Hemodialysis catheter care: current recommendations for nursing practice in North America.
Describe current hemodialysis (HD) catheter usage and complications in North America, and provide an overview of the research and recommendations for nephrology nursing in caring for those patients, adult and pediatric, who use a catheter for HD.
1. Discuss the current need for and complications of hemodialysis (HD) catheter usage.
2. Discuss current challenges of HD catheter care and the nephrology nursing process using those guidelines and recommendations.
3. Define "best practices" and describe current recommended practices for both prevention and treatment of catheter-related complications in adults and children.
4. Describe the team approach and continuous quality improvement (CQI) process in implementing these recommendations.
The "catheter conundrum," explicated as "hate living with them but can't live without them" (Schwab & Beathard, 1999), continues today. The hemodialysis (HD) catheter is an extremely important device because it is the only vascular access that can be used for lifesaving HD when there is no other appropriate access option available. In the most recent U.S. Renal Data System (USRDS) (2009) report, 82% of the 101,688 patients who began HD in 2007 did so using a catheter. Once the urgency has passed and maintenance HD is established, all patients must be assessed by the HD interdisciplinary team (U.S. Department of Health and Human Services [DHHS], & Centers for Medicare & Medicaid Services [CMS], 2008) and referred to the vascular access team (VAT). The role of the interdisciplinary VAT is to follow the recommended access algorithm with each patient (National Kidney Foundation [NKF], 2006).
For patients assessed as ineligible for a well-functioning fistula or graft, an HD catheter remains the only access. It can deliver effective and safe HD when properly placed and managed. While a physician usually places both short- and long-term catheters (see Table 1), the nephrology nurse is responsible for their management using best practices derived from the most current guidelines and recommendations. Best practices in this article are defined as those evidence-based practices and recommendations for clinical practice that have been formulated into guidelines by authoritative government agencies, such as the Centers for Disease Control and Prevention (CDC), or professional, interdisciplinary, specialty expert workgroups, such as the NKF's Kidney Disease Outcomes Quality Initiative (KDOQI) or the Clinical Educators Network. The authors deem these most reliable to assure desired patient outcomes and fulfill the Nephrology Nursing Standards of Practice and Guidelines for Care (Burrows-Hudson & Prowant, 2005).
The Need for and Complications Of Current Catheter Usage
According to the 2007 Dialysis Outcomes and Practice Patterns Study Report (DOPPS3) (Arbor Research Collaborative for Health, 2009), in HD catheter usage, Canada ranked second in the world (38%), and the U.S. ranked fourth (29.2%). Also during 2007, prevalent U.S. catheter usage was reported in the Clinical Performance Measures (CPM) Report of 2008 as 27% (CMS, 2008). According to the Fistula First Data site (Mid-Atlantic Renal Coalition, 2010), the percentage of catheter use in the U.S. has decreased to 24.3%, with an overall downward trend over the preceding 46 months. This is good news because a large study, also using 2007 data reported by Lacson, Wang, Lazarus, and Hakim (2009), reconfirmed that mortality continues to be much higher for patients in the U.S. using HD catheters (HR of 1 .76) than in those patients with fistulas. Mirroring this study is the Canadian study by Moist, Trpeski, Na, and Lok (2008) in which the hazard ratio of death in patients with a central venous catheter (HD catheter) was 1.6. It is clear that HD catheter use is associated with a greater burden of morbidity and mortality; thus, catheter reduction efforts, both incident and prevalent, must be vigorous. The solution to the significant clinical challenge of the remaining catheters is less clear.
The usual precursor to mortality is morbidity. The morbidity of HD catheter usage is very evident in terms of life-threatening bacteremias, catheter-related thrombosis with accompanying central vessel stenosis and occlusion, and comparatively lower HD adequacies (CMS, 2008). Other, more subtle manifestations include lower-average hemoglobins and hypoalbuminemia (CMS, 2008), and subclinical inflammation (Goldstein, Ikizler, Zappitelli, Silverstein, & Ayus, 2009). An interesting but not well-understood finding associated with HD catheter-related mortality is that patients using an HD catheter have a higher risk for cardiovascular death than patients using an arteriovenous fistula despite having a similar burden of co-morbidities (Astor et al., 2005). These sequellae of HD catheter use present challenges for innovations in technology and a focused commitment to best practices in care.
Vascular access infections, especially catheter-related bacteremias (CRBs), are difficult to quantify and report because no clearly established mechanisms exist across the entire HD population in either the U.S. or Canada. Studies over the past decade, however, show a range of CRBs from 1.6 to 5.5 per 1000 catheter days. U.S. national guidelines recommend the rate of HD catheter-associated bloodstream infections to be reported as a rate event per 1000 catheter days (NKF, 2006; O'Grady et al., 2002). This accounts for infections over time and adjusts risk for the number of days an HD catheter is in use. It should be applied not only to HD CRBs, but also to HD catheter-related tunnel infections and HD catheter exit-site infections. Such standardization of terminology is required for optimizing HD catheter care and benchmarking. Standardized definitions are required for the diagnosis, monitoring, and reporting of CRBs. The nephrology community uses definitions for HD catheters borrowed from the literature of intensive care, oncology, apheresis, and general intravascular catheter use (Lok, 2006). These definitions are well established for these central venous catheter uses; however, they are not unique to HD catheters, and therefore, require further criteria for catheter removal and culture to make a definite diagnosis of a CRB (Lok, 2006; Mermel et al., 2009). From a quality assurance and research standpoint, any epidemiologic or interventional study involving catheter-related infections (CRIs), CRBs, and/or their consequences would need to include definitions of CRIs as part of its protocols; however, such standardizations are not currently well established within the nephrology community (Lok, 2006).
