Vascular Access Management and Care a Nursing Best Practice Guide for Central Venous Catheter

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PRINTING This book is an initiative of Maria Teresa ParisottoFOR (Chief Nurse Advisor, Care Value Management, Fresenius Medical Care Deutschland GmbH), Germany NOT Co-editor of this best practice guide: Cristina Miriunis RN, B.Ec., Germany

Authors of this best practice guide:

Bruno Pinto RN, BSc, Portugal Cristina Miriunis RN, B.Ec., Germany MEMBERS Dr. Francesco Pelliccia RN, MSc, Italy ONLY Iain Morris RN, United KingdomBY Iris Romach RN, MA, Israel USE João Fazendeiro Matos RN, BSc, MBA, Portugal REPRODUCTION Lisa Webb RN, BHSc, GDipHM, Australia Nicola Ward RN, United Kingdom Ricardo Peralta PERMITTEDRN, BSc, Portugal PERSONAL Contributor to this best practice guide: COMMERCIAL Dr. Stefano StuardFOR MD, PhD, Nephrologist, Germany PRINTING FOR

NOT Reviewers of this best practice guide:

Cathy Poole RN, RSCN, MSc, PG Dip, United Kingdom Marjelka Trkulja RN, MSN, Germany Raquel Ribeiro RN, MSN, CNS, PdD (Health Mng), Germany Nusret Mehmedovic RN, Bosnia and Herzegovina Dr Žarko Belavic MD, Nephrologist, Zagreb, Croatia MEMBERS ONLY BY

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NOT All rights are reserved by the editor, authors and publisher,MEMBERS including the rights of reprinting, reproduction in any form and translation. NoONLY part of this book may be reproduced, stored in a retrieval systemBY or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor andUSE publisher. REPRODUCTION Illustrations included in this publication are the property of Fresenius Medical Care Deutschland GmbH and cannot be used without prior permission of the owner. PERMITTED PERSONAL First edition: September 2018

European Dialysis and TransplantCOMMERCIAL Nurses Association/ European Renal Care Association (EDTNA/ERCA)FOR SeestrassePRINTING 91, CH 6052 Hergiswil, Switzerland www.edtnaerca.org FOR

ISBN: 978-84-09-04228-9 D.L.: M-28118-2018NOT Layout, Binding and Printing: Imprenta Tomás Hermanos Río Manzanares, 42-44 · E28970 Humanes de Madrid Madrid - Spain www.tomashermanos.com 7

Acknowledgements

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Acknowledgements This book is an initiative of Fresenius Medical Care Deutschland GmbH. We kindly thank the authors, the contributors and the reviewers for their collaboration and enthusiasm for this project. The content created is an excellent example MEMBERSof multidisciplinary, international teamwork, developing a best practice guide for ONLY the most important aspect of the haemodialysisBY patient’s care.

Editor USE Maria Teresa Parisotto, REPRODUCTION Chief Nurse Advisor, Care Value Management, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany PERMITTED PERSONAL COMMERCIAL FOR PRINTING FOR

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Table of Contents

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1. Preface...... 17

2. Introduction...... 23 2.1 Aims for the use of this best practice guide...... 28 2.2 Groups likely to benefit from this best practice guide...... 28 2.3 Scope of this best practice guide ...... 29

3. Background ...... 31

4. Vascular Access for Haemodialysis...... MEMBERS 37 ONLY 4.1 Vascular Access Types...... BY 38 5. Central Venous Catheter...... 41 5.1 Anatomy and physiology of central veinsUSE and functional evaluation...... REPRODUCTION42 5.2 Identify the candidate...... 44 5.2.1 Patient selection...... 45 5.3 Types of CentralPERMITTED Venous Catheter ...... 46 5.3.1 Advantages of Tunnelled catheters...... 48 5.3.2 DisadvantagesPERSONAL of Tunnelled Catheters...... 49 5.3.3 The main uses of Central Venous HaemodialysisCOMMERCIAL Catheters...... 52 5.4 InsertionFOR and management requirements...... 52 PRINTING5.4.1 Insertion location...... 52 5.5 Skin preparationFOR ...... 53 5.5.1 Insertion site...... 53 5.6 CatheterNOT fixation...... 55 5.6.1 Tunnelled cuffed catheters...... 55 5.6.2 Non-tunnelled non-cuffed catheters...... 56 5.7 Dressing type and replacement intervals...... 57 Table of Contents

6. Hygiene and Infection Control...... 61 6.1 Hand hygiene...... 62 6.2 Personal Protective Equipment (PPE) and work uniform...... 69 6.2.1 Gloving...... 70 6.2.2 Face protection...... 70 6.2.3 Hair covers...... 70 6.2.4 Aprons and gowns...... MEMBERS 71 6.2.5 Uniforms...... ONLY 71 BY 7. Performing Treatment through a Central Venous Catheter..... 75

7.1 Competencies and responsibilities...... USE 77 7.2 Preparation and assessment...... REPRODUCTION78 7.2.1 Aseptic Non-touch technique...... 79 7.2.2 Preparation...... 80 7.2.3 Assessment...... 84 7.3 Connection ofPERMITTED a CVC...... 84 7.3.1 ProcedurePERSONAL...... 84 7.4 Disconnection of a CVC...... 89 7.4.1 PreparationCOMMERCIAL...... 89 7.4.2 AssessmentFOR ...... 90 PRINTING7.4.3 Procedure ...... 90 7.5 Locking theFOR CVC ...... 93 7.5.1 Locking solutions types...... 93 7.5.2 Procedure...... 94 7.6 CareNOT of the Exit Site...... 96 7.6.1 Type of dressing ...... 97 7.6.2 Type of disinfectants ...... 98 7.6.3 Type of local antibiotics...... 99 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

8. Catheter Related Complications...... 103 8.1 Catheter related bloodstream infections...... 104 8.2 Late catheter dysfunction...... 110 8.3 Catheter related venous air embolism...... 116

9. CVC Monitoring and Surveillance...... 123 9.1 Dialysis efficiency...... 124 9.2 Blood flow...... MEMBERS124 9.3 Arterial and Venous Pressures...... 125 ONLY 9.4 Recirculation...... BY 126 9.5 Transmembrane Pressure ...... 127 9.6 Urea Reduction Ratio and Kt/V...... USE 127 REPRODUCTION 10. Reporting of Central Venous Catheter Dysfunction...... 133 10.1 What, When and Why to report...... 134 10.2 Reporting responsibilities...... 140

11. Patient EducationPERMITTED for Central Venous Catheter Care...... 143 11.1 Protect the lifelinePERSONAL – things to consider in the patient´s daily life ...... 145 11.2 CVC daily care...... COMMERCIAL 148 11.3 ManagingFOR incidents & complications at home...... 149 12. RecommendationsPRINTING ...... 153 FOR 13. Conclusions...... 157 14. AppendixNOT...... 161 14.1 Table of abbreviations...... 162

15. Bibliography...... 165 Table of Contents

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Preface

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18 1. Preface Patients with end stage renal disease are fragile and vulnerable population. For those who depend on haemodialysis (HD) to treat their kidney failure, the ongoing success requires access to blood vessels capable of providing high volume extracorporeal blood flow to execute efficient HD procedure. Indeed a properly functioning and reliable autogenous arteriovenous fistula (AVF) is one of the key successes of the HD treatment. There is general consensus that AVF are preferableMEMBERS to other currently available vascular access options. Current clinical ONLY practice guidelines recommend thatBY patients with chronic kidney disease should be referred for creation of an AVF at

least 6 months before the anticipated HDUSE initiation. REPRODUCTION Although chronic haemodialysis utilizes an AVF as the preferred vascular access, HD central venous catheters (CVC) are the interim vascular access in patients with no end stage renal disease preparation or patients with acute kidney insufficiency.PERMITTED Moreover, CVC can be considered as permanent vascular access,PERSONAL preferably in the internal jugular vein, in patients with recurrent access thrombosis, low blood pressure (cardiomyopathy),COMMERCIAL severe vascular disease ("steal" syndrome), trypanophobiaFOR (fear of needles), in case of prematurePRINTING exhaustion of veins needed for AVF creation and reduced life expectancy.FOR Single-lumen catheters were initially used, either with a reciprocating dialysis pump that alternated the inflow and outflowNOT of blood through a single conduit or with continuous flow through two catheters placed in the same renal vein or in different locations such as the femoral artery and femoral vein. Subsequent improvements centered on rheologic properties Preface

and placement in more reliable locations, such as the right 19 internal jugular vein with tips location in the right atrium, using ultrasound and guide wire techniques that facilitated optimal positioning and improved performance. Double-lumen devices have increased the HD adequacy and the addition of subcutaneous cuffs to serve better anchor the catheter and prevent infection in tunneled CVC. Nowadays haemodialysis is considered as an efficient, safe and routinely performed treatment for end stage kidney disease patients. This statement is largely confirmed by the fact that more than 2.5 million ESKD patientsMEMBERS are receiving haemodialysis treatment worldwide meaning ONLYthat more than a million of sessions are performed BY daily without significant safety issues. Unfortunately the CVC continues to be referred to as the “Achilles Heel” of the HD procedure.USE REPRODUCTION Complications are associated with CVC placement (puncture of the associated artery, bleeding, major venous laceration, atrial perforation, pneumothorax, air embolism) and use (malfunction and limitationPERMITTED of dialysis performances, central vein stenosis or thrombosis, catheter infection). For patients who are treated withPERSONAL HD, the risks of major cardiovascular events, fatal and non-fatal infections and overall mortality are far greater with cathetersCOMMERCIAL than with AVF. In an observational study of 79,545FOR patients, conversion from CVC access to a workingPRINTING fistula or graft was associated with 30% decreases in both hospitalisationFOR and mortality. In a meta-analysis of 545,441 patients, CVC use was associated with 53% higher risk of death and more than twice as many fatal infections comparedNOT with working AVFs. The importance of CVC assessment and maintenance in the dialysis center and at home has been emphasized by many authors: Best practices utilisation for assessment and Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

20 maintenances of CVCs prior to, during and at the end of the HD are the basic principles preventing many complications related to CVC utilization. A well trained nursing team on assessment and maintenance of CVC and the application of standardised hygiene guidelines are key success factors strongly influencing the incidence of CVC long term complications. In this handbook dedicated to haemodialysis central venous catheters, Maria Teresa Parisotto and her collaborators have nicely and comprehensively summarised, what should be known by each actor of dialysis care to prevent or to manage effectively the central venous catheters.MEMBERS One must acknowledge Maria Teresa for having updated ONLYour knowledge in this field in a very pragmatic and didacticBY way.

USE Dr. Stefano Stuard - MD, PhD, Nephrologist,REPRODUCTION Vice President Head of Center of Excellence Clinical & Therapeutical Governance Care Value Management EMEA Fresenius Medical Care PERMITTEDDeutschland GmbH PERSONAL COMMERCIAL FOR PRINTING FOR

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Introduction

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24 2. Introduction Patients with End Stage Renal Disease (ESRD), requiring an urgent start of the extracorporeal blood purification therapy, may not always have the opportunity for creation and maturation of a native arteriovenous fistula or an arteriovenous graft implantation. Haemodialysis requires access to blood vessels capable of providing high extracorporeal blood flow. Immediate haemodialysis access should be straightforward, readily available for immediate use, and have minimal complications in the short term (days to weeks). MEMBERS Large bore central venous catheters play an important role ONLY in the treatment of acute and chronicBY haemodialysis. They represent a means for immediate vascular access in cases of

urgently needed renal replacement therapyUSE (RRT). Bedside implantation is possible even in the emergencyREPRODUCTION room and during cardiopulmonary resuscitation. Cuffed tunnelled catheters are used for RRT of intermediate duration and even for chronic haemodialysis in patients where peripheral arteriovenousPERMITTED access is felt to be problematic or impossible. Recently, PERSONALsubcutaneous port devices have been developed1,2, suggesting that in the near future central venous access might become anCOMMERCIAL acceptable and reliable alternative to a functioning arteriovenousFOR fistula.3 If dialysisPRINTING for more than one week or so is likely, a cuffed, tunnelled catheterFOR should be used. Cuffed, tunnelled catheters can also be placed for patients who require dialysis but do not have a functional permanent vascular access. Ideally, when permanentNOT dialysis access is required, a native arteriovenous fistula is created or a prosthetic arteriovenous graft is placed. Once the fistula or graft can be used reliably, the catheter is removed. Introduction

