Dialysis

Catheter Care Management in Haemodialysis

Regin Lagaac
Clinical Nurse Specialist in Vascular Access, Cambridge University Hospitals, NHS Foundation Trust

Abstract
There are three main types of dialysis access: arteriovenous fistula (AVF), arteriovenous (AV) graft and central venous catheters (CVC), both permanent and temporary. It is our interest to look up the catheter locking solutions and the nursing care management of CVC. Traditionally, heparin has been used to lock CVC to maintain patency. Since it is primarily an anticoagulant, heparin does not reduce or impede bacterial growth. In 2006, we replaced with trisodium citrate (TSC) 46.7 %. It acts as a local anticoagulant by binding ionic calcium, thereby limiting calcium-dependent interactions in the coagulation cascade. A retrospective study for haemodialysis (HD) patients receiving HD through CVC were identified using our electronic patient database from September 2006 to May 2011 have been identified. Between March 2007 to May 2011, there were no recorded cases of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in the HD unit. Changing catheter lock from heparin to TSC 46.7 % will not work alone to prevent and decrease the rate of catheter-related bacteraemia infection (CRBI). It is essential to uphold best clinical practices; the use of sterile procedure in inserting lines and adequate catheter care using a unit-based central venous access device (CVAD) care record.

Keywords
Haemodialysis, central venous catheter, catheter locking solutions, central venous catheter care record
Disclosure: The author has no conflicts of interest to declare. Received: 13 June 2011 Accepted: 28 July 2011 Citation: European Nephrology, 2011;5(2):13842 Correspondence: Regin Lagaac, Clinical Nurse Specialist in Vascular Access, Cambridge University Hospitals, NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK. E: regin.lagaac@addenbrookes.nhs.uk

The National Health Service (NHS) in the UK has given a priority for the prevention and control of healthcare associated infections (HCAI). Effective infection control practice is an essential aspect of protecting patients. Haemodialysis (HD) is a life-saving and life-sustaining treatment. Effective HD requires a reliable, long-term and safe vascular access. Native arteriovenous fistulae (AVFs) are the preferred vascular access in view of the low complication rates and longevity.14 It is our interest as a healthcare provider to prevent the incidence of catheter-related bacteraemia infection (CRBI) and to promote cost effectiveness by reducing healthcare cost. This effort is multidisciplinary, involving healthcare professionals who insert and remove the dialysis catheters, staff nurses in the dialysis unit and the managers that allocate resources and the patients who are capable of assisting in the care of their central venous catheter (CVC). Our goal is to prevent and eliminate CRBI from our HD patients who are dialysing through CVC. As a clinical nurse specialist in vascular access, it is my interest to share our practices to enhance nursing care of CVC care. This article will address the role of anticoagulant locking (ACL) solutions in the HD patient population and the nursing management of HD patient with CVC.

has reported a prevalent growth of HD patients from 19822008 (see Figure 1).5 In our facility, 73 % of our patients were managed with HD. Of these patients, approximately 18 % received dialysis via CVC and 82 % of patients were dialysed via AVF. Our strategy in reducing CVC rates is the establishment of our dedicated pre-dialysis clinic. The pre-dialysis nurse specialist has an essential role in co-ordinating pre-dialysis management of patients with chronic kidney disease (CKD). A joint vascular access with low clearance clinic at CUHNFT has been established to ensure an early referral to the vascular access nurse/surgeons, which increases our number of patients commencing dialysis with a permanent vascular access. According to vascular access guidelines published by the Renal Association Standard (RAS) and the National Kidney Foundation's Kidney Dialysis Outcomes Quality Initiative (NKF-KDOQI), AVF is the preferred method of vascular access for patients who require a chronic HD.6 CVCs are considered the third choice of vascular access, due to complications associated with their use (see Table 1). Despite an increasing number of HD patients with AVF, it is likely that nephrologists and nurses will continue to struggle with the medical management of CRBI, due to medical contraindications for AVF placement, ending up with CVC as an access for HD. Indications for CVC use are outlined in Table 2. Fistula failure due to poor surgical technique, secondary failure post-AVF creation, arteriopathy, late recognition of end-stage renal disease (ESRD), difficulty in access placement and late referrals to the

Background
The prevalence of end-stage renal disease (ESRD) continues to increase yearly at Cambridge University Hospitals NHS Foundation Trust (CUHNFT) and in the UK. There are different modalities available like peritoneal dialysis (PD), kidney transplantation and HD. The UK Renal Registry