A recently published CDC article (Kallen, Arduino, & Patel, 2010) reports that the National Healthcare Safety Network (NHSN) rate for patients with catheters who have bloodstream infections was 4.2 per 100 patient months, which is analogous to 1.4 per 1000 catheter days. These data represent only 32 of the more than 5000 dialysis facilities in the U.S. (Klevens et al., 2008), but with the implementation of the revised CMS regulations, proposed vascular access infection-related CPMs, and the anticipated data collection through CrownWeb, more global data should be available in the future.
While these data are not currently available, the consequences of infection are known. The 2009 USRDS report shows that 37.5% of hospitalizations of patients on HD in 2007 were due to infection, making it the leading cause of hospitalization and the second leading cause of death. This cost is not just in patient lives but also in dollars. The USRDS 2009 report shows that catheter costs per person per year were almost $80,000--a figure much higher than either graft or fistula cost. A single center study concluded $23,451 is the mean cost of a CRB hospitalization, and the mean length of stay is 17 days (Ramanthan et al., 2007).
As frontline caregivers, what can nephrology nurses do to reduce CRIs and CRBs? An exemplar is taken from a nephrology nurse who presented an abstract at the American Nephrology Nurses' Association (ANNA) 2010 National Symposium (Bakke, 2010). This nurse undertook the challenge and showed the number of CRIs decreased from 1.8 to 0.0 per 1000 catheter days during a six-month period (p = 0.04) and that $125,872 USD was the projected annual savings in just one dialysis unit. Bakke (2010) concluded that CRIs in patients on HD are preventable by implementing published guidelines.
Two other relevant studies, one large (Miller & Emanual, 2008) and one small (Beathard, 2003) show that when a strict infection control policy is utilized, CRIs can be significantly reduced. The larger study by Miller and Emanuel (2008) evaluated a protocol that employed simple steps with catheter placement and management. It was designed to routinely implement five evidence-based procedures:
* Have clinicians wash their hands.
* Use full-barrier precautions during insertion of central venous catheters.
* Use chlorhexidine for skin cleansing before catheter insertion.
* Minimize the use of the femoral site for catheter insertion.
* Remove unnecessary catheters.
The result was a dramatic decrease in CRIs. The goal was to reduce CRIs in 103 ICUs at 67 Michigan hospitals. At baseline, the participating hospitals had a median of 2.7 infections per 1000 catheter days; after three months, the median had dropped to 0.0 and remained there for 18 months.
In the nephrology nursing specialty, Beathard (2003) reported a reduction in the incidence of CRB after instituting a catheter management protocol for CRB prophylaxis. Data were collected for a 24-month study period and compared to retrospectively collected control data for the immediately preceding nine months in the same patient population under the same conditions except for the prophylaxis protocol. Incidence of CRBs fell from an average level of 6.97 per 1000 catheter days during the control period to an average of 1.68 during the study period. The average incidence during the last 18 months of the study period was 1.28 per 1000 catheter days. Staff compliance with the protocol required repetitive education and assessment. The protocol was to follow the catheter care management guidelines in the Dialysis Outcomes Quality Initiative (DOQI) guidelines (NKF, 1997). The most recent KDOQI guidelines (NKF, 2006) for vascular access revision is replete with guidelines to prevent CRIs. Many are based on the CDC's (2002) guidelines and are underscored in the 2010 CDC document on preventing infections in the HD population (Kallen et al., 2010).
Preventing Catheter-Related Infections
The basis of preventing CRIs is for all staff and patients to strictly follow the CDC's recommended infection control practices for HD units (CDC, 2001), as well as wear masks and use strict aseptic technique when opening catheter lumens or exposing the exit site (NKF, 2006). There are no exceptions. Exit site and hub cleaning are as per facility protocol. Highlights of the CDC guideline recommendations for routine preventive care are listed in Table 2. but evidence suggests these are not strictly followed. For example, Patel, Kallen, and Arduino (2010) noted that recommended exit site topical agents are underutilized despite the demonstrated infection prevention. Reasons could be cost or the added care step, which are not acceptable excuses given the literature supporting this practice. There are several options for topical agents. The application of these agents takes less than one minute, and the cost is minimal, especially when compared to the cost to treat an infection. As with any agent that comes into contact with catheter material, the catheter manufacturer's recommendations must be reviewed to assure compatibility.
Topical Agents at the Catheter Exit Site
In a prospective, randomized, controlled trial of 129 patients on HD, researchers compared topical povidone-iodine ointment with no treatment at the exit site of temporary subclavian HD catheters (Levin, Mason, Jindal, Fong, & Goldstein, 1991). Exit-site infection was reduced by 72%, tip colonization by 52%, and CRBs by 93% in the povidone-iodine group. Other topical agents, such as mupirocin, were used at the tunneled permanent HD catheter exit site and showed a benefit of preventing infection. However, the concern of rising mupirocin resistance and the recommendations from the CDC limit its clinical use (Johnson et al, 2002; Sesso et al, 1998).
Lok et al. (2003) conducted a multi-centered, randomized, double-blind, controlled trial in Canada comparing an antibiotic ointment composed of 500 units/g bacitracin, 0.25 mg/g gramicidin, and 10,000 units/g polymyxin B to placebo ointment applied at the HD catheter exit site. They found a 4-fold reduction in all CRIs and CRBs, as well as a reduction in infection-related deaths and all-cause mortality.
