Nottingham Renal and Transplant Unit

Nottingham Renal and Transplant Unit GUIDELINES FOR THE COMMENCEMENT AND TERMINATION OF EXTRA CORPOREAL THERAPIES VIA A CENTRAL VENOUS CATHETER (TUNNELLED AND NON TUNNELLED) USING CITRATE 46.7% LOCKING SOLUTION Author: Contact Name and Job Title Directorate & Speciality Initial version by Dr Z. Pitman (SpR). Current version revised by Tina Bennison, Haemodialysis Nurse Specialist. Cancer and Associated Specialities (Renal/Transplant) Date of submission July 2014 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Applies to: All patients under the care of the Nottingham Renal and Transplant Unit (including patients dialysing at Kings Mill Hospital, Ilkeston Community Hospital and South Nottingham Lings Bar Haemodialysis Units) who are receiving extra-corporeal therapy via a central venous catheter. Version 3 Excludes: Patients who do not have a central venous catheter in situ. If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Replaces previous version 2012 Evidence level 2a (for use of citrate solution) and 5 (procedural guidance) Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta-analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case locking solution). Produced February 2008. Updated September 2011 and July 2014. 1

studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) These guidelines were developed in conjunction with medical and nursing staff within the renal unit. Renal Unit Senior Staff Meeting July 2014 Renal unit medical and nursing staff 2019 A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Evidence base of policy These guidelines have been derived using the following evidence base: 1. National Kidney Foundation Dialysis Outcomes Quality Initiative Update 2000 (NFK-DOQI) guidelines: Vascular access: 3, 5, 6, 15, 30 2. North Bristol NHS Trust Guidelines for the use of Citra Lock 2006 3. Citra-Lock catheter lock solution. Nursing notes and FAQ s. Medical Access Ltd 4. Randomised, Clinical Trial Comparison of Trisodium Citrate 30% and Heparin as Catheter-Locking Solution in Haemodialysis Patients. Journal of American Society of Nephrology (2005) Vol 16, 2769 2777 5. Saving lives High impact intervention No 3, Renal dialysis catheter care bundle. 6. University Hospital Birmingham NHS Trust Renal & Urology Group: Percutaneous Access For Haemodialysis: Procedure For Change Of Dressing and Line Connection 21/11/2001 7. Medcomp Duralock-C TM FAQ s www.duralock.com/faq.html Audit Plans The following are the subject of prospective audit: 1. Prevalence of Line Use 2. Central Venous Catheter (CVC) Infection Rates 3. Adherence to procedure by staff commencing and terminating dialysis 4. Multi Racial Visual Inspection Catheter Tool Observation Record score entries on the electronic patient records locking solution). Produced February 2008. Updated September 2011 and July 2014. 2

Training and implementation Handling and management of lines is taught in the clinical areas by the Haemodialysis Nurse Specialist, clinical educator and registered nurses experienced and competent in haemodialysis. Management of Dialysis lines is discussed in the junior doctor s induction programme. Changes from previous guidelines Introduction of annual competency assessment for accessing central venous catheters (nursing, assistant practitioners and medical staff) Monitoring This guideline will be rolled out fully across the renal areas. All staff (100%) will; Receive annual competency assessment for accessing a central venous catheter (tunnelled and non tunnelled). Be compliant in the ongoing care of renal dialysis catheters. This will be monitored using the High Impact intervention No.3 renal dialysis catheter care bundle review tool and reported monthly. Additional Relevant Guidelines 1. Care bundle for the insertion and maintenance of central venous catheters within the Renal and Transplant Unit. 2. Guidelines for the diagnosis and treatment of central venous catheter related infections in haemodialysis patients. 3. Guideline for the Management of Tunnelled Cuffed Central Venous Catheters Dysfunction in Haemodialysis Patients 4. Guidelines for performing Haemodialysis in Established Renal Failure. 5. Any other guideline for extra corporeal therapy using a central venous catheter. Introduction Central venous catheters are an acceptable form of vascular access in patients with limited access options. Non cuffed non-tunnelled double lumen percutaneously inserted catheters are used when haemodialysis access of less than 3 weeks duration is anticipated. Tunnelled cuffed catheters are widely used, often while waiting for permanent vascular access to be created or mature, or when permanent vascular access fails. Some patients may have no further options for other vascular access and in these cases tunnelled catheters may be used as a permanent form of access. Catheter dressing changes and manipulation place the patient at risk of infection. Catheter infection can occur following transmission of hand or aerosolised bacterial contaminants. For this reason it is important that all interventions with CVCs are as clean as possible. There is evidence from clinical trials that citrate based line locks reduce the rate of catheter related infections when compared to heparin based solutions. Renal Support Workers Only registered nurses, assistant practitioners and medical staff can access haemodialysis catheters using this Guideline after receiving training and attaining competence. Renal Support Workers can act as the assistant for the procedure. locking solution). Produced February 2008. Updated September 2011 and July 2014. 3