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Number of patients

low clearance clinic ensure the continued use of CVC. CRBI constitutes a substantial component of hospital-acquired infections and hospital admissions for vascular access infection have doubled in the last decade.7 It will result in consumption of resources such as admission in the hospital, antibiotic therapy and replacement of an infected line. Above all, CRBI increases the medical cost. Nephrologists are aware of the prevalence and serious morbidity associated with CRBI in HD patients. There has been growing recognition in the past few years that a bacterial biofilm form rapidly in the lumens of most CRCs and this biofilm is the major source of CRBI. The treatment of CRBI with antibiotics alone (without catheter removal) is relatively ineffective in eradicating the source of infection.8 This problem is preventable through proper aseptic technique and antimicrobial catheter lock solutions to prevent CRB.9 Incidence figures for infections of a dialysis line are estimated nationally to be between 0.5 to 13 per 1,000 patient-days with HD catheters. In a multicentre prospective study involving 988 end-stage renal failure (ESRF) patients, it was estimated that the relative risk of infection was 7.64-fold higher in patients requiring catheters compared to those with a native AVF.10

Figure 1: Growth in Prevalent Patients by Treatment Modality at the End of Each Year
50,000 40,000 30,000 20,000 10,000 0

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HD = haemodialysis; PD = peritoneal dialysis.

Table 1: Complications Associated with Central Venous Catheters 2731

Infection Exit site Tunnel Bacteraemia Metastatic complications such as endocarditis, osteomyelitis and septic arthritis Thrombosis Central venous stenosis or occlusions Increased mortality risk Shorter access lifespan with premature removal of central venous catheters Inadequate dialysis due to lower blood flow rates Increased frequency of hospitalisation Discomfort and cosmetic disadvantage of an external appliance

Catheter Locking Solutions

Catheter locking solutions (CLSs) have been increasingly studied. CLSs are divided into antimicrobial antibiotic and antimicrobial lock solutions. CLSs used in clinical trials include gentamicin and heparin, taurolidine and citrate. Several meta-analyses have been performed in recent years, all of which confirm the benefit of antibiotic lock solutions, but do not give insights as to the optimal choice of catheter lock.11,12 The meta-analyses have suggested that antibiotic lock solutions are superior in terms of infection prevention, but there are concerns around microbial resistance developing. These concerns have not been confirmed in any publications to date. In contrast, solutions such as taurolidine or citrate have been effective, although possibly less so than antibiotic solutions. They also have a range of side effects and cost implications. Traditionally, in our unit, heparin has been used to lock CVC to maintain patency. Since it is primarily an anticoagulant, heparin does not reduce or impede bacterial growth. Heparin has actually been shown to increase Staphylococcus aureus biofilm. 13 There are literature published citing locking solutions that have both antimicrobial as well as anticoagulant effects as possible prevention solutions to reduce CRBI. Trisodium citrate (TSC) 46.7 % acts as a local anticoagulant by binding ionic calcium, thereby limiting calcium-dependent interactions in the coagulation cascade. The use of the TSC-locking solution (4 %) is associated with significantly lower rates of CVC failure and thrombolytic use compared to heparin (5,000 units per lumen) and is more cost-effective.14,15 The randomised clinical trial comparison of TSC 30 %, and heparin as a catheter locking solution in HD patients, demonstrated that using TSC 30 % rather than heparin to lock dialysis catheters leads to the reduction in CRBI.16 TSC 46.7 % solution is indicated for use as a catheter lock solution to prevent coagulation of the blood and infection in any type of intravenous catheter. TSC 46.7 % solution replaced heparin (one in 5,000) in maintaining patency of catheters in all patients who had HD via a catheter in September 2006. In 2006, the use of TSC 46.7 % was accepted by the CUHNFT Joint Drugs and Therapeutic Committee for addition to the Trust formulary.

Table 2: Indications for Central Venous Catheter use in Haemodialysis 32,33

Acute kidney failure HD for overdose or intoxication Patient presenting for HD with no permanent vascular access Patients who have lost effective use of their permanent vascular access and are awaiting the establishment of an alternative permanent access PD patients whose PD catheter has been removed due to peritonitis Patients post renal transplantation needing temporary HD Patients requiring plasmapheresis Patient with poor vasculature so permanent vascular access cannot be created Where all options of permanent access are exhausted
HD = haemodialysis; PD = peritoneal dialysis.