Contamination of the catheter hub has been shown historically to contribute substantially to intraluminal colonization of long-term catheters (Linares, Sitges-Serra, Garau, Perez, & Martin, 1985; Raad et al., 1993; Sitges-Serra, Linares, Perez, Janrrieta, & Lorente, 1985). Multiple manipulations of the HD catheter at its hub by healthcare professionals increase the risk for intraluminal contamination and resulting CRBs. To reduce infection risks while handling the catheter hub, different types of closed luer lock access devices have been made available in the market. When attached to the arterial and venous catheter hub during the dialysis treatment, those connectors create a mechanically and microbiologically closed system that has been shown to decrease CRBs in HD catheters (Adams, Karpanen, Worthington, Lambert, & Elliot, 2006; Casey et al., 2003).
Bouza, Munoz, and Lopez-Rodriguez (2003) have shown that using a microbiologically and mechanically closed and swabable device decreases contamination and possible CRBs at the hub, as well as at the catheter insertion site. Since evidence has shown such devices can decrease the incidence of HD catheter hub contamination, Eloot, De Vos, Hombrouckx, and Verdonck (2007) trialed a microbiologically and mechanically closed device to assure better infection control was not a trade off with lower blood flows. The Tego[TM] trial, which evaluated the significance of blood flow because the caps stay in place during HD, demonstrated resistances to blood flow were minimal in the Tego and Codan connectors, while they were significant in the Becton-Dickinson connector (Eloot et al., 2007). The Tego catheter is also designed as a "neutral displacement connector," which means when the blood tubing or a syringe is removed from the cap, a minimal reflux of blood flows into the catheter lumen, thus potentially eliminating the need for a heparin lock. In the indications for use of these caps, a saline flush is used to maintain the patency of the HD catheter lumens. However, the U.S. Food and Drug Administration (FDA)(2010) has issued an alert concerning this technology since it has received three reports of death associated with bloodstream infection and positive displacement needleless connectors. The FDA is requiring post-market surveillance studies of up to three years on infection rates and demographics of the patients involved, and will rule on the need to regulate these devices when the studies are complete.
An area of growing interest and research for both CRI prevention and treatment is the use of interdialytic locking solutions. Of note, terminology for locking solutions varies. The CDC defines the antimicrobial locks in two categories: antibiotic antimicrobials (such as gentamicin) and non-antibiotic antimicrobials (such as citrate) (Kallen et al., 2010). The KDOQI guidelines define the first category as antibiotic locks and the second as antimicrobial locks (NKF, 2006). Ash (2010) defines them all as antimicrobials with subsets of antibiotic and antiseptic (such as citrate).
The accepted practice for locking the HD catheter has been to instill heparin, usually 5000 units per mL, to the exact volume of each lumen. Any systemic anticoagulation resulting from this practice was thought to be as a result of overfill or improper locking technique. A recent study by Ash (2010) clearly describes how the fluid dynamics of catheter-locking results in some degree of heparinization, with the unintended consequence of increased partial thromboplastin times. A European study (Agharazii, Plamondon, Lebel, Douville, & Desmeules, 2005) demonstrated this phenomenon of inadvertent leakage of locking solution from the catheter. In this in vitro study, 4.5 mL of a heparin solution were instilled into the tip of a catheter of which 3.38 mL (75%) leaked out after only 30 minutes. Along with unintentional systemic anticoagulation, heparin interferes with specific laboratory studies (Agharazii et al., 2005) and may predispose patients to other complications, such as heparin-induced thrombocytopenia (HIT) (Warkentin et al., 1995).
The risk of bleeding alone has led many facilities to lower the heparin strength to 1000 units per mL and to use a thrombolyfic, such as tissue plasminogen activator (tPA), if necessary if clotting occurs. The team at the University of Alabama showed that using 1000 units per mL heparin lock solutions required twice the amount of thrombolytic therapy but did not decrease overall cumulative HD catheter patency when compared with 5000 units per mL heparin (Maya, Smith, & Allon, 2010). However, the biggest problem with using heparin as a locking solution is not so much what it does as what it does not do. Since it is primarily an anticoagulant, heparin does not reduce or impede bacterial growth. Heparin has actually been shown to increase S. aureus biofilm (Shanks et al., 2005). Locking solutions that have both antimicrobial as well as anticoagulant effects are seen by many clinical scientists in both Canada and the U.S. as being the possible prevention solution to reduce CRIs.
In Canada, the basic philosophy is to decrease the patient's risk of bleeding by using the lowest dose of anticoagulant possible to achieve optimum HD catheter function for maintenance HD (Clinical Educators Network, 2006). At marly dialysis centers, HD catheter lumens are flushed with normal saline at the completion of each HD session; sodium citrate 4% is then instilled into each lumen as a locking agent in volumes corresponding to the luminal capacity (Grudzinski, Qninan, Kwok, & Pierratos, 2007; Lok, Appleton, Bhola, Khoo, & Richardson, 2007).