Guidance notes 1. All items should be disposed of immediately after use into the sharps bin or waste bag as appropriate and in line with trust policy for clinical waste disposal. 2. The extensions of the catheter may change colour when using citrate-locking solution, particularly if the solution is left in place for longer periods of time. This is not clinically significant. 3. Routine dressing change is weekly or sooner if dressing is no longer intact or moisture collects under the dressing. Epic3 guideline- general principle for invasive catheter care. 4. Wash and dry hands please refer to the 6 Steps for Effective Hand Washing and NUH Trust policy. locking solution). Produced February 2008. Updated September 2011 and July 2014. 4

Procedure for Line Connection and Change of Dressing Equipment List Clean dressing trolley Alcohol gel One pair non sterile gloves, aprons and visor apron Four 10ml syringes Clinell wipes green general purpose One renal pack containing 2x 50cmx50cm tissue backed sterile field and yellow waste bag. Two pairs sterile gloves 10ml 0.9% sodium chloride Sharps bin 3 x Sani-Cloth CHG (70% alcohol and 2% Chlorhexidine) 4x Sani-Cloth CHG when attaching patients to the Fresenius 5008 machine or 5008S. One 21g needle (blunt) Additional Equipment for Dressing Change 3M Tegaderm 1635 I.V. dressing 8.5x10.5cm ChloraPrep SEPP 0.67ml applicator 10ml 0.9% sodium chloride Sterile gloves Registered Nurse /Assistant locking solution). Produced February 2008. Updated September 2011 and July 2014. 5

Registered Nurse /Assistant 1 Ensure that you obtain patient positive identification. Confirm that the dialysis prescription is correct for the patient. Ensure the correct parameters have been entered and second checked by two nurses. Check whether any blood tests are required and collect the correct blood bottles, bags and patient identification labels needed. DO NOT ATTACH THE BLOOD LABEL ONTO THE BLOOD BOTTLE UNTIL BLOOD OBTAINED AND PATIENT POSITIVE IDENTIFICATION GAINED by two nurses or by asking the patient to check the identification details on the labels prior to them being attached to the blood samples. Ensure patient is comfortable in a suitable reclining chair or bed in a semi recumbent position. Take and record the patient's temperature, pulse and blood pressure. Assess any developing vascular access, if applicable, and document findings on renal IT system. Put on apron and visor. 2 Wash & dry hands apply alcohol gel and allow to dry. 3 Open the renal pack carefully using the corners only. Gather the equipment as above and take to the patient. Clean the trolley using Clinell wipes. Put on apron. Ensure sharps bin is in close proximity to the dressing trolley Wash and dry hands apply alcohol gel, allow to dry. Put on non-sterile gloves. Tip the renal pack onto the trolley, ensuring that the open ends of the pack are uppermost. Ensures that the patient receives the correct treatment for their condition. To ensure patient positive identification is maintained. To assess for possible infection. To ensure timely use of developing access. The apron protects against the risk of transfer of pathogenic microorganisms. The visor provides protection against blood borne infection To minimise the risk of infection by removing pathogens from the hands. To minimise contamination. Maintains the sterile field on the dressing trolley locking solution). Produced February 2008. Updated September 2011 and July 2014. 6