TSC 46.7 % solution replaced heparin (one in 5,000) in maintaining patency of catheters in all patients who had HD via a catheter. Our aim of replacing heparin with TSC 46.7 % was therefore, to reduce the incidence of CRBI and intend to reduce the number of hospital admissions, reduce the use of Urokinase to unblock a catheter and reduce catheter removal/replacement.

Effectiveness of Trisodium Citrate 46.7 %

TSC 46.7 % solution causes anticoagulation by chelation of ionised calcium on the extracorporeal circuit into a soluble complex. As calcium is an integral ion involved in the clotting cascade, local removal by

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Figure 2: Methicillin-resistant Staphylococcus aureus Bacteraemia Cases in the Haemodialysis Unit at Cambridge University Hospitals NHS Foundation Trust from 2005 to 2011
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Number of cases

3 2 1 0 2005 2006 2007 2008 Years MRSA bacteraemia 2009 2010 2011

Within the HD unit, there has been a very low incidence of adverse effects. Prior to TSC 46.7 % solution being introduced, all patients with catheters were written to by the clinical governance team to explain the changes in the solution, which would be used to lock their line and the adverse effects that may occur. Mild and transient tingling of the fingers has been reported, as has a metallic taste in the mouth, but no patient has found these effects to be problematic and none has discontinued use of TSC 46.7 % solution as a result.

Haemodialysis Patient Study

We conducted a retrospective study for HD patients receiving HD through tunnelled HD catheter. The patients were identified using our electronic patient database. The number of dialysis patients at CUHNFT gradually increased and so we expanded to haemo homecare in 2010, which incorporates home HD and PD. All patients at CUHNFT with methicillin-resistant S. aureus (MRSA) bacteraemia from September 2006 to May 2011 have been identified by the infection control team based on data obtained from the microbiology and transplant database, the electronic medical records and electronic discharge files. The HD patients microbiology result has been segregated and the incidences of MRSA bacteraemia of CVC in patients within the dialysis unit have been reviewed. All incidences of MRSA bacteraemia in all patients with permanent and temporary dialysis lines in situ were investigated and those where the line was the site or source of infection were further reviewed. Between January and June 2007 there were 12 recorded incidences of dialysis line infections in 11 patients undergoing HD via a line on the dialysis unit or renal ward at CUHNFT.

MRSA = Methicillin-resistant Staphylococcus aureus.

Table 3: Prevention of Catheter-related Infections

Guidelines 1 Recommendations We recommend that venous catheters should be employed as a method of last resort for long-term vascular access to reduce the overall risk of infectious complications in HD patients 2 3 4 We suggest that aseptic technique should be mandatory at every manipulation of central venous dialysis catheters We recommend that the catheter exit site should be cleaned with chlorhexidine 2 % We suggest that an antimicrobial or antibiotic lock solution be used to reduce catheter-related bacteraemia and other infections
HD = haemodialysis. Source: Renal Association Standard (RAS) Guidelines (2011).5

Result
With the introduction of TSC 46.7 % between September 2006 and February 2007, the incidence of dialysis line infections in patients undergoing HD via a line on the dialysis unit at CUHNFT had fallen to four recorded incidences in 2006 and one case in February 2007 (see Figure 2). Since March 2007 to May 2011, we have had no incidence of MRSA bacteraemia in the HD unit. This is an excellent innovation and contributes to the reduction of MRSA rates at CUHNFT, which placed the hospital as the best acute hospital in the UK in 2008 (Health Service [HS] Journal Award, 2008).

citrate prevents the activation of clotting co-factors, factor X and prothrombin and hence, the ultimate formation of fibrin. Systemic anticoagulation does not occur.17 The antimicrobial effect of TSC 46.7 % occurs through the binding and removal of calcium, which may inhibit the growth and survival of microbes. Through a variety of actions, concentrated citrate is bactericidal and sporicidal when tested in vitro. 18 Therefore, it is expected that it would diminish the bacterial content of catheters after chance contamination of the catheter hub. On the other hand, a similar antibacterial effect could be obtained through the effect of citrate on biofilm: if the mild corrosive action of citrate helps to eliminate the biofilm, it would also eliminate bacteria trapped within the biofilm. The effect of citrate on bacterial contamination of catheters may decrease the risk of symptomatic bacteraemia in patients with catheters, without the risk of developing resistant strains of the bacteria (as will occur with antibiotic lock solutions).18

Cost and Usage Since the Introduction of Trisodium Citrate 46.7 %

Since the introduction of TSC 46.7 % solution in September 2006, the spending on urokinase by the dialysis unit has fallen and is now at less than 60 % of that prior to the introduction of TSC 46.7 % solution. Since September 2006, the number of urokinase (10,000 international units [IU]) vials used by the dialysis unit has fallen by approximately two-thirds over the six-month period. Locking the CVC with TSC 46.7 % is not the only factor that reflects the reduction rate of MRSA bacteraemia. The competency of our HD nursing staff when taking care of the dialysis line is also a major contributing factor.

