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):138–42 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.1–4
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.
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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has reported a prevalent growth of HD patients from 1982–2008 (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
© TOUCH BRIEFINGS 2011
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