Recently, the catheter-locking solution, trisodium citrate (TSC) (commonly known as sodium citrate), has become available in Canada as an alternative to heparin anticoagulation and is used in many HD units across the country. TSC 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 HD catheter failure and thrombolytic use compared to heparin (5000 units per lumen) and is more cost-effective (Grudzinski e al., 2007; Lok et al., 2007). For example, in a prospective cohort study of 250 patients by Lok and colleagues (2007), with incident, long-term, tunneled cuffed catheters over two time periods, when either citrate or heparin was used as the catheter-locking solution, the HD catheter exchange rate for catheter dysfunction was lower in the citrate group compared to the heparin group (Lok et al., 2007). Tissue plasminogen activator (tPA) (alteplase)use was significantly less with TSC compared to heparin, and the time to catheter replacement was greater in the group that received the TSC catheter-locking solution than in the groups that received the heparin catheter-locking solution.
In the U.S., the CDC has been reviewing studies and trials utilizing antimicrobial locks and the metaanalyses of those studies. Kallen and colleagues (2010) state it is the belief of the CDC that although results are promising, problems are inherent in the studies. They question the generalizability of the results, the lack of clarity in regard to potential confounding effects, and the very real potential negative effects, such as antibiotic resistance. Ash (2010) has cited several instances of antibiotic resistance due to antibiotics containing locking solutions, and has elucidated the potential positive and negative effects of many non-antibiotic antimicrobials. Ash (2010) has also analyzed the properties of sodium cit rate and discussed the event that led the FDA to warn against using concentrated citrate as a catheter lock when a patient died several days after accidental infusion of 47% sodium citrate in 2000 (FDA, 2000).
The CDC noted that no specific prophylactic-locking solution recommendation was made by KDOQI in 2006, and continued with "the CDC does not currently recommend them for routine use in hemodialysis catheters" (Kallen et al., 2010, p. 7). Patel et al. (2010) further state that a compelling reason for not recommending any antimicrobial-locking solutions is that none has been FDA-approved.
The key words are "routine use," and it is to be remembered that a guideline is exactly that--a guideline (NKF, 2006). Guidelines were never intended to replace professional judgment, and the recent antimicrobial literature is rich with clinical experiences that may be the solution to a particular patient's clinical problem. The works by Ash (2010), Allon (2004), and Jaffer, Selby, Taal, Fluck, and McIntyre (2008) are helpful resources.
Treatment of Catheter-Related Infections
Suspected exit site infections should be cultured and treated with topical, oral, or IV antibiotics depending on the organism and the severity of infection. All tunnel and suspected bacteremias should be treated with IV antibiotics after cultures are obtained (NKF, 2006). Treatment with systemic antibiotics alone cures the infection in only approximately 30% of patients (Lok, Thomas, & Vercaigne, 2006; Mermel et al., 2009). Removal of the infected catheter with delayed placement of a new, tunneled catheter has shown to be more effective but requires the patient to endure multiple procedures, including use of a temporary dialysis catheter. Casey and colleagues (2008) evaluated bacteremia outcomes and survival rates when using guidewire exchange to place a tunneled HD catheter in comparison with a new-site replacement. Retrospectively, 408 HD catheters were identified as being placed in 329 patients: 46 had guidewire exchange and 362 new-site replacement. The bacteremia rate from the new-site insertion group was 3.0 per 1000 catheter days, while the guidewire exchange group demonstrated a rate of 2.8 per 1000 catheter days.
Guidewire exchange of the infected catheter in patients whose fever resolves within 48 to 72 hours of initiation of systemic antibiotics is recommended (Beathard, 1999; Robinson, Suhocki, & Schwab, 1998; Saad, 1999; Tanriover et al., 2000). In the two largest reports on this approach (Beathard, 1999; Saad, 1999), patients achieved an 81% to 88% infection-free catheter survival at 45 days after excluding patients with persistent fever. In patients with recurrent infection, use of an antibiotic lock after guidewire exchange in addition to systemic antibiotics may be necessary. Follow-up cultures are drawn one week after the cessation of antibiotics (NKF, 2006).
Catheters coated to prevent CRIs have been developed and studied. A meta-analysis of 12 studies showed HD catheters externally impregnated with silver sulfadiazine and chlorhexidine reduced the rate of HD CRBs but only if the catheter was used for less than two weeks (Veenstra, Saint, Saha, Lumley, & Sullivan, 1999). When compared with minocycline and rifampin impregnation luminally and externally in a large multicenter, prospective randomized trial, the minocycline-rifampin combination was superior in lowering the rate of HD CRBs (Trerotola et al., 1998). In a single study of long-term tunneled HD catheters, no difference was found in the rate of CRIs between silver-impregnated and control HD catheters (Johnson et al., 2002).
Blood Flow and Managing HD Catheter Dysfunction
HD catheters are designed to deliver blood flow to and from a blood vessel in excess of 400 mLs/minute, and to remain indwelling percutaneously in that vessel for as long as needed for HD access. The placement of this relatively large foreign body and leaving it in situ traumatizes the host vessel and significantly alters the hemodynamics. These conditions satisfy Virchow's triad for thrombus formation (Dinwiddie, 2004) in addition to providing a bacterial highway (Ash, 2010). The inflammation and scarring that result lead to vessel stenosis and occlusion--a highly significant outcome that will over time limit future vascular access potential. In the short-term, the formation of clots in and around the catheter, as well as fibrin sheath formation, lead to catheter dysfunction--a common complication of the HD catheter that further leads to the inability to deliver adequate dialysis.