Safety and Adverse Effects

The adverse effects commonly reported with TSC 46.7 % solutions are dysgeusia and paraesthesia. These adverse effects usually disappear within one minute but are a sign that the catheter lock volume is too great, leading it to pass out of TSC 46.7 % solution from the distal tip into the bloodstream. The recommendation from the manufacturers is that should this occur, the volume used at the next instillation should be reduced by 0.1 ml. The catheter, however, should be completely filled and have no air space left, in case a clot should develop.

Nursing Care Plan and Catheter Care Record

Patients on dialysis have an increased risk of infection with 25 % of mortalities related to infection.7 This increased risk relates to underlying uraemia, increased exposure to the hospital environment and to the method of renal replacement therapy, in particular the type of vascular access utilised. The use of CVC is the most common factor contributing to bacteraemia in dialysis patients.7 HD catheter is

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extremely important because it is the only vascular access that can be used for life-saving HD when there is no other appropriate access option available. In our facility, the renal doctor usually places the HD catheter in a vascular access unit. The dialysis nurses are responsible for the management of the dialysis catheter using evidence-based practices like putting a biopatch to CVC exit site within 21 days post-line insertions. We must keep in mind that we can never truly sterilise the skin, but must decrease the resident skin microflora load. A biopatch at the exit site will provide continuous release of chlorhexidine at the exit site, dramatically decreasing the regeneration of resident skin microflora at the exit site. It is very difficult to completely eliminate all risks associated with CRBI, but these strategies have been demonstrated in our unit to significantly decrease CRBI rates. It is very important to understand the pathogenesis of CRBI. At the time of insertion it is imperative that the following are applied: good hand hygiene; wash the skin (apply appropriate skin antiseptic on clean skin); chlorhexidine skin antiseptic (apply using friction for 30 seconds and allow to dry completely); maximum sterile barrier precautions; select the appropriate device for the patient's IV therapy needs in the appropriate site; ensure proper tip location; secure catheter to prevent catheter positioning; apply biopatch at the time of insertion; observation of the insertion procedure and the observer may stop the procedure if any breaks in sterile technique occur; and daily assessment of the need for the IV device and prompt removal if the device is no longer needed. Some of the recommendations above are mentioned in the Center of Disease Control and Prevention Guidelines for the prevention of CRBI.5,19 CRBI in patients on HD is preventable by implementing best practices. The basis of preventing CRBI is for all staff and patients to strictly follow the recommended infection control practices. The highlights of the RAS guideline recommendations for Prevention of catheter related infections are listed in Table 3. The proportion of patients who died was higher among those who were dialysed with a non-cuffed or cuffed catheter, compared to those dialysed with either a graft or a fistula.20 Clearly, the risk of infection is lower for those patients dialysing on AVF. CVC should be employed only as a method of last resort for the purpose of HD to reduce the overall risk of infectious complications.5 For CVC, the exit site remains a potential source of infection. The RAS has recommended that the exit site should be cleaned with Chlorhexideine 2 %.5 This has been shown to be superior to povoiodine in a number of settings.21 The exit site should be covered with a non-occlusive secure dressing to protect the exit site between dialysis sessions. We educated our patients on the importance of maintaining the integrity of the dressing and the importance of reporting problems with the exit site. The information leaflet on how to take care of CVC lines has been given to our individual patients. Every dialysis session, our dedicated nursing staffs inspect the exit site and evidence of inflammation is recorded to their catheter care record file. A Cochrane meta-analysis explored the benefit of a number of exit site strategies.22 The use of polysporin ointment reduced the risk of catheter-related bacteraemia (odds ratio 0.17) and reduced catheter-related infections related to S. aureus. Interestingly, there were discordant results in mortality-related infection, which was not reduced by mupirocin, polysporin or povoiodine therapy. Medihoney has also been tested. Medihoney, when applied to tunnelled

catheter exit site, was comparable to 2 % mupirocin in the number of catheter associated bacteraemia rates.23