Registered Nurse /Assistant 4 Pass the waste bag to the assistant. 5 Touching the corners only, position the waterproof backed sterile towels (x2) under the catheter at the same time and ensure that it is secure. 6 Apply alcohol gel to hands and allow to dry. Put on sterile gloves. 7 Using the green needle and 10 ml sterile syringe draw up 5ml of 0.9% sodium chloride into each 10ml syringe. Discard the needle into the sharps bin. 8 Prior to commencement visually inspect the lumens of the line checking for any signs of damage or punctures on the line. Using a non-touch technique, use one Sani-Cloth CHG to tightly wrap the arterial limb of the catheter including the clamp and rub vigorously for 30 seconds. Leave Sani-Cloth CHG in place. Repeat for the venous limb. Leave Sani-cloth CHG in place. Use the third Sani-Cloth CHG to wrap the saline/circuit connection and again rub vigorously for 30 seconds. If connecting a patient to a Fresenius 5008 OR 5008S put the bloodlines into recirculation prior to cleaning the recirculation connector with the Sani-Cloth CHG. Attach the waste bag to the dressing trolley with the adhesive strip on the bag. Open the remaining equipment onto the sterile field - except Sani-Cloth CHG Lift the catheter in order that the towels can be placed underneath Open the saline and hold the vial upside down to enable Registered Nurse to draw up the 0.9% sodium chloride. Open Sani-Cloth CHG by tearing the packet in half. Pass to the aseptic nurse one at a time. Assistant to hold circuit lines. To avoid Sani-Cloth CHG drying out The waterproof towels provide a sterile field around the catheter limbs and below the exit site. To reduce the risk of introducing infection. To minimise the risk of sharps injury ensure vial is held at the end keeping fingers well clear of the needle. Evidence suggests that catheter hub contamination is an important contributor to catheter related sepsis. Using a non-touch technique helps to prevent any contamination. Studies have shown that Chlorhexidine is the most effective disinfectant in the prevention of catheter related infections. locking solution). Produced February 2008. Updated September 2011 and July 2014. 7

Registered Nurse /Assistant 9 Ask patient to turn their head away from line. To avoid patient breathing on exposed line. Remove the Sani-Cloth CHG from the central venous catheter limbs and remove the first towel. Let the catheter limbs fall onto the sterile towel below. Remove sterile gloves. 10 Apply alcohol gel to hands and allow to dry. Put on fresh sterile gloves 11 Ensure both line clamps are closed. Hold the arterial limb of the catheter and remove the cap. Immediately attach an empty 10ml syringe, unclamp and withdraw 3-4ml blood, re clamp. If unable to aspirate the line lock, and after trying to release the line lock by moving the patients position and asking them to cough inject the line lock as described below: Patients should be informed of possible side effects, including a metallic taste in the mouth and tingling in the fingers. These side effects disappear within 1 minute. Attempt to inject the citrate locking solution into the patient SLOWLY (over 30 seconds) using 10ml of 0.9% sodium chloride. If neither lumen can be aspirated, then flush each lumen separately as above but ENSURE AT LEAST 5 MINUTES GAP between the first and second injection. This provides a sterile field for the decontaminated catheter. The gloves will have become contaminated during this part of the procedure. To re-establish a sterile environment with which to handle the lines A clamped line will not bleed back when the cap is removed. Minimises the time that the open end of the catheter is exposed for. Withdrawing blood removes the previous Lock solution and provides an opportunity to check that the line is patent and the flow from each lumen. Patients need to be aware that they may experience side effects. Injection of citrate leads to a transient hypocalcaemia. Side effects are minimised by slow injection Citrate is metabolised to inactive compounds within 5 10 minutes of injection. Leaving a gap between injections allows for metabolism. locking solution). Produced February 2008. Updated September 2011 and July 2014. 8