The definition of HD catheter dysfunction varies in the literature and includes variable rates of blood flow ranging from less than 100 to 350 mL/minute (NKF, 2006). The 2006 KDOQI vascular access guidelines define HD catheter dysfunction as failure to attain and maintain extra-corporeal blood flow sufficient to perform HD without significantly lengthening the HD treatment and considered insufficient extracorporeal blood flow to be less than 300 mL/minute (except in small adults and children) (NKF, 2006). This recommendation has been interpreted as the need to maintain blood flows above 300 mL/minute to ensure adequate dialysis. As a result, HD catheters are often run by reversing the lumens or using thrombolytic agents, such as a thromboplastin inhibitor (including tPA), or catheters are exchanged when blood flow is consistently less than 300 mL/minute (Lok et al., 2006; Moist, Hemmelgarn, & Lok, 2006).
In response to the increase in HD catheter prevalence, increased use of thrombolytics, and resulting increased costs, Moist and colleagues (2006) examined the relationship between HD catheter blood flow and dialysis adequacy. It was determined that the blood flow and achieved dialysis adequacy demonstrated no difference in adequacy achieved when HD catheter blood flows were 250 mL/minute, 275 mL/minute, or 300 mL/minute (Moist et al., 2006). HD units vary in the accepted maximum arterial and venous pressures. As recommended by KDOQI guidelines (NKF, 2006), blood flow may be maximized according to arterial and venous pressures to a maximum not exceeding -250 mmHg (arterial) and +250 mmHg (venous), or as ordered by the attending physician/nurse practitioner (Clinical Educators Network, 2006).
In Canada, when catheter flow is not optimal, the minimum blood flow accepted to maintain treatment is 200 mL/minute to maintain blood circuit patency and an adequate clearance for that single treatment (Clinical Educators Network, 2006). It is recommended that the management of HD catheter dysfunction should be based on the presentation and the ability to maintain adequate blood flows (Clinical Educators Network, 2006). Flushing the catheter with normal saline and repositioning the patient may resolve dysfunction, but in some cases, the dialysis treatment will not be possible. A follow-up chest X-ray to reconfirm position of HD catheters inserted during the previous seven days and that present with poor flows is recommended (Clinical Educators Network, 2006).
In the U.S., the KDOQI guidelines (NKF, 2006) recommend similar measures be taken to resolve a possible mechanical dysfunction and allow for a one-time line reversal to assure dialysis, but further recommend that a recently placed catheter be assessed under fluoroscopy and appropriately corrected. If, however, the catheter has functioned adequately over time and no mechanical cause for dysfunction is found, a thrombolytic dwell is recommended either predialysis, intradialytically, or interdialytically. A trend of decreasing flows, decreasing dialysis adequacy (laboratory values), and increasing frequency of alarms is the indication to intervene with a thrombolytic before the dysfunction becomes complete occlusion.
As in Canada, untreated, persistent dysfunction may adversely affect the quality of a patient's life, increase patient morbidity, and consume dialysis resources. Algorithms for assessment and treatment can be found both in the KDOQI guidelines (NKF, 2006) and ANNA's Core Curriculum for Nephrology Nursing (Dinwiddie, 2008). Canada's Clinical Educators Network (2006) guideline to attempt to salvage an HD catheter also recommends thrombolysis for suspected intraluminal thrombus using an appropriate thrombolytic agent, such as tPA, 1 mg/mL, to fill the HD catheter volume up to a maximum of 2 mg (2 mL). If the HD catheter lumen capacity exceeds 2 mL, the remaining volume may be filled with 0.9% saline solution behind the thrombolytic to ensure the tPA reaches the HD catheter tip (Clinical Educators Network, 2006).
HD catheter non-function due to thrombosis is the most common indication for HD catheter removal in North America. Thrombolytic instillation and dosing protocols are based on two large randomized trials in patients not on HD that have shown tPA used to restore flow in occluded non-HD catheters does not cause serious adverse events, such as major hemorrhage, intracranial hemorrhage, or embolic events (Deitcher et al., 2002; Ponec et al., 2001). Since tPA was not studied in patients on HD, there is no FDA-approved indication for its use in this population in the U.S., even though there have been many small studies (NKF, 2006) and a decade worth of positive experience. Trials of a new thrombolytic, tenecteplase (TNK), have been conducted and reported in the HD population in the U.S. (Dutka et al., 2010; Wade Hardie et al., 2010), but the drug has not yet been approved for commercial sale and use.
Catheter-Related Inadequacy, Anemia, and Hypoalbuminemia
Catheter-related co-morbidities of inadequacy, anemia, and hypoalbuminemia could possibly be positively influenced by nephrology nursing intervention. In the U.S., the CPM data of 2007 data show the mean Kt/V for catheters is 1.47 compared with 1.62 for patients with grafts, and only 73% of those patients with catheters had a Kt/V greater than 1.3 (CMS, 2008). The difference in blood flow rate potential between catheters and grafts explains the difference in adequacies and is one of many reasons that a peripheral access yields better patient outcomes.
The exacerbated anemia and hypoalbuminemia are not so easily explained. Patients with an HD catheter in 2007 (CMS, 2008) had an average hemoglobin (Hgb) of 11.7 g/dL, trailing the fistula-related average of 12.0 g/dL, which does not look so different; however, 26% of patients with HD catheters had Hgbs less than 11 g/dL vs. only 15% in those with a fistula. Similarly, albumin levels are lower in patients with catheters (fistula 88% versus catheter 68%) above 3.5 g/dL using bromocresol green (BCG). The obvious reason for these differences is the increased amount of blood loss patients with catheters experience. Every time their catheters are opened for HD, at least 6 mL of the blood and locking solution mixture are withdrawn and discarded. Nursing research to determine the minimum amount that can be withdrawn without compromising patient safety or quality of assessment needs to be conducted. Less easy to quantify is the increased blood loss due to clots in the HD lines and the dialyzer secondary to lower average blood flows and thrombus associated with catheters. The presence of inflammation, both evident and subclinical, is highly associated with anemia (Goldstein et al., 2009; Nassar, Fishbane, & Ayus, 2002) and hypoalbuminemia (Agarwal, Davis, & Smith, 2008), and the blood loss can be logically extrapolated to both the increased anemia and hypoalbuminemia.