CVCs afford the luxury of immediate access to the blood 25 circulation without the requirement for cannulation; however, these devices are plagued by their propensity for infection, thrombosis and inadequate blood flow, damage to large central veins, overall cost and increased mortality risk which make their use problematic. Patients with catheters have a significantly higher mortality risk than patients with arteriovenous fistula (AVF) or arteriovenous grafts (AVG).4 Materials play an important role in terms of indwelling time of the catheter. During the past decade, there has been an emergence of technological advancementsMEMBERS in the design of dialysis catheters in an attempt to reduceONLY catheter malfunction, decrease infection rates,BY and improve their long-term efficiency. The availability of plastic polymers such as polyethylene, polypropylene, polyvinylUSE chloride, and fluorocarbons (polytetrafluoroethylene) REPRODUCTIONprovided tubing that began to meet many of the properties required for intravascular implantation. These materials are relatively thrombogenic by present day standards and also quite rigid, contributing to endothelial injury.5 PERMITTED Today, the most importantPERSONAL materials used for CVCs are silicon and polyurethane, both of which are biocompatible and durable. There is COMMERCIALno significant difference in the overall duration of functionFOR between silicone and polyurethane catheters;PRINTING however, it has been observed that the infection rates were 3.6 FORper 1,000 catheter-days for silicone catheters and 3.5 per 1,000 catheter-days for polyurethane catheters.6 From the aspect of catheter and patient survival, ‘permanent catheter’NOT is a contradiction in terms. Haemodialysis via CVC is less effective and reliable than via an arteriovenous access. A CVC reduces the success rates of later arteriovenous access procedures, enhances the risk of infection, and as a result of Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

26 these complications reduces the patient’s life expectancy. The same has to be suspected for totally implantable devices as long as prospective studies have not shown any significant advantage over tunnelled, cuffed catheters.3 Thus, it seems worthwhile to update the literature with respect to what we know and do not know about acute and chronic central venous access for haemodialysis. The basic principles governing the use of catheters for haemodialysis and the general features of non-tunnelled and tunnelled catheters are the subject of this booklet.7 MEMBERS To a large extent, the success of long-term ONLY haemodialysis (HD) depends upon the patient havingBY trouble-free vascular access (VA). VA-related complications remain a serious clinical

problem, with VA failure being a majorUSE cause of morbidity, hospitalisation and mortality. REPRODUCTION The arteriovenous fistula has been in use since it was first created over 50 years ago. If a patient is not aPERMITTED suitable candidate for an Arteriovenous Fistula (AVF), an Arteriovenous Graft (AVG) should be considered before thePERSONAL insertion of a Central Venous Catheter (CVC).8 The main user and carerCOMMERCIAL of vascular accesses in the dialysis community is FORtraditionally the nurse; however, there are very few PRINTINGrecommendations, guidelines and educational materials available for dialysisFOR nurses at present in published literature, and almost every dialysis unit has its own procedure. The large majority of available guidelines are mainly targeted at physiciansNOT and do not describe vascular accesses handling. In 2014 a Vascular Access Guide addressed to nurses was published. This Guide, which was developed by an international Introduction

panel of experts, defined AVF cannulation practices based on 27 the available clinical evidence, and provides recommendations for AVF cannulation and care.9 In 2016 a second Vascular Access Guide addressed to nurses was developed. The Guide defines the AVG best cannulation practices and provides recommendations for AVG cannulation and care.10 AVF remains the gold standard for haemodialysis access, demonstrating both improved survival and lower complication rates than either AVG or CVC.11 An AVG (synthetic or biological) is the second best option for haemodialysisMEMBERS and should be preferred over a CVC because of fewer complicationsONLY and better survival rates.12 BY

Cuffed, tunnelled dialysis catheters haveUSE the advantage of immediate usability and relatively easy placement.REPRODUCTION However, they are associated with strikingly high rates of patient morbidity and mortality. They should only be used as a bridge for arteriovenous access or as a long-term vascular access in patients who havePERMITTED exhausted all other peripheral access options. Tunnelled catheters are, unsurprisingly, associated with a high rate of PERSONALlocal exit site infections, bacteraemia/ septicaemia (“line sepsis”), and thrombotic complications. The importance of line sepsisCOMMERCIAL as a cause of death in ESRD patients cannot be overemphasised.FOR There is up to a 300-fold higher sepsisPRINTING mortality rate in all dialysis patients compared with the general population,FOR and the incidence of catheter-associated blood stream infection is at least two to four episodes per 1000 patient-catheter days.13 The clinician needs to be ever vigilantNOT in the care of the patient with a tunnelled line. Clinical findings suggestive of a catheter infection include a fever, tenderness over the tunnel or exit site and rigors during dialysis. If infection is suspected, intravenous vancomycin and Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

28 gentamicin (or according to local hospital procedures) should be administered pending the results of blood cultures. The coverage can be adjusted when the results of bacteriologic evaluation and antimicrobial sensitivity are available.

2.1. Aims for the use of this best practice guide • To raise awareness of the importance of CVC to be the last VA option for haemodialysis patients • To provide recommendations for CVC connection, disconnection and management, including the exit site care, based on the MEMBERS available clinical evidence and expert opinions, and ONLYso to minimise complications BY • To improve quality of patient care and consequently USE their quality of life. REPRODUCTION 2.2. Groups likely to benefit from this best practice guide • Nurses PERMITTED • PhysiciansPERSONAL • Healthcare Assistants • Patients COMMERCIAL • HealthcareFOR authorities PRINTING Nurses, in particular,FOR play a crucial role in the management, maintenance and preservation of CVCs; therefore it is essential to focus on their educational needs and provide guidance in this area.NOT This best practice guide has been designed to help and support all staff involved on the most appropriate approach to Introduction

manage, preserve and prolong the patency of the CVC and to 29 educate patients in all aspects of CVCs.

2.3 Scope of this best practice guide In scope: • Central Venous Catheter ▫▫ Responsibilities of the nurse ▫▫ Hygiene and infection control ▫▫ Timing of inserting a central venous catheter MEMBERS ▫▫ Assessment of catheter insertion ONLY ▫▫ Assessment prior to connectionBY ▫▫ Connection and disconnection techniques ▫▫ Exit site care principles andUSE technique REPRODUCTION ▫▫ Complications: prevention and detection ▫▫ Documentation and reporting ▫▫ Education of the patient and/or family member and/orPERMITTED care giver Out of scope: PERSONAL • ArteriovenousCOMMERCIAL Fistula (AVF) • ArteriovenousFOR Graft (AVG) PRINTING• Patient self-care FOR

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Background

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32 3. Background Vascular access for haemodialysis is closely linked to the history of dialysis. In the early days, the challenge of repeated vascular access use prevented dialysis from becoming a routine method of treatment. In 1924 Georg Haas from Germany performed the first haemodialysis treatment in humans. In a 15-minute procedure, he used glass cannulae to access the radial artery and return blood into the cubital vein.14 In 1943, Willem Kolff from the NetherlandsMEMBERS developed a “rotating drum kidney” with a larger filter surfaceONLY area made from a cellophane membrane. The firstBY patient he dialysed received 12 dialysis treatments, but the therapy was then USE stopped due to a lack of access sites, sinceREPRODUCTION placing each cannula required a separate incision along the artery.14 The outcome changed dramatically in the 1960s, when the idea of connecting an artery and a vein with rubber tubing and a glass cannula,PERMITTED originally considered by Nils Alwall from Sweden, was developed by Quinton, Dillard and Scribner into an external AV Teflon PERSONALshunt. Their first patient survived for more than 10 years after the insertion of his first Teflon AV shunt 15 COMMERCIAL in March 1960.FOR The tapered ends of two thin-walled Teflon cannulas were inserted into the radial artery and the adjacent PRINTING cephalic vein, respectively,FOR in the distal forearm. When not in use for dialysis, the external ends were connected by a curved Teflon bypass tube and later replaced by flexible silicon rubber tubing. NOT In 1961, when unable to find a surgeon to place the necessary dialysis cannula, Stanley Shaldon used the Seldinger technique to insert catheters into the femoral artery and vein.16 Background

The native AVF was born in 1966, when Brescia, Cimino, Appel 33 and Hurwich17 published their landmark account of 14 side-to side anastomoses between the radial artery and the cephalic vein at the wrist. In 1968, Lars Röhl presented results from 30 patients with radial artery side to vein end anastomosis.18 Then, in 1977, the Gracz fistula was presented and subsequently modified by Klaus Konner. This was a proximal forearm fistula that relied on the perforating vein from the superficial to the deep forearm venous system to limit blood flow in the fistula and prevent occurrence of the steal syndrome in patients with peripheral arteryMEMBERS disease due to 19 age, hypertension or diabetes. ONLY In 1969 George Thomas attached BYDacron patches to the common femoral artery and vein, which were then connected with a silastic tube and brought to the USEsurface of the anterior thigh.20 REPRODUCTION For patients with a lack of and/or exhaustion of peripheral veins, a new concept was developed. Flores Izquierdo (Mexico 21 22 City) and May (Sidney,PERMITTED Australia) proposed to remove the segment of the saphenous vein between the groin and knee and to connect it in aPERSONAL U-shaped fashion in the elbow region with the brachial artery and a suitable vein. As a variant it was proposed to implant theCOMMERCIAL totally mobilised vein to the great vessels in theFOR thigh or to anastomose the distally mobilised saphenousPRINTING vein to the femoral artery. The first step of using a graft in vascularFOR access surgery was born! In 1972, three new graft materials, one biological and two synthetic, were introduced. A modified bovine carotid artery biologicalNOT graft (Arte-graft, Johnson & Johnson), a product of research by Rosenberg was introduced for construction of vascular access in eight haemodialysis patients by Chinitz Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

34 (Philadelphia, USA). It was the first xenon-graft and received some acceptance during the 1970s.23 Soyer (Denver, USA)24 used expanded polytetrafluoroethylene (ePTFE) in animal experiments to replace various major thoracic and abdominal veins. In 1976 Baker (Phoenix, USA) presented the first results with ePTFE grafts in 72 haemodialysis patients. Since Dacron was not widely accepted25, ePTFE continues to be the material of choice. This highlights the fact that in the field of vascular access for haemodialysis special criteria must be met by the graft material: MEMBERS ONLY • Safety and ease of handling duringBY surgery • No formation of pseudo-aneurysms after repeated USE cannulation REPRODUCTION • Low infection rates • Easy surgical replacement of graft segments in case of complications In the absence of PERMITTEDa proper timely scheduled arteriovenous fistula surgical creation, a temporary vascular access for immediate use is required.PERSONAL The subclavian cannula (SC) as modified by Uldall et al.26 has gained a large clinical acceptance in recent yearsCOMMERCIAL27 since it remains in situ without restricting mobilityFOR when not in use. However, the SC carries specificPRINTING risks related to the technique of implantation and to the stiffnessFOR of the cannula itself. These include pleural effraction, venous laceration, fatal pericardial effusion, and all the potential hazards of long-term indwelling catheters such as infectionsNOT and thrombosis. In addition, its use is restricted to a single-needle double-pump machine. This limitation has been overcome by the introduction of the double-lumen catheter. However, there is still need for a simple yet safer method of Background

vascular access satisfying the following requirements: easy to 35 insert at the bedside, immediately usable with standard HD apparatus, ensured patient mobility and comfort, implantable in a relatively clean site, subcutaneously tunnelled to prevent infection, preserved peripheral vascular capital, high blood flow rate permitted, made of haemo-biocompatible material, and adapted for long-term use.28

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NOT Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter 38 4. Vascular Access for Haemodialysis 4.1 Vascular Access Types There are three types of VA for haemodialysis, which have different life spans once created: • Central Venous Catheter can be used directly after insertion (see Figure 1) • Arteriovenous Grafts can be used for dialysis treatment 2–3 weeks after placement; some of them (early cannulation Grafts) can be assessed for use one day after placement (see Figure 2) MEMBERS • Arteriovenous Fistula can be used for dialysisONLY treatment between 6–12 weeks after creationBY and can be assessed for use 4 weeks after creation (see Figure 3) USE The choice of VA is dependent on the vascularREPRODUCTION status and clinical condition of the patient, and the time available before initiation of haemodialysis. Compared to AVF or AVG, CVC is associated with: PERMITTED • An effective and convenient vascular access in dialysis patients PERSONAL • Maintaining CKD patients treated on an ambulatory mode COMMERCIAL • Flow performancesFOR close to AVF and AVG permitting to PRINTINGschedule the beginning of the therapy at a much shorter notice FOR • Immediate solution for establishing an extracorporeal circuit • Shorter patency and higher complication rates • MoreNOT episodes of thrombosis and infections • Increased hospital admissions • Higher cost Vascular Access for Haemodialysis

Figure 1. Central Venous Catheter MEMBERS ONLY BY

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Figure 3. Arteriovenous Fistula MEMBERS ONLY BY

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5 Central Venous Catheter Central Venous Catheter is also known as a central line or a Central Venous Access Device (CVAD). A CVC is an indwelling 42 device that is inserted into a vein of the central vasculature. CVCs are being used increasingly in haemodialysis (HD) settings to provide long-term venous access and have become essential in maintaining patients on HD. CVCs represent a good choice, especially when urgent or emergency HD is required either at the time of initiation of renal replacement therapy or when a permanent access via an AVF becomes dysfunctional. These devicesMEMBERS are universally available, can be inserted into different sites ofONLY the body, and maturation time is not required, allowingBY immediate HD.29

USE 5.1 Anatomy and physiology of centralREPRODUCTION veins and functional evaluation Central venous catheter access utilises the following vein choices: PERMITTED • Internal/External Jugular • Subclavian PERSONAL • Femoral COMMERCIAL The best approachFOR or access point varies depending on clinicalPRINTING need, patient condition, current coagulation state, tools available and inserterFOR skill set.