Registered Nurse /Assistant If blood samples are required: Use a clean 10ml syringe to aspirate and return blood from the catheter ten times. Remove the syringe. Hold line so vacutainer can be attached by assistant. Ensure patient positive identification 12 Clamp line. If no bloods were required, remove the 10 ml syringe and attach the 10ml syringe containing 5ml 0.9% sodium chloride immediately. Unclamp and flush the line. Check blood flows by withdrawing 10mls blood from the line and returning whilst assessing for any resistance. Reclamp the line. 13 Repeat steps 11 and 12 for the venous limb. 14 Disconnect arterial line from the recirculator and attach to the arterial limb of the catheter (unless there is poor flow in which case lines should be reversed). Detach venous line and attach to other limb of catheter. 15 Refer to the relevant Guideline for performing Renal Extra Corporeal Therapies If the lines are reversed regularly: Refer to guidelines for dysfunctional central venous catheters. Immediately take the samples with the vacutainer and connector making sure not to touch the sterile end of vacutainer or line Attach the identification labels to the blood bottles after ensuring positive patient identification Remove the Sani-Cloth CHG from the saline circuit using the corner Stop the dialysis pump; clamp both arterial line and venous line on the machine. Clamp saline. Pass the lines to registered nurse without contaminating the connection. Continue to hold the arterial and venous lines until connected. Refer to the relevant Guideline for performing Renal Extra Corporeal Therapies This ensures that there is no line lock left in the line. Avoids contamination of the catheter line To ensure identification of the correct patient Flushing with saline maintains patency and reduces the risk of air embolism. Ensures that flow, whilst dialysing can be maintained using minimal pressure This allows Chlorhexidine to dry ensuring appropriate level of decontamination Ensures that lines are connected to the patient whilst maintaining sterile connections. locking solution). Produced February 2008. Updated September 2011 and July 2014. 9

Registered Nurse /Assistant 16 Assess the patient's exit site through the transparent dressing. Score using the MRVICTOR (Multi Racial Visual Inspection Catheter Tool Observation Record) score table. Inform Medical staff if exit site infection suspected and follow guidelines for the treatment of catheter related infections. Ensure that the MRVICTOR score is entered onto the electronic system when inputting the patient s data. If dressing change required: IV Tegaderm 1635 dressing /Opsite IV 3000; Change weekly unless there is a suspected infection, dressing no longer intact or moisture collects under the dressing For non-transparent dressing Change every dialysis session prior to the commencement of dialysis If exit site is bloodstained or has a visible discharge: Inform Nurse in charge and Doctor covering the dialysis unit. Swab the nose and exit site for culture, sensitivity and send for microscopy If dressing change required: Remove gloves, gel hands and replace with fresh non sterile gloves. Remove old dressing and then dispose of both gloves and dressing. Apply alcohol gel to hands and allows to dry. Provide swab for registered nurse to use. To assess for exit site infection. If infection is suspected please refer to Guidelines for the Diagnosis and Treatment of Central Venous Catheter Related Infections in Haemodialysis Patients locking solution). Produced February 2008. Updated September 2011 and July 2014. 10

Registered Nurse /Assistant Clean the exit site of visible contamination using 0.9% sodium chloride on gauze. Ensure that the patient is not allergic to Chlorhexidine. To clean and decontaminate the exit site: Hold SEPP applicator with sponge tip facing downward snap vial and gently squeeze. Press tip against skin and apply solution in a concentric circular motion for 30 seconds. Allow to dry for 30 seconds minute (Do not blow or blot to hasten drying). If the patient is allergic to Chlorhexidine then betadine antiseptic solution should be used. The drying time for Betadine antiseptic solution is 2 minutes. Apply the new dressing as per instructions ensuring the exit site is well covered by the transparent part of the dressing. If alternative dressing used document this on patient s prescription in regular treatments. In addition to the above, if there is evidence of exit site or tunnel infections: Refer to Guidelines for the Diagnosis and Treatment of Central Venous Catheter - Related Infections in Haemodialysis Patients Remember to document the MR VICTOR score on the renal electronic system. Empty 10ml 0.9% sodium chloride on to the remaining pieces of sterile gauze to dampen Open Chloraprep SEPP 0.67ml applicator and tip onto sterile field. Open Tegaderm IV dressing or similar if patient allergic to Tegaderm IV onto sterile field Releasing Chlorhexidine solution for a controlled flow. To maximize effect of decontamination. To ensure decontamination is complete prior to applying a clear dressing To ensure that the exit site is fully protected. locking solution). Produced February 2008. Updated September 2011 and July 2014. 11