Catheter removal followed by infection control is the management of choice for these problems, and nurses are key to accomplishing these outcomes. Increased vigilance in preventing dysfunction, minimizing blood withdrawal from the catheter, and minimizing clotting in the lines and dialyzer could make a difference. One consideration in the latter, and especially for those patients in whom heparin use is a problem, is to use dialysate that contains a small quantity (2.4 mEq/L) of citric acid to provide mild anticoagulation in the extracorporeal circuit. In studying this dialysate, Ahmad, Callan, Cole, and Blagg (2000) found that the dose of dialysis was increased (Kt/V from 1.23 +/- 0.19 to 1.34 +/- 0.20; p = 0.01) from the first to last dialysis, respectively. These authors concluded that citric acid dialysate was well tolerated and safe.
Acute Mechanical Complications
The literature holds many discussions on acute complications related to HD catheter placement. Less is written with respect to complications of HD catheters during dialysis and at home. Staff education and continuous quality improvement (CQI) initiatives are essential in preventing poor patient outcomes in the event of acute catheter complications.
Although air embolism can occur during insertion of an HD catheter, it is more commonly seen as a complication of catheter removal (Heckmann et al., 2000). It is crucial to be aware of possible air entry during catheter insertion, exchange, or removal (Boer & Hene, 1999), since 100 milliliters of air can pass through a 14-gauge needle in one second (Kim et al., 1998). Air embolism has occurred during accidental hub disconnection (Zafronte, Hammond, & Rahimi, 1996), through an unhealed or patent residual catheter track (Phifer, Bridges, & Conrad, 1991), and has been reported to lodge in the coronary circulation (Viguaux, Borrego, Macron, Cariou, & Claessens, 2005). When air embolism occurs, the usual treatment is to position the patient in left lateral Trendelenburg, perform air aspiration, and commence 100% oxygen. However, if these methods are unsuccessful, hyperbaric oxygen treatment can be helpful (Blanc, Boussuges, Henriette, Sainty, & Delefile, 2002).
Immediate action by the healthcare provider is vital if the integrity of the external catheter is compromised, such as the external catheter cracking or breaking (Dinwiddie, 2004). Some adverse events that can occur are the presence of air in the blood tubing during HD due to possible cracks in luer locks or breaks in the integrity of the catheter at any place from the exit site to the hubs. Air embolization due to catheter fracture is reported to occur in 0.5% to 3% of patients with indwelling catheters (Bessoud et al., 2003; Kutter, 2004). Immediate action is also required if the catheter dislodges or is pulled out during HD. Staff must be taught how to immediately assess and manage any type of catheter compromise and know when to report to the nephrologist/nurse practitioner for referral to a surgeon or interventionalist depending on the severity of risk (Dinwiddie, 2004). Catheter extensions can be a source of accidental catheter dislodgement if allowed to become entangled or tugged on by exterior forces during patient mobility. Many nurses secure these with tape to the chest or place the extensions in a pocket protector (commercially manufactured or devised by nurses using gauze and tape). The literature is lacking concerning the rate of accidental catheter dislodgement, but it does occur. Nurses are primarily responsible for educating patients about catheter care at home and the danger of accidental catheter dislodgement.
Following insertion of an HD catheter, it is imperative that the patient is educated on how to safely care for the catheter to prevent potential complications. Complications from the HD catheter can occur at any time. Patients should be instructed to call the HD unit if they experience any of the following: bleeding that soaks through the dressing; shortness of breath; the development of or increase in bruising, swelling, or discharge at the exit site or over the tunnel; increase in pain at the incision site(s) than was initially felt; fever or chills; or catheter leakage.
Unless the patient is taught to do so at home, HD unit staff will do the routine HD catheter care, such as dressing changes, flushing the catheter, and changing the cap over the hubs. Patients 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, minimizing 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 patient's current access status, the complications of HD catheters, and other access options, if appropriate (Dinwiddie, 2004). Regardless, increasing a patient's knowledge of optimal catheter management may increase the level of self-management and responsibility for optimal outcomes. A suggested tool is to use a monthly report card (analogous to the dietitian's laboratory report card). Figure 1 provides patient education, explaining each variable. Some type of medical alert with the patient's access history, status, and care warnings is also highly desirable.
Pediatric HD Catheter Considerations
The KDOQI guidelines (NKF, 2006) were the first to publish vascular access practice recommendations for children. The CPM reports that in 2007, there were 740 prevalent patients on HD less than 18 years of age (CMS, 2008). As with adults, long-term access in the form of a fistula or graft is the preferred form of vascular access for most pediatric patients on maintenance HD because of poorer catheter-related outcomes (see Table 3).
