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 patient’s 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 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.
1. Huber T, Carter W, Carter R, et al., Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review, J Vasc Surg, 2003;38(5):1005–11.
2. Mehta S, Statistical summary of clinical results of vascular access procedures for hemodialysis. In: Vascular Access for Hemodialysis-II, Second edition, Chicago IL: Gore, 1991;145–57.
3. Nassar GM, Ayus JC, Infectious complications of the hemodialysis access, Kidney Int, 2001;60(1):1–13.
4. Pisoni RL, Young EW, Dykstra DM, et al., Vascular access use in Europe and the United States: results from the DOPPS, Kidney Int, 2002;61(1):305–16.
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8. Donlan RM, Biofilms: Microbial life on surfaces, Emerg Infect Dis, 2002;8:881–90.
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11. Jaffer Y, Selby N, Taal M, et al., A meta-analysis of haemodialysis catheter locking solutions in the prevention of catheter related infections, Am J Kidney Dis, 2008;51:233–41.
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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
Staphylococcus aureus Biofilm Formation, Infect Immun, 2005;73(8):4596–606.
14. Grudzinski L, Quinan P, Kwok S, et al., Sodium citrate 4% locking solution for central venous dialysis catheters – An effective, more cost-efficient alternative to heparin, Nephrol Dial Transplant, 2007;22:471–6.
15. Lok C, Appleton D, Bhola C, et al., Trisodium citrate 4% – An alternative to heparin capping of haemodialysis catheters, Nephrol Dial Transplant, 2007;22(2):477–83.
16. Weijmer CM, Randomised, clinical trial comparison of trisodium citrate 30% and heparin as catheter locking solution in haemodialysis patients, J Am Soc Nephrol, 2005;16:2–9.
17. Winnett G, Nolan J, Miller M, et al., Trisodium citrate 46.7% selectively and safely reduces staphylococcal catheter-related bacteraemia, Nephrol Dial Transplant, 2008;23(11):3592–8.
18. Ash S, Concentrated sodium citrate for catheter lock, Haemodialysis International, 2000;4:22–31.
19. Center of Disease Control and Prevention Guidelines, 2011. Available at: http://www.cdc.gov/mrsa/prevent/index.html
(accessed 28 June 2011).
20. Pastan S, Soucie JM, McClellan WM, Vascular access and increased risk of death among haemodialysis patients, Kidney Int, 2002;62(2):620–6.
21. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al., Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis, Ann Intern Med, 2002;136:792–801.
22. McCann M, Moore ZE, Interventions for preventing infectious complications in haemodialysis patients with central venous catheters, Cochrane Database Syst Rev, 2010;20(1):CD006894.
23. Johnson DW, Van Eps C Mudge DW, Randomized controlled trial of topical exit site application of Medihoney versus Mupirocin for the prevention of catheter –associated infections in haemodialysis patients, J Am Soc Nephrol, 2005;16:1456–62.
24. Lagaac R, Patient information leaflet: Dialysis line insertion (central venous access) Cambridge University Hospitals NHS
Foundation Trust, 2011. Available at:
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25. Dinwiddie LC, Bhola C, Hemodialysis catheter care: Current recommendations for nursing practice in North America, Nephrol Nurs J, 2010;37(5):507–21.
26. Lagaac R, Streater C, and Thompson A, Procedure: Central Venous Access Device – Care Record for dialysis patients. Cambridge University Hospitals NHS Foundation Trust, 2011. Available at:
http://connect/media/pdf/7/4/tunnelled_central_venous_cath eters.pdf (accessed 11 October 2011).
27. Pastan S, Soucie J, McClellan W, Vascular access and increased risk of death among hemodialysis patients, Kidney Int, 2002;62(2):620–6.
28. Polkinghorne K, McDonald S, Atkins R, et al., Vascular access and all cause mortality: a propensity score analysis, J Am Soc Nephrol, 2004;15(2):477–86.
29. Weijmere M, Vervloet M, Wee P, Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use, Nephrol Dial Transplant, 2004;19(3):670–7.
30. Morkrzycki M, Zhang M, Cohen, et al., Tunnelled haemodialysis bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality, Nephrol Dial Transplant, 2006;21(4):1024–31.
31. Ethier J, Mendelssohn D, Elder S, et al., Vascular access use and outcome: an international perspective from the dialysis outcomes and practice patterns study, Nephrol Dial Transplant, 2008;23:3219–26.
32. Levey J, Morgan J, Brown E, Indications for central venous catheter use in haemodialysis. In: Oxford Handbook of Dialysis, Second edition, Oxford: Oxford University Press, 2004;186–8.
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