Procedure for Line Disconnection Equipment List Clean dressing trolley Clinell wipes Sharps bin Visor Two plastic aprons Alcohol gel Recirculation connector One CVC pack Two 10ml 0.9% sodium chloride Citrate locking solution (citrate 46.7%) Three Sani-Cloth CHG (70% alcohol 2% Chlorhexidine) Two pairs sterile gloves Two 21g needles (blunt) Two 10ml syringes Two 2.5ml syringes Two sterile bungs Non sterile gloves and apron Registered Nurse /Assistant Ensure that you obtain patient positive identification. Ensure that the patient details on the dialysis prescription are correct. Ensure patient is comfortable in a suitable reclining chair or bed in a semi recumbent position. Take and record patient s temperature. Put on the apron and visor. 2 Wash, dry hands, apply alcohol gel and allow to dry. 3 Open the pack carefully using the corners only. Pass the waste bag to the assistant. Gather the equipment as above and take to the patient. Clean the trolley using a Clinell wipe. Put on apron. Wash and dry hands, apply alcohol gel and allow to dry. Put on non-sterile gloves. Tip the renal pack onto the trolley, ensuring that the open ends of the pack are uppermost. Attach the waste bag to the side of the trolley and place the sharps bin within easy reach. Open the remaining equipment onto the sterile field - except Sani-cloth CHG. To reduce the risk of the patient receiving the wrong treatment plan To reduce the risk of air embolism and to allow easy access to the line. The apron protects against the risk of transfer of pathogenic microorganisms. The visor provides protection against blood borne infection. To minimise the risk of infection by removing pathogens from the hands. To minimise contamination. locking solution). Produced February 2008. Updated September 2011 and July 2014. 12

Registered Nurse /Assistant 4 Touching the corners only, position the waterproof backed sterile towels(x2) under the catheter and ensure that they are secure. 5 Apply alcohol gel to hands and allow to dry. Put on sterile gloves. 6 Using the green needle draw up 10ml of 0.9% sodium chloride into each 10ml syringe. Discard the needle into the sharps bin. 7 Using a non-touch technique, use one Sani-Cloth CHG to tightly wrap the arterial limb of the catheter including the clamp and rub vigorously for 30 seconds. Leave in place Repeat for the venous limb. Leave in place. Use the third Sani-Cloth CHG to wrap the 0.9% saline infusion line and arterial bloodline infusion port and again rub vigorously for 30 seconds. If disconnecting patient from a 5008/5008S Fresenius machine ask assistant to open right hand door and place third Sani-Cloth around substitution port and bloodline. Ask assistant to close door to ensure blood pump continues. 8 Ask patient to turn their head away from line. Remove the Sani-Cloth CHG from the central venous catheter limbs and remove the top waterproof sterile towel. Catheter limbs will be on the second towel. Remove gloves. 9 Apply alcohol gel to hands and allow to dry. Put on fresh sterile gloves Lift the catheter in order that the towels can be placed underneath Open saline and hold the vial upside down to enable Registered Nurse to draw up 0.9% sodium chloride. Open the Sani-Cloth CHG by tearing the packet in half. Pass to the nurse. Open each Sani-Cloth as required. Hold the arterial bloodline close to the arterial infusion port on the 5008/5008S machine. Help by lifting blood lines The towels provide a sterile field around the catheter limbs and below the exit site. To reduce the risk of introducing infection. To minimise the risk of sharps injury ensure vial is held at the end keeping fingers well clear of the needle To minimise the risk of sharps injury Evidence suggests that catheter hub contamination is an important contributor to catheter related sepsis. Using a non-touch technique helps to prevent any contamination. Studies have shown that chlorhexidine is the most effective disinfectant in the prevention of catheter related infections. To avoid contamination. This provides a sterile field for the decontaminated catheter. The gloves will have become contaminated during this part of the procedure. To re-establish a sterile field locking solution). Produced February 2008. Updated September 2011 and July 2014. 13