In some circumstances, however, an HD catheter may be necessary. These include lack of local surgical expertise to create a fistula or place a graft, or the patient may be too small to support peripheral access. Further, the vascular access may only be needed as a bridge to peritoneal dialysis (PD) or scheduled transplantation, or the access may only be for temporary use, as in the event of PD catheter removal for peritonitis. Every effort should be made to locate a skilled pediatric vascular surgeon, and all children weighing greater than 20 kg who are expected to be on HD for more than a year should be considered for a permanent vascular access. In such cases, catheter sizes should match patient sizes with the goal of minimizing endothelial trauma and obstruction to blood flow, while allowing sufficient blood flow for adequate HD. The KDOQI guidelines (NKF, 2006) contain a chart of catheter size to patient recommendations. Placement consideration and recommendations for preventive care are similar to those for adults. Blood flow rates should be minimally 3 to 5 mL/kg/minute and should be adequate to deliver the prescribed HD dose (NKF, 2006).
Catheter Management Using The Team Approach
The Institute of Medicine's (IOM) Committee on the Health Professions Education Summit (2003) recommends that to provide patient-centered care, healthcare providers must "work in interdisciplinary teams--cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable" (p. 4). The new CMS dialysis regulations (DHHS, 2008, 494.80) provide further direction on how to understand and put this recommendation into practice by stating:
While multidisciplinary team members work sequentially and use the medical record as the chief means of communication, interdisciplinary teams work collaboratively with regular meetings to discuss patient status and the evolving plan of care. Working us a team allows for working toward common goals, pooling of expertise, and a forum for problem solving.
This CMS mandate follows the KDOQI guidelines (NKF, 2006) recommendation that there must be an emphasis on educating patients, staff, and healthcare systems; and establishing a vascular access team (VAT) for shared responsibility. The KDOQI guidelines define this team as a "patient and group of professionals involved in management of vascular access (includes care-givers who construct, cannulate, monitor, detect problems in, and repair vascular accesses) ... Caregivers include the nephrologist, nephrology nurse, patient care technician, nurse practitioner, physician assistant, interventionalist, surgeons, and vascular access coordinator" (NKF, 2006, p. S182). A further explication of team dynamics in general and the VAT responsibilities in particular can be found in the NKF publication on the team approach in CKD care (NKF, 2008).
Team dynamics necessitate not only having qualified members to fill the necessary roles, but also a high degree of cohesion and communication among them. This is difficult to achieve when the various team members are in different locations and the needs are episodic, as is the case with vascular access care. Hence, there is the need for a vascular access coordinator (VAC), a highly specialized role that has developed because of the complexity of vascular access for HD (Dinwiddie, 2007). In both the U.S. and Canada, this role has been shown to be critical to the success of the VAT in the overall management of HD access (Beathard, 2003; Dinwiddie, 2003; Kalman, Pope, Bhola, Richardson, & Sniderman, 1999; Welch, Pflederer, Knudsen, & Hocking, 1998). While the scope of the role varies greatly in both countries, the VAC should be the key professional resource responsible for coordinating and overseeing VA information and care for the nephrology access program, with a focus on maintaining optimal access function and longevity.
Continuous Quality Improvement
The team approach and the process of CQI are inextricably intertwined. There is a specific KDOQI guideline stating, "Each center should establish a database and CQI process to track the types of accesses created and the complication rates for these accesses" (NKF, 2006, p. S258). Responsible catheter management cannot be done without both. The recent ANNA CQI publication, Applying Continuous Quality Improvement in Clinical Practice, 2nd edition (Dinwiddie, 2009) and ANNA's Core Curriculum for Nephrology Nursing (Dinwiddie, 2008) detail the process and give additional resources.
For those facilities that do not have good quality data access management and CQI process, the authors would recommend the CDC's National Healthcare Safety Network (NHSN) that includes a dialysis event surveillance component (CDC, 2010). This surveillance reports pooled mean rates of bloodstream infections stratified by vascular access type from participating facilities. The system offers a free Internet-based surveillance platform facilities can use to record and track several outcomes, including bloodstream infections. The system also allows participating facilities to compare their rates with other facilities nationally. NHSN dialysis event measures are based on information that is simple to collect, in contrast to definitions frequently used for clinical diagnoses or research purposes. Patel et al. (2010) report that the use of this surveillance system has helped decrease bloodstream infection rates as well as antimicrobial use and hospitalizations with the benefit of requiring minimal staff time. NHSN provides uniform validated measures necessary for rate comparability among programs.
In the U.S., the new CMS Conditions for Coverage require all ESRD facilities to conduct surveillance for infections, particularly vascular access infections (DHHS, 2008). In Canada, it is recommended that dialysis programs liaise with infectious disease programs and establish some form of HD catheter infection tracking (Lok, 2006). A sample of the University Health Network's (UHN) Suspected Catheter Infection Algorithm is illustrated in Figure 2 as a useful CQI tool (UHN Division of Nephrology, 2010). An interdisciplinary process that incorporates the participation of the VAT to monitor and track suspected infections and provide guidance for the management of HD CRIs is also recommended as an excellent CQI initiative. Meeting on a monthly basis with a dedicated, experienced VAT to review clinical outcomes and process strategies is a vital approach to reducing HD CRIs by adhering strictly to guidelines (Lok, 2006).
The KDOQI guidelines also stress the need for research to establish the very necessary evidence base (NKF, 2006). Nurses have a wealth of experience and knowledge to contribute to all aspects of the research process. For example, nurses know sodium hypochlorite is widely used and popular because of its universal compatibility, but the CDC has not found data related to decreasing infection rates to be compelling. More research is needed. Anecdotal evidence about skin reactions to agents, such as chlorhexidine, is heard, but an organized research effort has not been undertaken to pool data and analyze collective outcomes. From small questions that arise out of clinical problems and the variability in CQI-generated patient outcomes to those questions detailed for potential research in the KDOQI guidelines, nurses are essential in this challenging aspect of patient care.