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Left Right Internal Internal Jugular Vein Jugular Vein 43 Subclavian Vein

Inferior Vena Cava (Translumbar)

Right MEMBERSLeft Femoral Femoral Vein ONLYVein BY

USE Figure 4. Access Sites Used for CVCs (Adapted from Shier D. Hole’s humanREPRODUCTION anatomy & physiology. Dubuque, IA: W.C. Brown Publishers; 1996.)

Insertion of a CVC for HD is a relatively straightforward procedure for both temporary and permanent catheters. The universal availabilityPERMITTED of ultrasound and fluoroscopic guidance has resulted in recommendations from NKF-KDOQI regarding the use of both technologiesPERSONAL for placement of cuffed, tunnelled catheters.45 COMMERCIAL There are well-establishedFOR guidelines for selection of an insertionPRINTING site for CVCs. The preferred site is the right internal jugular (IJ) vein,FOR low in the neck and close to the jugular bulb so that there is little chance for the catheter to kink when tunnelling into the chest wall. The vein course from the right IJ vein toNOT the Superior Vena Cava (SVC) is straight and short when compared with other access sites, allowing a shorter catheter and higher flow rates. When the right IJ is occluded, the right external jugular (EJ) vein should be used before attempting access on the left side.46 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

The left IJ is the third choice, and is a technically challenging approach owing to the tortuous course from the left IJ to the SVC. Careful placement deep within the right atrium (RA) is 44 essential to avoid catheter malposition and malfunction, as after placement the catheter tends to retract out of the RA and may migrate as far as the innominate veins in patients with high body mass index. Once the IJ and EJ are exhausted in patients, other alternatives can be entertained, such as subclavian veins; however, it is well known that CVCs placed into the subclavian vein have a high likelihood of subsequent venous occlusion or stenosis, which can have disastrous effectsMEMBERS in patients who require patent central veins from their arms for functional AVF or AVG.47 The decision to use the femoral veinONLY for long-term access (catheter or graft) should beBY undertaken with great care. Any patient who has the option of undergoing a kidney USE transplantation should not have a femoralREPRODUCTION catheter placed to avoid stenosis of the iliac vein, to which the transplanted kidney's vein is anastomosed. These recommendations are explicitly detailed in the NKF- KDOQI guidelines.51PERMITTED Therefore, the subclavian and femoral veins are utilised as last resort in patients who have no other upper extremity access.PERSONAL

5.2 Identify the candidateCOMMERCIAL FOR Patients who require long term maintenance haemodialysis, shouldPRINTING be referred for timely placement of a permanent vascular access (arteriovenousFOR fistula or graft) to minimise use of CVCs. CVCs are often used as a bridge to a permanent vascular access, NOTeither because the patient starts dialysis without a mature fistula or graft, or because an existing permanent access has failed. CVCs are easy to place and can be used immediately for haemodialysis. The general recommendation for vascular access in patients on haemodialysis has been Central Venous Catheter arteriovenous fistula, although recently, emphasis has been placed on a catheter last strategy.38,39 Unplanned start (UPS) of dialysis remains a worldwide concern and it is estimated that 24-49% of patients commence dialysis 45 in such a way.40 UPS patients have more clinical problems such as increased morbidity and mortality41, require increased use of healthcare resources (e.g. hospital days), are less likely to receive a choice of dialysis modality and choose a home dialysis therapy, and typically start more often on in-centre haemodialysis compared with patients starting planned dialysis.42 Much of the problems related to UPS is access driven; patientsMEMBERS starting with a central venous catheter have a much higher mortality risk as ONLY 43 compared with those using with arteriovenousBY fistula or grafts. Despite the development of guidelines, better insight into the process of vessel remodelling and maturationUSE after the creation of an arteriovenous anastomosis, the numberREPRODUCTION of HD patients with autologous AVFs is declining. The major cause for this observation is the change in the demography of the dialysis population with increasing numbers of very old patients accepted for renal replacement therapyPERMITTED (RRT), with multiple comorbidities including obesity, chronic heart failure, diabetes mellitus, peripheral vascular diseasePERSONAL (PVD), and hypertension. Poor vessel quality, previous vein punctures, and infusions hamper the successful creation of autologousCOMMERCIAL AVFs in these patients. Other factors negativelyFOR influencing AVF outcome are late referral for accessPRINTING creation and cannulation failure.44 FOR 5.2.1 Patient selection The highestNOT addressability for CVC is in the population of patients with: • exhausted other access options • severe peripheral vascular insufficiency Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

• severe heart failure • morbid obesity

46 5.3 Types of Central Venous Catheter There are 2 CVC type classifications30,31,32 • Short-term CVCs ▫▫ Non-Tunnelled ▫▫ Non-Cuffed • Long-Term CVCs, which includes: ▫▫ Tunnelled CVCs ▫▫ Implanted Venous Access DevicesMEMBERS (IVAD) Short-Term CVC: Also known as a percutaneousONLY CVC, non- tunnelled CVC, or percutaneous sheath/introducerBY (see Figure 5). A CVC inserted by puncture directly through the skin and to the intended location without passing USEthrough subcutaneous tissue.33 Site placement is typically in eitherREPRODUCTION the subclavian vein or the internal jugular vein, though it may also be inserted into the femoral vein. If the CVC will be needed for greater than 2 weeks, consider a referral for a long-term CVC. The femoral site should be avoidedPERMITTED whenever possible due to the high risk of infection, thrombosis. Femoral CVCs inserted for HD under emergency circumstancesPERSONAL should be re-sited to another CVC site within 48 hours of insertion.34,35 COMMERCIAL FOR PRINTING FOR

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Figure 5. Temporary non-cuffed catheter Central Venous Catheter

Long-Term CVC: A CVC that stays in situ for months to years includes Tunnelled CVCs, Implantable Venous Access Devices (IVADs). The main types of Central Venous Catheters are as follows: 47 • Tunnelled CVC – A long-term CVC whose proximal end is tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site (see Figure 6). Most tunnelled catheters have one or two cuffs, one of which is a Dacron cuff on the tunnelled portion of the catheter and sit 7 – 12 cm (3 - 5 inches) above the skin exit site (see Figure 7). TheMEMBERS cuffs facilitate anchoring of the catheter through granulation with the ONLY51 tissue and acts as a barrier BYto infection. Tunnelled catheters may be single or double, lumen. Examples of Tunnelled Catheters are Hickmans®, Broviac® and USE ® long-term haemodialysis catheters (e.g.REPRODUCTION Perm-Cath , Hemosplit®, or Equistream®). • Implanted Venous Access Device (IVAD) also known as a “port”. A catheter that is surgically placed into a vessel, bodyPERMITTED cavity, or organ and is attached to a reservoir or “port” located under the skin.33 PERSONAL COMMERCIAL FOR PRINTING FOR

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Figure 6. External view of a Figure 7. Examples of cuffed catheter and position of cuff catheter Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Catheter Tip Location In long-term haemodialysis, CVCs should have their tips within the right atrium (see Figure 8). The central catheter tip location 48 should be determined radiographically and documented prior to initiation of haemodialysis therapy.48

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Figure 8. Internal view of catheter tip

5.3.1 Advantages PERMITTEDof Tunnelled catheters Tunnelled CVC havePERSONAL been shown to have the following advantages, compared to other access types51: COMMERCIAL • They areFOR universally applicable. PRINTING• They can be inserted into multiple sites relatively easily. FOR • No maturation time is needed, i.e., they can be used immediately. • NOTSkin puncture of VA is not required for the HD treatments. Central Venous Catheter

• They do not have short-term haemodynamic consequences, e.g., there are no changes in cardiac output or myocardial load. • They have lower initial costs and replacement costs 49 compared to surgical interventions for creating/ implanting AVF and AVG. • They possess the ability to provide access during a period of months, permitting fistula maturation in patients who require immediate HD. • They facilitate correcting thrombotic complication (by allowing urokinase instillation at theMEMBERS right moment). ONLY 5.3.2 Disadvantages of Tunnelled CathetersBY Tunnelled cuffed venous catheters possess the following USE 51 disadvantages relative to other access types:REPRODUCTION 1. High morbidity and mortality caused by: • Thrombosis • Infection. 2. Risk for permanentPERMITTED central venous stenosis or occlusion. PERSONAL 3. Discomfort and cosmetic disadvantage of an external appliance. COMMERCIAL 4. ShorterFOR expected use-life than other vascular access PRINTINGtypes. 5. Overall FORlower blood flow rates (BFR), requiring longer dialysis times. The 2012 Caring for Australasians with Renal Impairment (CARI) NOTand the 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF/KDOQI) Guidelines51,75 provide extensive clinical practice guidelines for vascular access including central venous catheters. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

50 Account for the majority of central line– associated bloodstream infections More commonly used than long-term CVCs 36,37

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PERMITTED of Use Duration Short term* PERSONAL COMMERCIAL

Table I. Comparison of the Major Types of Central Venous Catheters of Central Venous I. Comparison of the Major Types Table FOR

Key: * Short term: usually less than three weeks. † Long weeks to months. PRINTING FOR Entry Site Percutaneously inserted into central veins (internal jugular, subclavian, or femoral vein) NOT Type Catheter Non- tunnelled CVCs Central Venous Catheter

51 Lower rate of infection than non-tunnelled CVCs Dacron inhibits cuff migration of organisms into catheter tract when ingrown Lowest risk for central line–associated bloodstream infections

MEMBERS Require surgical insertion Require local or general anaesthesia Increased cost Require surgical insertion and removal Require general anaesthesia ONLYIncreased cost BY

USE REPRODUCTION Improved body image (low visibility of port) Patient comfort Local catheter site care and dressing not needed when not in use

PERMITTED Long term † Long term † PERSONAL COMMERCIAL FOR PRINTING FOR Inserted in the subclavian or internal jugular vein. Tunnelled beneath the skin; subcutaneous port accessed with a non- coring needle. Implanted into internal jugular, subclavian, or femoral vein NOT Implanted Venous Access Devices (IVAD) Tunnelled Tunnelled CVCs Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

5.3.3 The main uses of Central Venous Haemodialysis Catheters As a temporary vascular access 52 • acute kidney injury • awaiting peritoneal dialysis catheter healing • awaiting transplantation

As a backup vascular access • failure of peripheral vascular access MEMBERS • dialysis access graft revision or replacement ONLY • removal of peritoneal catheterBY

Bridge access to allow time for maturationUSE of haemodialysis permanent vascular accessREPRODUCTION • native arteriovenous fistula • PTFE arteriovenous graft PERMITTED Permanent vascular access • Exhaustion of PERSONALall other vascular access options • Severe peripheral vascular disease COMMERCIAL • SevereFOR Heart Failure – cardio renal syndrome PRINTING• Morbid obesity FOR 5.4 Insertion and management requirements 5.4.1 InsertionNOT location Imaging facilities (fluoroscopy, intravenous contrast studies and standard radiography) should be available for the insertion of tunnelled central venous catheters (CVC).36,50,51 Central Venous Catheter

Tunnelled and non-tunnelled CVCs should be inserted by a clinician in an area where sterile conditions can be maintained (e.g. interventional radiology suite, surgical operating room) and where the patient can be monitored (i.e. ECG and pulse 53 oximetry). Radiologic insertion, in both adult and paediatric populations, has been found to increase procedure success, decrease acute complications, and result in long-term safety comparable with or better than that achieved by surgical insertion.36,50,56 Ultrasound-guided access of short-term catheters also minimises insertion complications.36,50,57,58 MEMBERS ONLY A chest x-ray should be performedBY post-CVC insertion. A further chest x-ray will be required if the patient becomes dyspnoeic or complains of lateral chestUSE wall discomfort. REPRODUCTION 5.5 Skin preparation 5.5.1 Insertion site Before placing a CVCPERMITTED (including guide-wire exchanges), it is recommended that any person who enters the sterile field to assist in the procedurePERSONAL should use maximal barrier precautions including a cap, mask, sterile gown, sterile gloves, and a sterile full body drape.62,63,64 COMMERCIAL FOR PRINTING• The patient’s hair should be entirely covered with a surgicalFOR cap. • Place surgical cap on head to cover all hair and then put on protective eyewear and surgical mask (the NOTmask should cover the nose and mouth tightly). • CVC insertion requires a surgical aseptic technique65 and therefore a surgical scrub should be performed prior to the procedure. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