Registered Nurse /Assistant 10 Clamp the arterial limb of the catheter. Ensure the roller clamp on the 0.9% saline infusion set is closed. Stop the blood pump. Clamp the arterial blood line. Remove the Sani-Cloth CHG touching the edge only from the saline connector. Support the weight of the line. Ensures that the saline does not flow during connection to the arterial blood line To discontinue treatment. To prevent back flow of blood when the line is disconnected to attach the saline washback solution. To expose the required connector point. To prevent the line from falling away from the patient. 11 Disconnect the 0.9% infusion set and immediately, using a recirculation connector, connect to the arterial blood line, and pass to assistant. On a Fresenius 5008/5008s machine connect to the online fluid connection. 12 Unclamp catheter limb and slowly (over 8-10 seconds) flush the arterial limb of the catheter with 10ml of 0.9% saline, reclamp. 13 Leave the syringe in situ. Repeat steps 11 and 12 for the venous limb. Commence and complete wash back at a pump speed of 200ml/min. At the end of wash back switch off the blood pump and clamp the venous bloodline. Minimises the length of time that the open ends of the lines are exposed. Minimises the length of time that the circuit is in standby mode prior to wash back being completed. To clear the arterial limb of blood. Injecting slowly reduces the risk of blood refluxing back into the catheter. To prevent introduction of infection and air embolism by keeping the end of the catheter limb covered. To avoid leakage of fluid from the circuit when the lines are removed from the machine. locking solution). Produced February 2008. Updated September 2011 and July 2014. 14

Registered Nurse /Assistant If blood samples are required: Remove the syringe. Hold line so vacutainer can be attached by assistant. Refer to Guidelines for performing Haemodialysis in Established Renal Failure (Appendix 2) for procedure for obtaining URR samples. Ensure patient positive identification is carried out. When taking blood if possible ask the patient to confirm that the identification label to be used on the blood bottle are their correct identification details. If there has been a need to recirculate during therapy: Use additional Sani-Cloth's to clean the arterial and venous limb threads. If there have been problems with poor flow: The lock volume should be reviewed and, if previously decreased, reset to the line volume stated on the catheter hubs. For lines previously locked with heparin: If the lock volume is less than the volume stated on the hub then this needs to be reassessed on a fortnightly basis for the first three months. To do this give the original stated lock volume and then adjust as below. Immediately take the samples with the vacutainer and connector making sure not to touch the sterile end of vacutainer or line Open the Sani-Cloth to clean the arterial and venous limb threads. Reduces the risk of contamination and minimises the length of time that the line is exposed. To ensure that the correct patient details are recorded on the blood specimens. To protect against contamination. New lines that have not been locked with heparin will not have a bio film. The citrate will dissolve the bio film in the line and therefore increase the lock volume required. locking solution). Produced February 2008. Updated September 2011 and July 2014. 15

