Alcohol swabs 1 Sterile 10cm x 10cm gauze 210565 1 Anticoagulant label 730206 1 Anticoagulant:4% Sodium Citrate pre-loaded syringe 140550 OR Syringe of alternate anticoagulant as ordered Tape If heparin is ordered as an anticoagulant instillation 1 3 ml syringe 1 Blunt fill needle (18 gauge, 1 ½ inches) 155645 1 0.9% Sodium Chloride 10 ml Vial 1 Heparin 10,000 units/ml concentration 1 Alcohol swab PROCEDURE: 1. Verify physician order/medication administration record (MAR) for anticoagulant instillation order. 2. Prepare anticoagulant as per physician order: i. 4% Sodium Citrate: amount equals the volume of catheter lumen + 0.1 ml (volume of One-Link connector). ii. Instillation of heparin lock (rare: must be specifically ordered by the physician) Page 7 of 10
Heparin instillation: 5,000 units of heparin (10,000 units per ml concentration). Dilute the 5,000 units of Heparin with a vial of 0.9% NaCl, to equal the volume of the catheter lumen plus an additional 0.1 ml of NaCl for the One-Link connector volume. Example: Heparin 5, 000 units (0.5 ml) + ml 0.9 % Sodium Chloride for remaining volume of catheter + 0.1 ml of 0.9% Sodium Chloride (One-Link connector volume) = total instillation volume 3. Stop the IV infusion and disconnect IV tubing from One-Link connector. 4. Scrub the One-Link Connector with an alcohol swab for 15-30 seconds. Allow to air dry. 5. Place cleansed One-Link Connector on a sterile 10cm x 10cm gauze. 6. Using turbulent injection technique flush with two 10mL 0.9% Sodium Chloride prefilled syringes. Scrub the One-Link Connector with an alcohol swab for 15-30 seconds. 7. Instill prepared anticoagulant, then clamp the catheter. 8. Apply anticoagulant label. 9. Wrap 10cm x 10cm gauze around the lumens of the catheter and secure it with tape. If needed, tape the wrapped lumens to the skin, ensuring the catheter lies in a natural position, with no kinks. DOCUMENTATION: 1. Medication Administration Record (MAR): i. Anticoagulant, amount, time due 2. 24 hour flowsheet i. Dressing care 3. Integrated Progress Notes i. Patient tolerance, any complications or unexpected events, and education provided. 4. Interprofessional Kardex i. Date of insertion, type ii. Care and management schedule 5. Outpatient clinical documentation record. PATIENT TEACHING: 1. Teach the patient to avoid infection: i. Keep catheter dressing clean and dry, do not shower. ii. The mask requirement during dressing change respects both the immunosuppression and the Staphylococcus Aureus nasal carrier susceptibility of the hemodialysis population. iii. Do not take caps off catheter. iv. Inform nurse of the following symptoms: Chills Page 8 of 10
Bleeding, swelling or tenderness in access area 2. Teach patient to avoid injury: i. Do not pull on catheter 3. If catheter comes out, patient should: i. Lie down. ii. Apply pressure directly over the exit site. iii. Call for help. RELATED POLICIES/LEGISLATION: Nursing Policy #00054 Central Venous Access Device (CVAD) - Blood Procurement Nursing Policy #00051 Central Venous Access device (CVAD)- Removal of Nephrology Policies and Procedures Hemodialysis Catheter # No.:00750 Section 06- Neph 6-03-Management of the Hemodialysis REFERENCES: Centre for Disease Control and Prevention. Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients. MMWR 2001 /50(RR05); 1-43. Counts, C.S. (2008). Core Curriculum for Nephrology Nursing (5 th Ed.). American Nephrology Nurses Association; 748-751. NKF-DOQI Clinical practice guidelines for vascular access. (2006). American Journal of Kidney Disease; 48(1); Suppl 1. Young, E. (2005) Incidence and Influencing Factors Associated with Exit Site Infections in Temporary Catheters for Hemodialysis and Apheresis. Nephrology Nursing Journal, 32(1), 41-49. Page 9 of 10
APPENDIX A PHYSICIAN S ORDERS SPO 147 Page 10 of 10