It is recommended that: • Hair at the insertion site should only be removed by a clinician (prior to antiseptic application), using clippers 54 (not shaved) to improve adherence of the dressing.54 • The skin should be physically cleaned (if necessary) prior to applying the antiseptic solution and inserting the catheter. • Removal of skin lipids (defatting) by a clinician with alcohol, ether or acetone is not recommended.66 • Use alcohol-containing skin preparatory agents if no contraindication exists. The most effectiveMEMBERS disinfectant (chlorhexidine or povidone iodine) toONLY combine with alcohol has not been establishedBY in the literature (be aware that either agent may be contraindicated e.g. USE sensitivity, allergy) REPRODUCTION • If alcohol is contraindicated (e.g. allergy, sensitivity, skin condition) clinicians should use aqueous povidone-iodine 10%* or sterile normal saline 0.9% (*NB: the drying time for aqueous based antiseptics is longer than PERMITTEDalcohol based products). • 70% alcohol solutionPERSONAL (including alcohol-impregnated swabs) should not be used by clinicians as it has no residual antimicrobialCOMMERCIAL activity on the skin. • The solutionFOR should be applied vigorously by the PRINTINGclinician to an area of skin approximately 30 cm in diameter,FOR in a circular motion beginning in the centre of the proposed site and moving outward, for at least 30 seconds.54 Do not use a forward and backward NOTmovement. The clinician should repeat this step a total of three times using a new swab for each application. Central Venous Catheter

• The clinician should allow the antiseptic to air dry completely prior to inserting the catheter; do not wipe or blot36 • Clinicians should not palpate the insertion site after the 55 application of antiseptic, unless an aseptic technique is maintained36,67 • The length of the line used should be noted prior to insertion and clearly documented in the patient’s records54 • There is currently no data specifically related to the haemodialysis patient population MEMBERSthat recommends routine parenteral antibiotics at the time of insertion of a CVC to prevent catheter colonisation ONLYor bloodstream infection. BY

USE 5.6 Catheter fixation REPRODUCTION 5.6.1 Tunnelled cuffed catheters Suture at the insertion and anterior chest wall puncture sites: the suture at the insertionPERMITTED site is usually removed between 7-10 days; the second suture at the exit site should be removed after three weeks or asPERSONAL per local protocol. Sutureless securement devices: A sutureless securement device has been shownCOMMERCIAL to be superior in reducing infection risk, length of FORtime required to secure the catheter to the skin andPRINTING avoiding the addition risk of needlestick injury associated with suturing.36 FOR The potential for this device to reduce infection may derive from theNOT elimination of skin suture wounds that are contiguous to the newly inserted catheter and from minimisation of the to-and-fro positioning of the catheter, which may promote Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

invasion of the tract by cutaneous microorganisms through capillary action.36 Sutureless securement devices should be used in accordance 56 with manufacturer’s instructions.

5.6.2 Non-tunnelled non-cuffed catheters Non-tunnelled central venous catheters are used for short term therapy and emergency situations. These catheters are fixed on the skin usually with non-absorbable sutures (prolene or ethilon) to avoid slippage of the catheter. Since non tunnelled catheters do not have a cuff MEMBERSlike their tunnelled counterparts the suture is the only thing that isONLY keeping these catheters secured to the patients. BY

Nontunneled haemodialysis catheters USE(NTHCs) are typically used when vascular access is required REPRODUCTIONfor urgent renal replacement therapy (RRT). Because of the important role NTHCs play in enabling timely RRT, proficiency in NTHC insertion is a requirement of nephrology training in Canada. In the setting of acutePERMITTED kidney injury (AKI), when the duration of RRT is difficult to predict, NTHCs are the recommended initial vascular access.PERSONAL However, due to an increased risk of complications, NTHCs are the least preferred access for chronic hemodialysis patients.COMMERCIAL68 In the absenceFOR of the cuff and/or subcutaneous tunnel the CVCsPRINTING require a method of fixation to the skin. One of the most used option is FORthe classic suture to the skin, but nowadays sutureless fixation/securement devices are also available. However,NOT they are subject of a risk as they can easily migrate and in such cases it is forbidden to re-advance the catheter. Suturing the catheter has to take place in the same aseptic condition as for the placement. Attention must be paid to the Central Venous Catheter selection of the suturing material in regards of skin compatibility and minimising the patient discomfort. Patients should be instructed to refrain from scratching in the area of the suture and make sure the clothes do not pull the end of the sutures. 57

5.7 Dressing type and replacement intervals Only trained dialysis staff should change haemodialysis catheter dressings and manipulate catheters that access the patient’s bloodstream. MEMBERS Table II: Dressing types and replacement intervals ONLY Dressing type ReplacementBY interval

62,67,69 Transparent, semi-permeable, Weekly*USE self-adhesive polyurethane REPRODUCTION Each haemodialysis Gauze treatment*57,62

70 Chlorhexidine-impregnatedPERMITTEDWeekly* *All dressings should be replaced routinely as well as when the dressing becomes damp,PERSONAL loosened, no longer occlusive or adherent, soiled, if there is evidence of inflammation, or excessive accumulation of fluid. Manufacturer’sCOMMERCIAL recommendations should be followed. FOR PRINTING The following recommendationsFOR should be considered: Transparent, semi-permeable, self-adhesive, (standard or hyper-permeable),NOT polyurethane63,72 dressings. Benefits include protecting the site from extrinsic contamination, allowing continuous observation of the insertion site, and helping stabilise and secure the catheter.66,73 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

The nurse should inspect the dressing on the exit site at each haemodialysis treatment. Sterile gauze dressing secured with adhesive tape or semi-permeable dressing69,74: 58 • If gauze is used in combination with a semi-permeable dressing, it is considered a gauze dressing and should be changed at each haemodialysis treatment.36,70 • Gauze dressings should only be used by clinicians if there is a true contraindication to polyurethane dressings including diaphoresis or excessive ooze from the insertion site and should be replaced by a 63,66 transparent dressing as soon as possible.MEMBERS • Chlorhexidine-impregnated dressings ONLYand sponges have been shown to reduceBY the risk of exit site infection,75 and catheter-related bloodstream infection 76,77,78 (CRBSI). USE • The dressing (including polyurethaneREPRODUCTION types) should not be immersed or submerged in water.36 Showering is preferable to bathing, and swimming or spa bathing should be avoided with any external catheter, in order to prevent colonisation with Gram negative organisms, especially PseudomonasPERMITTED spp. Application of antimicrobialPERSONAL ointments on the exit site (e.g. medical grade honey) may require the dressing to be changed more frequently.71 COMMERCIAL FOR PatientPRINTING as well as environmental factors should be considered when selectingFOR the most appropriate dressing for use on a haemodialysis catheter.

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NOT Hygiene and 61 Infection MEMBERS ONLY BY Control USE REPRODUCTION

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6 Hygiene and infection control Healthcare-Associated Infections (HCAIs) relate to infections associated with healthcare delivery and are recognised as a major cause of death worldwide. An effective hygiene and infection control programme/policy is essential, and healthcare staff must be trained and educated appropriately and provided with the necessary resources/equipment to carry out tasks 62 and procedures safely and effectively. Infectious catheter-related risk is seven times higher than AVF and three times higher than AVG.79,80 MEMBERS Infection prevention and control is a collective term used for ONLY 81 those activities intended to protect peopleBY from infections. Standard precautions prevent healthcare-associated transmission of infectious agents USEamong patients and healthcare workers, and they must be appliedREPRODUCTION to all patients – regardless of their infection status – in all healthcare settings. They are based on the assumption that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranesPERMITTED may contain transmissible infectious agents. PERSONAL 6.1 Hand hygiene COMMERCIAL The hands of FORHealthcare Workers (HCW) play a major role in the PRINTINGtransmission of HCAIs. FOR In accordance with the World Health Organization’s (WHO) goals, this best practice guide pursues the following prevention targets:NOT • Colonisation with possible resulting exogenous infection of patients Hygiene and Infection Control

• Endogenous and exogenous infection in patients • Infection in HCW • Colonisation of the healthcare environment and HCWs

The Five Moments of Hand Hygiene Concept The World Health Organisation (WHO)82 defines five moments of hand hygiene. They correspond to the concept of patient 63 area, healthcare zone and critical sites, and are applicable to all care activities in the clinic: 1. Before touching a patient MEMBERS 2. Before clean/aseptic procedure ONLY 3. After body fluid exposure risk BY

4. After touching a patient USE 5. After touching patient surroundings REPRODUCTION

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The concept of “My five moments of hand hygiene”

When? Clean your hands before touching 1 a patient when approaching him or her Why? To protect the patient against harmful Before patient germs carried on your hands 64 contact

When? Clean your hands immediately before 2 any aseptic task Why? To protect the patientMEMBERS against harmful Before aseptic germs, including the patients’ own germs, entering his or her body ONLY task BY

When? Clean your hands immediately after an 3 exposure risk toUSE body fluids (and after glove removal) Why? To protect yourselfREPRODUCTION and the healthcare After body fluid environment from harmful patient germs exposure risk

When? Clean your hands after touching a patient 4 and his or her immediate surroundings when leaving PERMITTEDWhy? To protect yourself and the healthcare After patient environment from harmful patient germs contact PERSONAL

When? Clean your hands after touching any object 5 or furniture in the patient’s immediate surroundings, COMMERCIALwhen leaving – even without touching the patient After contact FOR with patient Why? To protect yourself and the healthcare environment from harmful patient germs surroundingsPRINTING

Reference: WHO Guidelines FORon Hand Hygiene in Health Care (2009)

Figure 9. My five moments of Hygiene” adapted from WHO NOT In accordance with the WHO consensus recommendations, hand hygiene should routinely be performed by cleansing with alcohol- based hand rub. Hygiene and Infection Control

There are indications when hands must be washed with soap and water. Each HCW must be trained on when to use which methods of hand hygiene and how to carry out the respective techniques. To ensure that hand rubbing or hand washing is carried out effectively, it must be ensured that alcohol-based rub or water and soap, respectively, covers the entire surface of the hands and wrists. Rings, wristwatches and bracelets must not be worn when carrying out direct patient care activities. The only exception to this is a single 65 plain wedding band, which must be manipulated during the hand hygiene process to ensure the skin underneath is effectively cleaned and dried. MEMBERS ONLY Hand hygiene and using the correct asepticBY or aseptic non-touch techniques when caring for the central venous catheter are the most important actions in relation to infection control.USE It has been proven through several studies, that correct and properREPRODUCTION hand hygiene, associated with correct techniques, have reduced the incidence of Catheter-Related Bloodstream Infections CRBSI.83

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Hand in hand The programme for safe hand hygiene

Washing with Rubbing with soap and water alcohol-based formulation Duration of the entire procedure: 40 sec (rubbing Duration of the entire procedure: 40 – 60 sec time 20 – 30 sec, 10 sec to allow hands to dry)

1a 1b 1 66 Wet hands with Apply a palmful water and apply of the product enough soap to in a cupped hand cover all hand and cover all surfaces. MEMBERSsurfaces. ONLY 2 3 BY 4 ... right palm over left Rub hands ... palm to palm with dorsum with interlaced palm to palm ... fi ngers interlaced ... fi ngers and vice versa ... USE 5 6 7 REPRODUCTION ... rotational rubbing, ... backs of fi ngers ... rotational rubbing backwards and forwards to opposing palms of left thumb clasped with clasped fi ngers of with fi ngers in right palm and right hand in left palm interlocked ... vice versa ... and vice versa. PERMITTED 8a 8b 9 ... dry thoroughly Rinse hands PERSONALwith a single use with water ... towel ... COMMERCIAL 10a 10b FOR 11 8 ... once dry, Once dry, PRINTING ... close tap ... your hands your hands FOR are safe. are safe.

NOT Figure 10. Hand hygiene Hygiene and Infection Control

Hand washing technique Handwashing with soap removes micro-organisms from hands. This helps prevent infections because: • People frequently touch their eyes, nose, and mouth without even realising it. Micro-organisms can get into the body through the eyes, nose and mouth and make us sick. • Micro-organisms from unwashed hands can get into 67 foods and drinks while people prepare or consume them. Micro-organisms can multiplyMEMBERS in some types of foods or drinks, under certain conditions, and make ONLY people sick. BY • Micro-organisms from unwashed hands can be transferred to other objects, likeUSE handrails, table tops, or toys, and then transferred to anotherREPRODUCTION person’s hands. • Removing micro-organisms through handwashing therefore helps prevent diarrhea and respiratory infections andPERMITTED may even help prevent skin and eye infections (https://www.cdc.gov/handwashing/why- handwashing.html).PERSONAL COMMERCIAL Many diseasesFOR and conditions are contracted simply because an individual or their caretaker did not wash his/her hands PRINTING correctly. This FORis especially dangerous for Chronic Kidney Disease patients receiving dialysis since their immune systems are already weakened, and infections account for approximatelyNOT twenty percent (20%) of total mortality (death), as reported by the Clinical Journal Of The American Society Of Nephrology (https://www.kidneybuzz.com). Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

The Hand washing technique – ideally have an elbow or hands free operated tap 1. Wet hands with water 2. Apply enough soap to cover all the hand surfaces 3. Rub hands palm to palm: right palm over 68 left dorsum with interlaced fingers and vice versa, palm to palm with fingers interlaced, back of fingers to opposingMEMBERS palms with fingers interlocked, rotational rubbing of left thumb clasped in right palm and viceONLY versa, rotational rubbing, backwardsBY and forwards with fingers of right hand in left palm and USE vice versa. REPRODUCTION 4. Rinse hands with water 5. Dry thoroughly with disposable paper towels PERMITTED PERSONAL Hand rubbing technique Contaminated hands ofCOMMERCIAL HCWs are among the most common modes of transmissionFOR of healthcare-associated infections. HandPRINTING hygiene, therefore, is singled out as the most important infection preventionFOR intervention.