14 Registered Nurse /Assistant CITRATE 46.7%LOCK SOLUTION AND LOCK VOLUME MUST BE CHECKED BY 2 REGISTERED NURSES Using the second green needle draw up the EXACT VOLUME OF CITRATE LOCKING SOLUTION (as stated on the administration record) required for the ARTERIAL lumen into a 2.5ml syringe. Open second green needle. Open vial of citrate 46.7% locking solution. It is important that the EXACT VOLUME for each lumen is drawn up and given to ensure adequate fill volume and to avoid unnecessary side effects. 15 When pre filled Citrate 46.7% lock solution syringes are used ensure the correct volume for the individual patient s lumen s is checked by two registered nurses. Hold the arterial limb. Remove the 10 ml syringe attach the syringe containing the correct volume of citrate locking solution to the ARTERIAL limb. If prefilled syringes containing Citrate 46.7% locking solution are used ensure that the solution is checked by two registered nurses before opening the packet onto the sterile field. This prevents the risk of confusing the arterial and venous lock syringes if both are drawn up together. DO NOT unclamp line yet. Dispose of the 10ml saline syringe into the waste bag. 16 Draw up the EXACT VOLUME OF CITRATE LOCKING SOLUTION (as stated on the administration record) required for the VENOUS lumen into a 2.5ml syringe. It is important that the EXACT VOLUME for each lumen is drawn up and given to ensure adequate fill volume and to avoid unnecessary side effects. When pre filled Citrate 46.7% lock solution syringes are used ensure the correct volume for the individual patient s lumen s is checked by two registered nurses. Discard the needle into the sharps bin. If prefilled syringes containing Citrate 46.7% locking solution are used ensure that the solution is checked by two registered nurses before opening the packet onto the sterile field. To minimise the risk of sharps injury locking solution). Produced February 2008. Updated September 2011 and July 2014. 16

17 18 Registered Nurse /Assistant Inform the patient of possible side effects of citrate locking solution including; -a metallic taste in the mouth -tingling in the fingers. These side effects should disappear within 1 minute. SLOWLY INJECT THE ARTERIAL LIMB CITRATE LOCKING SOLUTION OVER 8 10 SECONDS. If the patient experiences side effects: The lock volume can be reduced by 0.1ml at the next dialysis session. However, there is a risk that a reduction in volume will increase the chances of clotting within the lumen. Patients need to be aware that they may experience side effects. If these are experienced by the patient, the volume of citrate locking solution can be reduced next time. - See section 18 below Injecting slowly reduces the risk of blood refluxing back into the catheter. In general, patients should be asked to accept some minor short-lived side effects to ensure that sufficient volume of citrate locking solution is instilled into catheter lumen to prevent clotting clinical judgement is required when assessing risk of clotting and patients comfort. Wait until symptoms subside before injecting second lock. 19 20 Minimum lock volume is 0.2ml per lumen below the stated line volume on the catheter hubs. Remove the syringe and attach a sterile bung. Repeat the steps 18 19 for the venous limb. 21 Record the volume of Citrate 46.7% locking solution administered, and any dose adjustments for next dialysis, on the Citrate 46.7% locking solution administration card. 2 registered nurse signatures are required If recirculation is required during therapy. 1 Registered Nurse /Assistant Follow steps 1-10 of procedure for line disconnection Assistant Follow steps 1-10 of procedure for line Disconnection Rationale locking solution). Produced February 2008. Updated September 2011 and July 2014. 17

2 3 Repeat step 10 for the venous limb and hand circuit to assistant Unclamp and slowly (over 8-10 seconds) flush the arterial limb of the catheter with 10 ml of 0.9% saline, reclamp Recirculate at 200mls/min once recirculation circuit established. Dialysis and ultrafiltration should be suspended during recirculation. To avoid coagulation of the extracorporeal circuit. Leave the syringe in situ. 4 Repeat for the venous limb. Once ready to reconnect Follow steps 1-10 of Procedure for line connection. Follow steps 1-10 of Procedure for line connection. 5 (There is no need for step 7 drawing up saline ). Disconnect the arterial line from the connector and attach to the arterial limb of the catheter (unless there is poor flow in which case lines should be reversed). Detach venous line and attach to other limb of catheter. Stop the dialysis pump; clamp both arterial and venous blood lines. Remove the Sani-Cloth CHG from the saline circuit using the corner. Pass the sterilised connector to the registered nurse without contaminating the connection. Continue to hold the arterial and venous blood lines until connected. Recommence blood pump flow and therapy. locking solution). Produced February 2008. Updated September 2011 and July 2014. 18