Patient Education
It is important that the patient should be educated on how to safely care for the catheter to prevent potential complications. Complications from the HD catheter can occur at anytime. The CUHNFT patient information leaflet is summarised below.24 Make sure that your line is covered with a dressing and secured in place at all times. The less your line is able to move, the less likely it is to become infected. If you must touch your line, make sure you have washed your hands. This applies to anyone touching your line including doctors and nurses. Immediately report any signs of swelling, tenderness, fever, bleeding that soaks through the dressing, shortness of breath, pain or oozing from the exit site to the nursing staff on your dialysis unit. The patient and families should be instructed on what to do if the HD catheter is pulled or slips out or begins to bleed at home. Discuss precautions needed for showering and not being able to swim. Educate patients about securing the catheter, minimising manual manipulation and avoiding sharp objects, such as scissors, near the catheter. The patient or family should never open the catheter clamps or remove the caps, unless trained in home HD. Education of the patient and family should include a discussion of the patients current access status, the complications of HD catheters and other access options, if appropriate.25 Increasing the patients awareness and knowledge of catheter management may increase the level of self-management and responsibility for optimal outcomes. Still, it is our responsibility to provide an optimum level of care. The CUHNFT dialysis centre has devised a central venous access device (CVAD) care record for pre- and post-dialysis treatment.

Haemodialysis Central Venous Access Device Care Record

All patients on dialysis with CVAD in situ should be cared for according to trust policy and procedures. The full CVAD care record can be obtained by contacting the author).

Pre-dialysis
(Can be answered by YES or NO). If the answer is NO, it should be documented and reported immediately to the nurse in-charge. Has the catheter exit site been inspected for any signs of infections? Is the CVAD secured with clean and dry dressing? Is the dressing labelled with the date of the last dressing changes? If not dated on the dressing, it should be documented on the nursing notes.

Post-dialysis
Are the catheter hubs securely and safely screwed to both lumens (arterial and venous line)? Has the line been locked with TSC 46.7 % labelled and dated?

The Summary of our Recommendations

The CVAD for HD patients should be secured with a sterile transparent dressing to allow observation and inspection of the exit site.

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The CVAD care record should be used for all HD patients with CVC and all elements completed every dialysis session (normally, three-times-per-week). Date and time of insertion of the line should be recorded in the patients notes and date of insertion added to the dressing if applicable. Assessment and inspection of the catheter exit site should be performed and documented every dialysis session. All manipulations should be performed in accordance with the aseptic non-touch technique (ANTT) for the administration of drugs and fluids by intravascular device procedure. ChlorPrep (chlorhexidine gluconate 2 % weight/v aqueous solution) should be used for dressings. All CVAD for HD patients should be removed by a competent practitioner when no longer required and CVC line tips should be sent to microbiology for culture. Line removal should be clearly documented in the patient notes. All elements of the daily care record must be completed every dialysis session.26 The use of TSC 46.7 % has proven cost effective when looking simply at the reduced spending on urokinase (down by approximately 90 %) and heparin (down by approximately 95 %). Reduced expenditure on admissions, line removals and the treatment of infection should also be considered. The use of TSC 46.7 % solution to lock the catheter line has been proven to reduce infections to HD patients. Changing catheter lock from heparin to TSC 46.7 % will not work alone to prevent and decrease the rate of CRBI but it is essential to uphold best clinical practices; the use of sterile procedure in inserting lines and adequate catheter care using a unit-based CVAD care record. The trust has launched the first central venous access service in the country with a dedicated theatre suite supporting safe line insertion. All CVAD for HD patients is inserted in the vascular access unit and contribute to the reduction of MRSA bacteraemia rate in the CUHNFT. Multidisciplinary education of the patient, the nursing staff and all dialysis unit personnel will be helpful in decreasing infections. We now have over five years of clinical experience with TSC 46.7 % and appear to be cost-effective, and it reduces CRBI for maintenance of long term CVAD for HD patients. It reduced expenditure on admissions, line removals and the treatment of infections. The CUHNFT HD unit adheres to the best clinical practice on the prevention and management of CRBI. Reducing the incident rate of MRSA bacteraemia in our unit raised the profile of the hospital nationally and we triumphed in the top award as best acute NHS organisation in the UK. n

Conclusions
The incidence of the dialysis line related infection has fallen by 75 % in the six months from September 2006 to March 2007, since TSC 46.7 % was introduced compared with a six-month period prior to its introduction. There were problems with adverse effects reported since the introduction of TSC 46.7 % as a line-locking agent in all patients with dialysis catheters in September 2007. Adverse effects experienced by the patients have been mild and have not caused the patients to discontinue with its use.

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