NOT Hygiene and Infection Control

Hand rubbing technique: 1. Apply a palmful of the hand disinfectant product in a cupped hand and cover all surfaces 2. Rub hands palm to palm, right palm over 69 left dorsum with interlaced fingers and vice versa, palm to palm with fingers, interlaced, backs of fingers to opposingMEMBERS palms with fingers interlocked, rotational rubbingONLY of left thumb clasped in right palm,BY and vice versa, rotational rubbing, backwards and forwards with fingers of right handUSE in left palm, and vice versa REPRODUCTION 3. Once dry, your hands are safe

PERMITTED PERSONAL 6.2 Personal Protective Equipment (PPE) and work uniform COMMERCIAL PPE (hand and FORface protection, aprons and gowns) serves to protect HCWPRINTING from hazards and preventable injuries in the workplace. Some PPE items, such FORas gloves and masks, protect HCWs and patients: • It must be ensured that PPE does not pose a hazard to others, e.g. PPE must be changed between patients • NOTPPE must be removed and discarded or disinfected after use • Hand hygiene must be performed after the removal of PPE Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

6.2.1 Gloving The wearing of medical gloves in a healthcare facility serves a dual purpose: • Gloves protect the HCW from the exposure to blood and other body fluids • Gloves reduce the spread of microorganisms from the HCWs’ hands to the environment, the transmission 70 between HCWs and patients, and the transmission from one patient to another. MEMBERS 6.2.2 Face protection ONLY The mucous membranes of the eyes,BY nose, and mouth need special protection during patient care activities that are likely to generate splashes or sprays of blood,USE body fluids and secretions or excretions. Mucous membranesREPRODUCTION are penetrated more easily by pathogenic organisms than intact skin. Therefore, a face shield or goggles and mask must be worn during connection and disconnection of CVC. PERMITTED 6.2.3 Hair covers PERSONAL Although nowadays the use of hair covers in haemodialysis units is under discussion,COMMERCIAL and more and more excluded as there is no clearFOR evidence of the benefit of this, there is still a strongPRINTING recommendation to apply this type of protective equipment whenFOR working with central venous catheters. For both, patients and nurses, it is highly important to avoid any hairNOT loss or touch to the area of the exit site or to the catheter lumens when manipulating them. There is no need of sterile equipment, as simple hair protection meant to prevent Hygiene and Infection Control any possible hair contact to the central venous catheter area and lumens would be simply enough. Head covers protect HCWs from splashes of blood or other body fluid as well as from bacterial contamination. They also protect the patient from pathogens on skin squames that may be shed by HCWs during critical situations. It is recommended that HCWs wear head covers when performing catheter connection/disconnection or manipulation of the catheter 71 that involves opening of the device to the environment. For catheter connection/disconnection, hair must be tied up above collar length as minimum precaution to avoidMEMBERS contamination of the open central venous catheter Luer Lock connector.ONLY BY When using head covers, the following conditions should be observed: USE • Head covers should be disposable REPRODUCTION • Head covers must cover the hair completely • Mirrors should be available to enable staff to check if the hair is fullyPERMITTED confined. 6.2.4 Aprons and gownsPERSONAL Aprons and gowns are part of the PPE that is worn to comply with standard precautionsCOMMERCIAL84 or contact precautions (to prevent transmission ofFOR infectious agents that are spread by direct or indirectPRINTING contact with the patient or the patient’s environment and for which transmissionFOR cannot be interrupted by standard precautions alone). NOT 6.2.5 Uniforms Uniforms are not considered as PPE. They do not protect against fluids because the cloth (usually cotton) is permeable. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

They do, however, serve a dual purpose. They provide the HCW with professional attire that supports the HCW in carrying out her or his work in the dialysis unit, while at the same time preventing cross-contamination between the workplace and the home. They also convey a professional image to the patient.

72 Do not perform any activities without appropriate hand hygiene. Always wear personal protective equipment MEMBERS ONLY BY

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7. Performing Treatment through a Central Venous Catheter The use of a CVC as a definitive vascular access for HD should not be considered as first option, since there are other types of vascular accesses (AVF/AVG) with better outcomes and inferior number of complications.85,86 Despite being considered the worst haemodialysis vascular access, CVCs have to be considered, they are used in a considerable amount of patients, up to 80%, either due to the need to start haemodialysis following emergency catheter placement or due to the lack of native vessels to createMEMBERS an AVF or place 87 an AVG. Alleged reasons for this high prevalenceONLY might 76 be connected to increased age ofBY dialysis patients and 77 concomitant comorbidities like diabetes, cardio-vascular and

rheological diseases. In fact, it is consideredUSE that this type of vascular access, although not desirable, is REPRODUCTIONconsidered a lifesaving option in these case scenarios. The goal of performing a haemodialysis treatment via a CVC should be the achievement of the best patient outcome as possible, while keepingPERMITTED all possible complications under control. For this propose it is fundamental that all team members are familiarPERSONAL with the principles of CVC care, which include usage, surveillance and maintenance.88 COMMERCIAL FOR PRINTING The usageFOR and manipulation of haemodialysis CVCs must be performed only by specialised healthcare professionals. The haemodialysis CVCs must be usedNOT strictly for connection to an extracorporeal blood circuit for haemodialysis. The only exceptions are the emergency lifesaving situations. Performing Treatment through a Central Venous Catheter

7.1 Competencies and responsibilities Vascular access is a complex chapter in dialysis care. Prolonging the life and patency of the CVC is an important objective. Therefore a highly-skilled dialysis nurse is required to ensure that each connection procedure is carried out with minimal or no complications.

Previous communication and patient education increases the procedure safety. MEMBERS At every haemodialysis session, and before eachONLY connection, 76 ensure that the patient’s CVC is functionalBY (i.e. that there is no 77 difficulty in obtaining the optimal blood flow rate) thus ensuring an adequate dialysis and that there areUSE no signs of infection. The competencies and responsibilities to achieveREPRODUCTION this are as follows: Nurse • CompetencePERMITTED in assessing the CVC • Competence in CVC handling techniques and care • Competence inPERSONAL managing CVC complications • Competence in patient education related to CVC COMMERCIAL • ResponsibilityFOR for ensuring patient comfort and safety PRINTING• Responsibility for reporting and documenting all complicationsFOR relating to CVC • Responsibility for liaising with the physicians to early identify and manage CVC complications NOT Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Physician • Responsibility for providing an optimal prescription for the preservation of the CVC • Responsibility for the effective management of complications

7.2 Preparation and assessment The procedures take place in the haemodialysis treatment room, a registered nurse or a health-care assistant ensures the optimal conditions for procedures (theMEMBERS room needs to be clean, windows closed, chair and machine in the correct ONLY 78 position etc.). BY 79 Every haemodialysis room/section must have an adequate number of sinks with running water, handUSE soap and disinfectant from a hands free operated dispenser and disposablesREPRODUCTION towels. Haemodialysis systems (machine, electric bed or chair) must be connected to a potential equalisation (earth cable) if the patient has a central venous catheter. Clean and disinfectPERMITTED the surface area and equipment used for procedure preparation.PERSONAL Place the materials required on the disinfected table or trolley. Refer to the user manual for machine preparation. COMMERCIAL When a CVCFOR is used, standard precautions must always be appliedPRINTING by nurses or other caregivers and patients.53, 89 Using sterile disposablesFOR and personal protective equipment has been suggested to protect against transmission of Staphylococci and/or other microorganisms. NOT Performing Treatment through a Central Venous Catheter

7.2.1 Aseptic non-touch technique Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to minimize the risk of infection. Healthcare workers use aseptic technique in operating rooms, clinics, outpatient care centres, and other health care settings. For both connection and disconnection, an aseptic non-touch technique may also offer the optimal framework for maintaining asepsis and is based on the concept of defining key parts and key sites to be protected from contamination.91 It aims to maintain asepsis and is non-touch in nature,MEMBERS and to prevent the contamination of susceptible sites, by ensuringONLY that only 78 uncontaminated equipment (key parts)BY or sterile fluids come in 79 contact with susceptible or sterile body sites during a clinical procedure. USE REPRODUCTION As an alternative, aseptic non-touch technique can be used under strict conditions as follows: • Hands have been effectively decontaminated prior to hygienicallyPERMITTED critical steps of the procedure • Nurses should ensure that they never contaminate the key parts PERSONAL • Nurses touch non-key parts with confidence COMMERCIAL Nurses must takeFOR appropriate precautions in case of signs of infectionsPRINTING and/or inflammation. FOR

When working with central venous accesses, the staff must NOT be trained for both aseptic and aseptic non-touch technique. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

7.2.2 Preparation Environment and devices • Before starting any haemodialysis treatment via a CVC, safety conditions must be checked. It is important that the treatment room is clean, as well the dialysis station (see Figure 11). • Both the haemodialysis machine and the dialysis chair (or bed) must be connected to a potential equalisation cable (see Figure 12 – 13). • Any other pieces of medical devices to be used on the patient during an HD treatmentMEMBERS performed via a CVC must be checked to identify if theyONLY also need a 80 potential equalisation cable. BY 81 • The haemodialysis machine and the extracorporeal blood circuit must be correctlyUSE prepared prior to the connection, with no alarms and air freeREPRODUCTION extracorporeal circuit. Wherever possible, the dialysis machine should be positioned on the same side of the patient’s vascular access. PERMITTED PERSONAL COMMERCIAL FOR PRINTING FOR

NOT

Figure 11. Hygiene preparation of the dialysis treatment Performing Treatment through a Central Venous Catheter

MEMBERS ONLY 80 Figure 12. Potential equalisationBY cable 81

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Figure 12. Plug in of a potential equalisation cable Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Materials All necessary disposables and materials needed for the haemodialysis treatment (bloodlines adaptors if required, CVC connection set or equivalent spare materials) should be available at point of use, on a trolley to support the nurses activities, as well as all required personal protective equipment and recommended disinfectant/antiseptic (for surfaces, hands, skin and exit site, the latter must follow the CVC manufacturer recommendations). • CVC connection set composition, or spare disposables are: MEMBERS ONLY 82 ▫▫ 2 sterile drapes BY 83 ▫▫ 2 pairs of sterile gloves ▫▫ sterile gauze USE REPRODUCTION ▫▫ 2 x 5 cc syringes (to remove locking solution) ▫▫ 2 x 10 cc syringes (for flush of respective CVC lumens) ▫▫ 1 x 20 PERMITTEDcc vial of 0.9% sodium chloride solution or dedicated saline solution bottle/bag ▫▫ Needles PERSONAL/ spike for withdrawal of the saline ▫▫ Sharp container COMMERCIAL FOR • Personal protective equipment required: PRINTING ▫▫ 2 headFOR covers (one for the patient, according to local requirements)) ▫▫ 1 apron NOT▫▫ 2 face masks (one for the patient) ▫▫ protective goggles (or face shield/visor) Performing Treatment through a Central Venous Catheter

Nurse • Perform hand hygiene according to WHO recommendations and wear PPE (refer to Chapter 6.1 – 6.2) • Place the material required on the disinfected surface (trolley/table) • Ensure the patients is relaxed, properly positioned and comfortable • Explain routine and non-routine procedures or activities to the patients, as required MEMBERS ONLY 82 Patient BY 83 • Wear comfortable clothes (remove jewellery if present) USE • Ensure the CVC is easily accessibleREPRODUCTION • Position the patient (lying semi Fowler position, flat if patient can tolerate position) • No pillows (to prevent air embolism) if possible • Ask the patientPERMITTED not to talk during connection/ disconnection (due to risk of infection) • Prior to connection/disconnectionPERSONAL procedure: ▫▫ give the hair cover (if required) and mask to the COMMERCIAL patientFOR and instruct him/her to put them on PRINTING▫▫ assist the patient if he/she is not capable of wearingFOR the mask and head cover on his/her own ▫▫ instruct the patient to turn the head to the opposite side to where the catheter is located and to hold NOTthe breath while the nurse opens the catheter Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

7.2.3 Assessment Evaluating the patient before haemodialysis treatment will assist the nurse in the identification of potential problems that may arise before and/or during the treatment. Attentively listen to the patient to detect any changes that could be relevant. Prior to any haemodialysis treatment, patient’s general condition must be assessed: • temperature • diet, loss of appetite and any other intercurrences between treatments like vomiting, diarrhoeaMEMBERS • or some other signs or symptoms ONLY 84 85 Weigh the patient and compare the valueBY with the last postdialysis weight and to the prescribed dry weight. Blood pressure and pulse must be evaluatedUSE and all treatment parameters should be validated. REPRODUCTION The catheter exit site must be examined thoroughly for the presence of any signs of infection described further in this booklet (refer to ChapterPERMITTED 7.6).