[FIGURE 2 OMITTED]
Variability in practices among dialysis units has contributed to challenges related to HD catheter care and maintenance. An interdisciplinary, collaborative approach is needed to establish and follow recommendations for the management of the HD catheter. HD catheter use should be reserved for situations where no other permanent vascular access is available or feasible, and promote a "catheter last" approach (Jindal, Chan, Soroka, Tonelli, & Culleton, 2006; NKF, 2006). However, catheters are and will continue to be a fact of life for many patients on HD. Nurses must do whatever they can to make it the best life possible. Nephrology nursing care is always about what is best for the patient, and the watchwords are "Patient First."
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Lesley C. Dinwiddie, MSN, RN, FNP, CNN, is an Independent Nephrology Nurse Consultant, Vascular Access for Education and Research, Cary, NC. She is a Past President of ANNA and a Member of ANNA's Cardinal Chapter. She may be contacted via e-mail at email@example.com
Cynthia Bhola, MN, BN, RN, CNephC, is a Hemodialysis Vascular Access Coordinator, University Health Network, Toronto, Ontario, Canada.
Note: This article is supported by an educational grant from Genentech.
Statements of Disclosure: Lesley C. Dinwiddie has disclosed that she is on the Genentech Speakers' Bureau and is also a consultant for Hemosphere Inc., Teleflex Medical, and Covidien.
Cynthia Bhola reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Table 1 Pertinent Definitions Long-Term Catheter: Also known as tunneled, cuffed catheter (TCC); a device intended for use more than 1 week that is typically tunneled and has a cuff to promote fibrous in-growth to prevent catheter migration and accidental withdrawal (NKF, 2006). Short-Term Catheter: A device intended for short-term use (less than 1 week) that is typically not tunneled. Intended for use in hospitalized patients; not for outpatient maintenance dialysis (NKF, 2006). Incident HD Patient: A patient starting HD during the calendar year (USRDS, 2009). Prevalent HD Patient: Any patient receiving maintenance HD. (Clinical performance measures count the number of patients receiving maintenance HD during their last session in December of the prevalent year.) Table 2 Highlights of the 2002 CDC Guidelines for CRB Prevention * HD catheters should be used only for hemodialysis. * Hand hygiene must be practiced by both patients and staff prior to contact with the HD catheter and/or exit site. * Clean skin for catheter insertion and dressing change with a 2% chlorhexidinebased solution. If contraindicated, an iodophor (povidone iodine) or 70% alcohol can be used instead. Povidone iodine must remain on skin for at least two minutes for the antibacterial properties to take effect. Chlorhexidine works on contact and does not require this time and procedure/dressing may begin as soon as the chlorhexidine is dry. * Sterile gauze or semi-permeable transparent dressings are suitable. Occlusive transparent dressings have been found to increase the risk of CRBs compared to gauze dressings. * Sterile gauze should be used if the patient sweats a lot, or the exit site is bleeding or oozing. * Change the dressing if it becomes damp, visibly soiled, or loosened. * Transparent dressings can be left up to a week. * Povidine-iodine ointment for HD catheter exit site. * If using IDPN/TPN, have a designated lumen. * Careful showering is allowed if a protective device is in place. * Dressings may not be needed in patients with well-healed exit sites. * Ensure catheter care is compatible with catheter material. Table 3 Comparative Pediatric Vascular Access-Related Outcomes from the 2008 CPM Report Adequacy - mean Mean Hgb Serum Albumin Catheter 1.54 11.2 g/dL 82% greater than 3.5 g/dL (BCG) Fistula 1.65 11.7 g/dL 95% greater than 3.5 g/dL (BCG) Figure 1 Monthly Vascular Access Report Card Name Date Type of Access Location Date of Placement Test/Machine Data Prescribed Actual Average Blood Flow Rate BFR x mLs/minute Average Treatment Time > -250 Blood Volume Processed < 250 Arterial Pressure > 1.4 Venous Pressure > 70% Kt/V (lab derived) URR Surveillance Prescribed Actual Access Flow (mLs/minute) > 400 to 500 AVF Monthly > 600 AVG Static Venous Pressure < 0.43 Arterial AVF Ratio Bi-Weekly < 0.35 Venous AVF < 0.75 Arterial AVG < 0.50 Venous AVG Monthly Physical Examination Yes/No (circle one) Finding Type of Event Date Action Taken Why do I need a monthly Vascular Access Report Card? The purpose of this report card is to give your hemodialysis nurse and technicians a tool to help you understand how your vascular access affects your hemodialysis treatments. Just as your cannot have hemodialysis without a functioning hemodialysis access, the quality of your treatment depends upon the the quality functioning of your access. The report card will also help you understand how your machine functions to give you safe and effective treatments. You should keep your most recent report card with you to take to any scheduled or emergency medical visits. The items listed on your report card tell you and your caregivers about specific functions of your access. See the meanings of these items on the back! Source: Used with permission from Teleflex Medical.
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|Title Annotation:||Continuing Nursing Education|
|Author:||Dinwiddie, Lesley C.; Bhola, Cynthia|
|Publication:||Nephrology Nursing Journal|
|Date:||Sep 1, 2010|
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