7.3 Connection of a PERSONALCVC The connection of a patientCOMMERCIAL via CVC requires competent staff members, withFOR knowledge of the haemodialysis principles, in additionPRINTING to knowledge of catheter usage and associated risks. FOR 7.3.1 Procedure If initial assessments confirm that patients are fit to receive their haemodialysisNOT treatment the procedure for connection via the CVC can commence. Performing Treatment through a Central Venous Catheter

Aseptic connection procedure 1. Perform hand hygiene 2. Prepare the nursing trolley / table (surface disinfected with disinfectant solution – materials needed: wipe and disinfectant solution, preferably having a short effective contact time, for example alcoholic solution) 3. Ensure that the necessary disposables were previously collected and are available at the point of use. Check for package integrity and expiry date. (refer to Chapter 7.2.2) MEMBERS NOTE: Remove patient clothing which prevents access to the ONLY 84 CVC, remember to take into account the patients privacy and 85 dignity. BY

4. Ensure that the haemodialysisUSE system/machine is prepared before the patient’s arrival in theREPRODUCTION treatment area. Position the clamps on the bloodlines close to the patient connector. 5. Put on personal protective equipment (apron, head cover, goggles and mask)PERMITTED 6. Using aseptic technique,PERSONAL open a sterile CVC set (or equivalent spare material) on the disinfected nursing trolley / table and makeCOMMERCIAL sure all disposables needed are easily accessible.FOR Pour the disinfectant solution onto sterile PRINTINGgauze or use disinfectant wipes as per centre policy. FOR 7. Perform hand hygiene 8. Inspect and assess the CVC exit site and surrounding skinNOT without completely removing the dressing. If the exit site shows signs of infection, obtain an exit site swab, if allowed by your local policies and immediately report to the head nurse/shift leader/physician and follow his/her Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

instructions. If there are no signs of infection cover the CVC exit site and secure the dressing 9. It is recommended to perform exit site care during the haemodialysis session to avoid performing this key clinical element of nursing care in a rush (or follow centre policies and procedures) 10. Perform hand hygiene 11. Place the first sterile drape underneath the catheter lumens, and remove the dressing or the protective pouch of the catheter MEMBERS 12. Perform hand hygiene ONLY 86 BY 87 13. Open and arrange all the required disposables including

the CVC connection syringes, alreadyUSE filled in a designated clear area with 0.9% NaCl solution (orREPRODUCTION prepared in a different location according to your centre policies or procedures) 14. Disinfect the bloodlines, patient connectors of the extra corporeal circuitPERMITTED (connected via a recirculation device) and its clamps with alcohol solution (or follow centre policies or procedure) PERSONAL 15. Perform hand hygieneCOMMERCIAL 16. Put on theFOR 1st pair of sterile gloves and place the syringes PRINTINGfrom the CVC connection next to the connection materials. FOR 17. Using an aseptic technique, wrap the gauze soaked with alcohol based disinfectant around each catheter lumen,NOT including the catheter lumen clamps (following the manufacturer’s recommendations for the contact time). 18. Remove the first sterile drape and the soaked gauze and following aseptic steps carefully place the second sterile drape under the catheter lumens. Performing Treatment through a Central Venous Catheter

19. Remove the gloves and perform hand hygiene procedure in accordance with best practices. 20. Put on the 2nd pair of sterile gloves. 21. Working with one catheter lumen at a time and using an aseptic technique, hold the catheter lumen with new dry sterile gauze. Remove the Luer Lock cap from the catheter lumen using a sterile gauze and dispose of it. Immediately attach an empty sterile syringe (3 - 5 ml). Clean the threaded part of the catheter with sterile gauze soaked with disinfectant. Ensure the open end of the catheter lumen does not come into contact with MEMBERSany surface. ONLY 86 22. Repeat the procedure for the secondBY catheter lumen. 87 23. Open the arterial catheter lumen clamp, withdraw 3-5 ml (locking solution mixed with blood)USE and close the clamp. If unable to aspirate locking solution fromREPRODUCTION the catheter lumen, notify head nurse/shift leader and/or physician to assess and, if necessary, provide intervention. 24. Repeat the procedurePERMITTED for the second catheter lumen 25. Ensure arterial and venous catheter lumens are clamped. Working with onePERSONAL catheter lumen at a time using an aseptic technique, remove the syringe filled with 3-5 ml of locking solution mixedCOMMERCIAL with blood from the catheter lumen. ImmediatelyFOR attach a syringe filled with 0.9% NaCl solution PRINTING(never less than 10 ml). FOR 26. Open the clamp of the arterial catheter lumen and slowly aspirate a small amount of blood into the syringe and observeNOT if it contains clots. If yes do not flush. If there are no clots, continue the procedure and gently flush the catheter lumen. After flushing, close the clamp and leave the syringe connected to the CVC lumen. If unable to flush 0.9% NaCl solution into the lumen, notify the head nurse/ Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

shift leader and/or physician to assess and, if necessary, provide intervention. 27. Repeat the procedure for the venous catheter lumen. 28. Remove the flushing syringe from the arterial lumen and connect the respective bloodline in an aseptic manner. Follow the same procedure for the venous lumen. Ensure all connections (catheter lumens/bloodlines) are secured and correctly positioned. Open all clamps and discard syringes 29. Protect the catheter with the drape duringMEMBERS the treatment. DO NOT cover the drape with a blanket or patient’sONLY clothing. 88 BY 89 30. Secure the lines of the extracorporeal circuit on the sterile

drape (using the adhesive tapes). USE 31. Close the sterile drape with adhesive tapes.REPRODUCTION 32. Secure the lines of the extracorporeal circuit to the patient. 33. Remove the glove and the personal protective equipment, discard the singlePERMITTED use protective equipment and perform hand hygiene. PERSONAL NB: Ensure that bloodlines are securely fixed to the patient (e.g. with adhesive tapeCOMMERCIAL or bloodline fixation/securing devices). The bloodlinesFOR must never be fixed to the chair or bed. PRINTING When theFOR lumens of the catheter are open exposure to the air should be as minimal as possible in order to avoid contamination.7, 88 Even theNOT threaded part of the catheter cleaning should be performed with the lumen covered with a luer- slip syringe, to reduce both exposure and risk of air embolism Performing Treatment through a Central Venous Catheter

7.4 Disconnection of a CVC The disconnection of dialysis via a CVC requires similar precautions as connection, since the risks associated are also similar.

7.4.1 Preparation All necessary disposables and materials required at the end of the treatment (bloodlines adaptors if required - depends on the disposables used a CVC disconnection set (or equivalent individual materials), all required personalMEMBERS protective equipment and recommended disinfectant/antiseptic,ONLY should 88 89 be available at point of use, on a trolley,BY for supporting the nurses activities. USE The syringes with 0.9% NaCl needed for flushingREPRODUCTION the lumens of the catheter and the syringes with the prescribed locking solution can previously be prepared in a clean and designated area as close to disconnection procedure as possible. This procedure is recommendedPERMITTED to be performed by two persons, one of them being a registered nurse. PERSONAL CVC disconnection set composition, or spare disposables are: COMMERCIAL • 1 sterileFOR drape; PRINTING• 2 pairs of sterile gloves; FOR • sterile gauzes and sterile exit site care dressing (sterile gauzes and adhesive bandage can be used) • NOT2 x 3 cc syringes (for locking solution); • 2 x 10 cc syringes (for flush of respective CVC lumens); • 1 x 20 (or 2 x 10) cc vial of 0.9% sodium chloride solution; or dedicated saline solution bottle/bag. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

• Needles / spike for withdrawal of the saline and / or locking solution • 1 (or more) vial of locking solution • 2 sterile catheter caps • 1 catheter pouch (if available) • Sharp container Personal protective equipment required: • 2 head covers (one for the patient and one for the nurse depending on local policy) MEMBERS • 1 apron ONLY 90 91 • 2 face masks (one for the patientBY and one for the nurse depending on local policy) USE • protective goggles (or face shield/visor)REPRODUCTION

7.4.2 Assessment After completing thePERMITTED haemodialysis treatment perform an assessment of the patients' general condition (temperature, blood pressure, pulsePERSONAL etc.) and check the adequacy of haemodialysis session by assessing if treatment targets were reached (e.g. UF, Kt/V, COMMERCIALtreatment time). FOR PRINTING 7.4.3 ProcedureFOR The CVC disconnection procedure must start only after a thorough documented patient assessment, at the end of the plannedNOT treatment time. In case the assessment reveals any need for intervention or corrective/preventive actions the disconnection procedure may be postponed and shift leader/ head nurse/physician advice may be required. Performing Treatment through a Central Venous Catheter

Aseptic disconnection procedure 1. Prepare all the necessary disposables: bloodlines adaptors if required - depends on the disposables used, CVC disconnection set (or equivalent individual materials) and the respective previously prepared syringes for flushing and locking the catheter, the sterile exit site dressing and the protective pouch. Check for package integrity and expiry date of all disposables 2. Perform hand hygiene 3. Prepare the nursing trolley (surfaceMEMBERS disinfected with disinfectant solution – materials needed:ONLY wipe and 90 disinfectant solution, preferably havingBY a short effective 91 contact time, for example alcohol based solution) USE 4. Perform hand hygiene REPRODUCTION 5. Prepare yourself with personal protective equipment (PPE) (apron, face and respiratory protection and head cover). 6. Uncover the catheterPERMITTED and remove the used gauze. 7. Perform hand hygienePERSONAL 8. Remove the sterileCOMMERCIAL CVC Disconnection set from the wrapping FOR package or place a sterile drape on the PRINTINGdisinfected trolley / table to be able to open and place the sterile materialsFOR needed. 9. Open the CVC Disconnection set (or equivalent spare material) on the sterile drape and distribute the components in orderNOT of needs; open the packages of bloodlines adaptor, the exit site sterile dressing and a protective CVC pouch (if available) and place them sterile onto the drape. Place the pre-prepared syringes filled with saline solution Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

and catheter’s locking solution (Always check and confirm the patient’s name / date of birth prior to administration of all medications) 10. Pour alcohol solution on the gauzes and wrap them around the connections areas of the catheter with the extracorporeal blood circuit including the clamps (following the manufacturer’s recommendations for the contact time). 11. Perform hand hygiene.

Disconnection of the arterial line and bloodMEMBERS reinfusion ONLY 92 1. Stop HD machine blood pump as per manufacturers 93 operating instructions (this step mayBY be performed after gloving only if sterile gauze is used to protect the gloves USE from getting contaminated by touchingREPRODUCTION the screen – Aseptic Non-Touch Technique) 2. Perform hand hygiene if not already being gloved 3. Put on one pairPERMITTED of sterile of gloves 4. Using an aseptic technique, lift the catheter up and place a sterile drapePERSONAL underneath. Place dry sterile gauze under catheter lumens and wrap disinfectant soaked gauze around eachCOMMERCIAL catheter lumen/bloodline connection (following FOR the manufacturer’s recommendations for the PRINTINGcontact time). FOR 5. Using sterile gauze, close the arterial catheter lumen and the arterial bloodline clamps and disconnect the arterial bloodlineNOT from the catheter lumen. 6. Using an aseptic technique, connect the 0.9% NaCl solution syringe (never less than 10 mL syringe) to the arterial catheter lumen, flush it and close the clamp. Performing Treatment through a Central Venous Catheter

Leave the syringe connected. If unable to flush 0.9% NaCl solution into the lumen, notify the head nurse/shift leader and/or physician to assess and, if necessary, provide intervention. 7. Perform reinfusion procedure according to the Haemodialysis System/Machine Operating Instructions. 8. Repeat the steps for the disconnection of the venous line, proceed to lock the catheter following the procedure. (refer to Chapter 7.5). 9. Remove the gloves and perform hand hygiene.MEMBERS ONLY 92 When the lumens (hubs) of BY the catheter are 93 open, exposure to the air should be as minimal as possible in order to avoid contamination.USE 7, 90 Even the threaded part of the catheter lumenREPRODUCTION l requires cleaning whilst the lumen is covered with a luer- slip syringe, to reduce both exposure and risk of air embolism PERMITTED 7.5 Locking the CVCPERSONAL Prophylaxis against catheter thrombosis, as well as against infection is important andCOMMERCIAL should be started immediately after the catheter insertionFOR and maintained during the entire life cyclePRINTING of the catheter. Discussion regarding the type of locking solutions, i.e. eitherFOR anticoagulant, or antibacterial or both, remains a topic for further research.92,93,94 NOT 7.5.1 Locking solutions types There are several types of locking solutions, saline solution at several concentrations, heparin (LMW or Unfractionated) and Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

sodium citrate, also at several concentrations, recombinant tissue plasminogen activator (rt-PA), Urokinase or even a combination of several types. In the following table there is a description of agents, indications, effects and complications.

Table III. Description of locking solutions, the benefits and the risks associated Anti- Bactericide/ Locking coagulant Bacteriostatic Risks associated Solution effect effect + - MEMBERSBleeding/ Heparin HaemorrhageONLY 94 BY 95 + +/- - 4% Citrate USE 30-46% + + CardiacREPRODUCTION arrest Citrate + - Bleeding/ Urokinase Haemorrhage PERMITTED

7.5.2 Procedure PERSONAL Immediately after the endCOMMERCIAL of the haemodialysis treatment, each lumen of the FOR catheter should be properly flushed with 0.9% SodiumPRINTING Chloride as prescribed followed by the administration of the prescribedFOR locking solution. This intervention should be carried out on each lumen independently. With this practice, the risk of both catheter infection and catheter thrombosis is reducedNOT although not eliminated. It is commonly accepted that each catheter lumen should be flushed with 0.9% Sodium Chloride at the end of haemodialysis, to clear blood prior to the administration of the locking solution. Performing Treatment through a Central Venous Catheter

This detail of the procedure may have more impact than the locking solution itself.7 Before flushing and locking the catheter, it is crucial that the Registered Nurse performing the procedure knows the following information: • The internal volume of each CVC lumen (see Figure 14) • The type of locking solution (e.g. heparin, citrate,) to be used or if only saline solution is prescribed for preserving the lumens • The concentration of locking solutionMEMBERS as prescribed ONLY 94 • The volume of locking solutionBY as prescribed 95

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NOT Figure 14. The volumes of each catheter lumen are visible on the extensions Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Once the type, concentration, and appropriate volume of locking solution have been determined, the following steps to properly flush and lock each catheter lumen should be observed:

• After the blood reinfusion, and disconnection of the bloodlines, the CVC lumens clamps remain close. Immediately connect a 10 ml syringe filled with 0.9% Sodium Chloride and gently, applying a moderate pressure, flush back the residual blood on the catheter lumens. Clamp the catheter lumen prior to removing the syringe to prevent blood from flowingMEMBERS back to the tip of the lumen while the hub of the catheterONLY is open. 96 BY 97 • Immediately attach the syringe with the prescribed

locking solution, unclamp theUSE catheter lumen, and gently apply the appropriate volume ofREPRODUCTION locking solution slowly (approximately 8-10 seconds).95,96 • Close the clamp on the catheter lumen and remove the syringe. • ImmediatelyPERMITTED close the hub with a sterile cap. • Repeat the procedurePERSONAL for the other catheter lumen. After both lumens of the catheter are closed, protect the connections, preferablyCOMMERCIAL with a sterile pouch. FOR PRINTING 7.6 Care of theFOR Exit Site The exit site of the CVC must always be inspected at each haemodialysis treatment for any signs of irritation, infection or developmentNOT of allergy to dressing or disinfectant solution, including tenderness, skin peeling, rash, swelling, exudate and redness. Eczema and skin granulation at the exit site can also develop.90 Performing Treatment through a Central Venous Catheter

According to Bander, et al.7 the catheter exit site takes around 2 to 3 weeks to heal, which is also the period for the subcutaneous tissue grow and develop into the polyester cuff of the catheter, so the removal of the sutures should not take place before this time period. European Renal Best Practice (ERBP) recommends to always ensuring the area being cleansed around the exit site is slightly larger than the final dressing and includes the section of the catheter that will be underneath the dressing.53 Therefore, central venous catheters need to be properly secured with a dressing thus preventingMEMBERS both the risk of dislodgement and infection. Moreover, itONLY must be as 96 97 comfortable for the patient as possible.BY

On the other hand, patients should be includedUSE in the process of caring and should be educated to respectREPRODUCTION the integrity of the dressing and to maintain it dry and adhere to strict hygiene measures. Also, both, the patients and/or the caregivers should know what to do in case of the exit site dressing is compromised (e.g. PERMITTEDbecoming loose or wet). Several papers demonstrate that the simple presence of a catheter care protocolPERSONAL at unit level leads to a substantial decrease in the incidence of catheter related blood stream 53,90 COMMERCIAL infections. FOR PRINTING 7.6.1 Type of dressingFOR There is a wide variety of different types of products for dressing and securing CVCs, but the superiority of one over anotherNOT has not yet been demonstrated. In accordance to ERBP, for long-term catheters sterile gauze is preferable, for enabling maximal natural airing of the exit site. However, several trials have been conducted to ascertain which type Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

of dressing (gauze or transparent dressings) are preferable in relation to infection rate; these trials have identified that there is a significant difference between transparent, semi- permeable dressings, and standard gauze dressings.89 Ullman, Amanda et al.97 in a recent literature review, including all randomised controlled trials that evaluated the effects of CVC dressings and securement devices for their impact on catheter-related blood stream infections, CVC colonisation, CVC exit-site infection, skin colonisation, skin irritation, CVC security, dressing condition or mortality, have shown that there is high quality evidence supporting dressingMEMBERS the catheter exit site with impregnated medication (chlorhexidineONLY gluconate- 98 impregnated or silver) reduces catheter-relatedBY blood stream 99 infection compared with a dressing without medication in the frequency of catheter-related bloodstreamUSE infections (CRBSI) per 1000 patient days.90 REPRODUCTION

7.6.2 Type of disinfectants There is a varietyPERMITTED of disinfectants available. However, according to literature, the most favourable cleaning solutions are chlorhexidinePERSONAL 2% and alcohol 70%. Povidone- iodine 10% solution remains considered. Moreover, comparative studies ofCOMMERCIAL these two antiseptics, randomized studies and FOR meta-analysis tend to demonstrate superior antisepsisPRINTING with chlorhexidine whereas povidone-iodine and alcohol remain FOReffective alternatives. In fact, Betjes88referring Chaiyakunapruk, N., stated that several studies demonstrate that solutions of 2% chlorhexidine in alcohol reduce the risk of CRBSINOT by 49%. 89,90 The combined use of chlorhexidine 2% plus alcohol 70%, combines the rapid effect of the alcohol with the optimal residual effect of chlorhexidine. Ensure that the CVC is compatible with Performing Treatment through a Central Venous Catheter

the skin disinfection solution. Most CVCs and other catheter materials are generally alcohol-resistant however; alcohol can damage some types of polyurethane and silicone CVC tubing; it is important to refer to the manufacturer’s advice.91

7.6.3 Type of local antibiotics Despite some controversies, topical antimicrobial ointment may be used for at least the first two to three weeks following CVC insertion.7 The use of topical antibiotic ointment atMEMBERS the catheter exit site has a beneficial effect in reducing CRBSIsONLY (75 to 93%) 98 99 and exit-site infections, especially afterBY catheter placement and until the exit site has healed. In fact, prolonging topical USE antibiotic ointment application offers no advantageREPRODUCTION and there is always the pending risk for resistance development and Candida Albicans colonisation. Topical ointments that have been researched and evaluated are mupirocin, povidone-iodine,PERMITTED and polysporin triple antibiotic ointment (bacitracin, gramicidin and polymyxin B). Lok, Charmaine, et al87. statedPERSONAL that in several studies enrolling peritoneal dialysis patients, muporicin-resistant strains COMMERCIAL were identifiedFOR in 3-16% in this population. On the other hand, regarding povidone-iodine there are still no reports of PRINTING microbial resistanceFOR in the dialysis population. Even using a polysporin triple ointment application at the catheter exit site has not demonstrated microbial resistance or loss of efficacy for infectionNOT prophylaxis in a 6-year prospective follow-up study.53, 89 Medical-grade honey was also demonstrated in at least one study that it was equivalent to mupirocin, without the impending Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

risk of resistance. In fact, medical-grade honey is effective against resistant bacteria, protozoa, viruses and fungi.89,90

In cases of exit site infection without fever, topical application of antibiotic at the CVC exit site is the first line of approach.

MEMBERS ONLY 100 BY 101

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8. Catheter related complications 8.1 Catheter related bloodstream infections Definition Infection is a major contributor for hospitalisation of dialysis patients, responsible for about 20% of hospital admissions. Moreover, according to literature, CVCs are associated with an increased risk of adverse events, including infection, dysfunction caused by obstruction, occlusion of a central vein, lower access life span and unpredictable blood flow.98 MEMBERS 99 Allon, Sexton et al. stated that patients on ONLYhaemodialysis with tunnelled CVCs have a relativeBY risk of bacteraemia approximately 10 times higher when comparing to the risk of

bacteraemia in patients with arteriovenousUSE fistulas (AVF). REPRODUCTION 104 The use of CVCs can lead to an exit-site infection, 105 tunnel infection, bacteraemia or any combination of them. PERMITTED PERSONAL COMMERCIAL FOR PRINTING FOR

NOT Catheter Related Complications

The exit-site infection can be defined as a culture-positive inflammation external to the cuff of the catheter and localized to the exit site and not extending beyond the cuff. It is characterized by local redness, crusting, and a variable amount of exudate. In most of these cases, the patients respond well with local measures, like topical antibiotic application (without fever).

Score 0 Score 1 Score 2 Score 3 intact, healthy reddening reddening reddening, skin <1 cm around > 1 < 2 cm secretion and the CVC exit around the pus around the site; fibrin CVC exit site;MEMBERS CVC exit site fibrin ONLY BY

USE REPRODUCTION

104 105 Figure 15. Scoring the exit site infection

A CVC tunnel infectionPERMITTED is defined as a culture-positive inflammation within the catheter tunnel but beyond the catheter cuff, with negativePERSONAL blood culture. In these situations, because of the infection around the cuff, the catheter can move freely back and COMMERCIALforth, posing a risk of extrusion and having a directFOR communication with the bloodstream. Usually it is PRINTINGcharacterized by erythema, tenderness and induration in tissues overlyingFOR the catheter and > 2 cm from the exit site.53,100 Catheter-related bloodstream infection (CRBSI) is definedNOT as the presence of bacteraemia originating from an intravenous catheter. It is one of the most frequent, lethal, and costly complications of central venous catheterisation and also the most common cause of nosocomial bacteraemia.101 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Aetiology Several interrelated factors have been proposed to participate in the pathogenesis of CRBSI. The catheter itself can be involved in 4 different pathogenic pathways like colonisation of the catheter tip and cutaneous tract with skin flora; colonisation of the catheter lumen caused by contamination; haematogenous seeding of the catheter from another infected site; and contamination of the lumen of the catheter. Resistance to antibiotic therapy due to biofilm formation also has an important role in development of bacteraemia. It is important to know that a negative catheter-relatedMEMBERS sample rules out CRBSI better than a positive sample ONLYindicating one. When the blood culture obtained fromBY the catheter is positive, but the percutaneous blood sample is negative, it indicates USE colonization of the catheter rather than CRBSI.REPRODUCTION However, if the organism is S. aureus or Candida, or if patient has heart valve 106 disease or neutropenia, close monitoring is required, which 107 includes evaluation for infective endocarditis and metastatic infection. PERMITTED Potential risk factors for CRBSI include underlying disease, method of catheter insertion,PERSONAL site of catheter insertion and duration. Local risk factors, such as poor personal hygiene, occlusive transparent dressingCOMMERCIAL (although not fully scientifically proven), and FOR moisture around the exit site, S. aureus nasal colonisation,PRINTING and contiguous infections support the role of bacterial colonizationFOR in the pathogenesis of CRBSI. Other risk factors for haemodialysis related blood stream infections include NOTcontamination of dialysate or equipment, inadequate water treatment, older age, higher total intravenous iron dose, increased recombinant human erythropoietin dose, lower haemoglobin level, lower serum albumin level, diabetes mellitus, peripheral atherosclerosis, and recent hospitalisation Catheter Related Complications

or surgery. CRBSI rate varies considerably in different studies.102

Signs and symptoms The diagnosis of CRBSI is often suspected clinically in a patient using a CVC who presents fever or chills, unexplained hypotension, and no other local sign.103,104 Mild symptoms include malaise and nausea, and severe symptoms include high fever with rigors, hypotension, vomiting, and changes in mental status inMEMBERS the setting of a 105 normal catheter exit site or tunnel, on physical ONLYexamination. CVC exit-site infection is indicatedBY by the presence of erythema, swelling, tenderness, and purulent drainage around

the CVC exit site and the part of the tunnelUSE external to the cuff. Severe sepsis and metastatic infectious complications,REPRODUCTION such as infective endocarditis, septic arthritis, osteomyelitis, spinal 106 epidural abscess and septic emboli, can prolong the course 107 of CRBSI106 and should be considered in patients who do not respond appropriatelyPERMITTED to treatment. Infective endocarditis should be suspected in those patients with onset of new cardiac murmur and/orPERSONAL repeatedly positive blood cultures. A clinical diagnosis can be made after exclusion of alternative sources of infection.103 COMMERCIAL FOR ManagementPRINTING FOR Assessment of infection has to be a broad-based approach relying on an entire gamut of historical, epidemiological, clinical, diagnosticNOT parameters (physical examination, haematological, biochemical, radiological) along with microbiology. Catheters should be removed from patients with CRBSI associated with any local or systemic inflammation or Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

immunocompromised condition. Antibiotic therapy for catheter-related infection is often initiated empirically and, if the infection is accompanied by fever, the catheter should be removed and culture of the catheter tip should be performed. The initial choice of antibiotics will depend on the severity of the patient’s clinical disease, the risk factors for infection, and the likely pathogens associated with the specific intravascular device. There are no compelling data to support specific recommendations for the duration of therapy for device- related infection. Vancomycin is recommended for empirical therapy for methicillin-resistant Staphylococcus aureus; for vancomycin minimum inhibitory concentrationMEMBERS values of >2 μg/mL; in addition, alternative agents, such asONLY daptomycin, should be used. Linezolid should notBY be used for empirical therapy.107 USE Empirical coverage for Gram-negative bacilliREPRODUCTION should be based on local anti-microbial susceptibility data and the severity of 108 disease (e.g., a fourth-generation cephalosporin, carbapenem, 109 or β-lactam/β-lactamase combination, with or without an aminoglycoside). InPERMITTED addition to coverage for Gram-positive pathogens, empirical therapy for suspected CRBSI involving femoral catheters inPERSONAL critically-ill patients should include coverage for Gram-negative bacilli and Candida species.108 For empirical treatmentCOMMERCIAL of suspected catheter-related candidemia, echinocandinFOR is used or, in selected patients, 109 fluconazole.PRINTING Antibiotic lock therapyFOR should be used for catheter salvage; however, if antibiotic lock therapy cannot be used in this situation, systemic antibiotics should be administered through the colonisedNOT catheter. Since the majority of infections involving long-term catheters or totally implanted catheters are intraluminal, eradication of such infections can be attempted by filling the catheter lumen with supra-therapeutic concentrations Catheter Related Complications

of antibiotics and leaving them indwelling for hours or days, thereby creating an antibiotic lock. Antibiotic lock therapy for CRBSI should be used in conjunction with systemic antibiotic therapy and involves installing a high concentration of an antibiotic, to which the causative microbe is susceptible in the CVC lumen. The likelihood of success varies with the site of infection (e.g., tunnel or port pocket infection are unresponsive to salvage) and with the microbe causing the infection (e.g., coagulase-negative staphylococci are likely to respond; S. aureus is not).110 MEMBERS Early diagnosis and treatment are vital to reduce the ONLY morbidity and mortality involved. ManyBY guidelines exist on the prevention of CRBSI, these should be followed, and

central venous catheter must be reviewedUSE daily. Different measures have been implemented to reduceREPRODUCTION the risk for CRBSI, including use of maximal barrier, precautions during 108 109 catheter insertion, effective cutaneous anti-sepsis, and preventive strategies based on inhibiting micro-organisms originating from thePERMITTED skin or catheter hub from adhering to the catheter. Establishing continuous quality improvement programs, training of PERSONALhealthcare workers, patient education, and adherence to standardised protocols for insertion and COMMERCIAL maintenance FOR of intravascular catheters significantly reduced the incidence of catheter-related infections and represent the PRINTING most importantFOR preventive measures. New technologies for prevention of infections directed at CVCs, which have been shown to reduce the risk of CRBSI, including catheters and dressingsNOT impregnated with antiseptics or antibiotics, new hub models and antibiotic lock solutions, are in use. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

8.2 Late catheter dysfunction Definition Central venous catheter dysfunction has a variety of definitions reported in the literature. These heterogeneous designations hinder the quality assessment of renal replacement therapy, and the interpretation of studies due to different outcomes can, in the long-term, affect patient quality of life and survival. The NKF⁄DOQI guidelines define dysfunction as the failure to attain a sufficient extracorporeal blood flow rate (BFR) of ≥300 mL/min with a pre-pump arterial pressure lower than -250 mmHg.130 MEMBERS ONLY The recommendation to define catheterBY dysfunction as BFR <300 mL/min was opinion based and some have advocated

that this definition is excessively USE simplistic, because the required blood flow for adequate dialysisREPRODUCTION could be higher (up to 400 mL/min) or lower than 300 mL/min, depending on 110 the length of each haemodialysis session, and the size of 111 the catheter lumen, among other factors6. The definition of catheter dysfunctionPERMITTED should not be based only on blood flow but should include more meaningful parameters for assessing the ability to provide adequatePERSONAL dialysis. 111

Aetiology COMMERCIAL FOR CVCPRINTING failure resulting from thrombosis is a common problem in haemodialysis patients.FOR Several factors make these patients more susceptible to thrombosis formation. Haemodialysis patients have unique blood physiology. The most important featuresNOT include endothelial injury during vascular access creation and during shear stress produced by turbulent blood flow; intraluminal stasis of blood in the intradialytic period; platelet activation upon attachment to the dialyzer membrane and the catheter surface; reduced levels of antithrombin Catheter Related Complications

III and protein C anticoagulant activity; increased levels of homocysteine and fibrinogen. The location and type of thrombus can be suspected according to symptoms and signs.112 An intrinsic thrombus forms within the CVC lumen (intraluminal), on the catheter tip, or on the fibrin sheath surrounding the external surface of the catheter. When a fibrin tail forms in the catheter tip, it acts as a one-way valve and there will be an ability to infuse but not withdraw blood.113 Thrombus: Insufficient anticoagulant locking solution within the catheter or leaking into the bloodstreamMEMBERS through the side holes can promote intraluminal thrombus. TheONLY portion of the catheter distal to the side holes and BYtoward the tip does not retain the locking solution, thus being predisposed to thrombus formation.112 USE REPRODUCTION

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Fibrin sheath: Responsible for 38–50% of haemodialysis catheter malfunctions. Formation of a fibrin sheath begins at the venous insertion site and then propagates distally along the catheter. Formation often begins within 24 hours of catheter insertion and total encasement of the catheter may occur within one week. The sheaths are composed of a combination of fibrin, collagen, endothelial cells, and thrombus (in various stages of organisation).

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Although a clear linkPERMITTED with the appearance of the biofilm has not been established,PERSONAL it has been shown that infectious complications increase the risk of catheter-related thrombosis.114 An extrinsic thrombus COMMERCIALmay form around the catheter in the vein leading toFOR catheter adherence to the vessel wall, or it may formPRINTING in the atria. Although mural thrombi are found in at least one third of patientsFOR with an indwelling central venous catheter of more than one month duration,115 only 5% develop clinical symptoms or signs of thrombosis. The main cause of mural thrombusNOT formation is vascular injury at the vascular entry site or at the catheter tip, where the cardiac cycle associated motion causes repetitive friction.116 Catheter Related Complications

Signs and symptoms The majority of thrombi associated with CVC are asymptomatic. Patients with chronic renal replacement therapy (CRRT) may have localized swelling, pain, tenderness, and erythema along the course of the involved arm or neck vein, especially when the thrombosis arises in a superficial vein. For patients with deep vein thrombosis (DVT), there may be ipsilateral swelling of the arm and tenderness over the course of the affected brachial, axillary, or internal jugular vein. If the thrombosis occludes the innominate vein or SVC, thereMEMBERS is often face and neck swelling, headache, and hoarseness. VisibleONLY collaterals involving the upper chest wall or shoulderBY area frequently develop with occlusion of the subclavian or innominate vein or SVC. If thrombosis involves the catheterUSE tip, it may not be possible to withdraw blood and/or to infuseREPRODUCTION fluids and there 112 may be leaking at the access site. Infection at the insertion 113 site should be considered because this increases the risk of concomitant catheter-related thrombosis and influences the management of thePERMITTED complications.117 In general, symptomsPERSONAL vary from local tenderness or pain at the site of entry to obstructive symptoms with swelling of the ipsilateral extremity, neck,COMMERCIAL or face. Atrial thrombi may become symptomatic, FOR with pulmonary or systemic (paradoxical) embolismPRINTING or catheter dysfunction, or may be incidentally found as an atrial mass.FOR In the experience of the authors of various studies, many patients who undergo an echocardiogram bring equivocalNOT reports describing valve vegetation versus tip catheters thrombi.118 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Management The goal in treatment is to provide safe, efficient, cost-effective and sustained catheter function while preserving future central vein access for AVF creation or AVG placement. When approaching a patient with CVC for treatment, a forceful saline flush is very important for maintaining and prolong patency of a dialysis catheter. Indeed, some literature suggests that in case of a malfunctioning catheter, this procedure should be the first approach in cases of catheters that had previously properly functioned. To adequately perform this procedure a luer-slip 10 mL syringe is the optimal choiceMEMBERS (one per lumen). 7 ONLY Endovascular and pharmacologic therapiesBY are available with different success rates.

USE Endovascular therapy REPRODUCTION 114 Effective procedures to prolong tunnelled catheter patency 115 barely exist and there is little reliable evidence on which method is the best PERMITTEDone. The method of choice advocated by the NKF-KDOQI is disruption of the fibrinPERSONAL sheath with a balloon and/or catheter exchange. According to Valliant, Chaudhry et al.119 exchange procedure does not COMMERCIALcause an increase in infectious complications FORand provides patency rates similar to those of de novoPRINTING catheter placements. FOR A recent paper compared the standard “exchange” of a catheter to a “revision” procedure. An exchange involves a well-describedNOT procedure where the catheter is really exchanged over a wire, the venotomy site is not entered and the exit site is unchanged. A revision involves an incision under sterile conditions at the initial venotomy site and then a Catheter Related Complications

new tunnel and exit site is made. The authors concluded that revision technique limits the risk of infection and allows any diagnostic or interventional study, including angiogram and/or angioplasty, to be performed more easily.120 The comparisons of sheath disruption by stripping or catheter exchange with or without an angioplasty balloon do not show any special advantages of the technique over the other.121 Catheter replacement with sheath disruption is invasive, inconvenient, costly, time-consuming and increases risk of additional complications in patients. The choice of technique should be guided by factors including costMEMBERS and patient and physician preference. ONLY Reposition is necessary when the catheterBY tip is malpositioned in a wrong vein, as well as when it is too upward or downward in the correct vein. This procedure shouldUSE ideally be performed with fluoroscopy to guide the endovascular REPRODUCTIONprocedure, locate 114 the tip position and diagnose central vein stenosis. 115

Pharmacological therapyPERMITTED The relative net benefit of anticoagulant therapies for prevention of catheterPERSONAL malfunction remains uncertain. Some authors found thatCOMMERCIAL prophylactic warfarin has shown some effect inFOR reducing thrombus formation rates in patients withPRINTING a tunnelled catheter, but this effect occurred only when the adequate internationalFOR normalized ratio was at the correct range, 1.5 to 2.0.94 It is well known that there is an increased risk of bleeding in dialysisNOT patients due to uraemia, which causes platelet dysfunction and heparin use during dialysis, among other factors, all of which make this approach difficult. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Moreover, use of warfarin in haemodialysis patients has become controversial because warfarin may promote vascular calcification.122 Of the commonly available antiplatelet agents, none of them – whether it be acetylsalicylic acid, clopidogrel or dipyridamole have shown consistent efficacy in preventing tunnelled dialysis catheter thrombosis.113 Further high-quality randomized studies, including safety outcomes, are needed. MEMBERS 8.3 Catheter related venous air embolism ONLY BY Definition

Venous air embolism (VAE), a subset ofUSE gas embolism, is an entity complication with the potential for severeREPRODUCTION morbidity and 116 mortality. It is a predominantly iatrogenic complication that 117 occurs when atmospheric gas is introduced into the systemic venous system. PERMITTED Central venous access procedures create a risk for venous air embolism. VenousPERSONAL air embolism is a serious and poorly recognized complication that can occur at the time of CVC insertion, while the catheterCOMMERCIAL is in place, or at the time of catheter removal.FOR123 PRINTING FOR Aetiology Air emboli exist only when there is a connection between air and theNOT vascular system. A pressure gradient is required to drive air into the vascular system; a central line or its tract (post-removal) is an example of such a connection. Often these lines terminate in the superior vena cava where low Catheter Related Complications

central venous pressure (CVP), below atmospheric pressure, further increases the likelihood of an air embolism. A venous air embolism occurs when air enters the venous system and eventually causes an obstruction in the pulmonary circulation. The gradient between external atmospheric pressure and the intravascular low CVP is especially increased by hypovolemia or during inspiration by creating a negative intrathoracic pressure which enhances the possibility of air entry. As CVP may be sub-atmospheric at baseline in up to 40% of patients, those patients in anMEMBERS upright position or those undergoing interventional radiologyONLY procedures such as haemodialysis catheter placementsBY are particularly susceptible.124 USE REPRODUCTION Signs and symptoms 116 117 Symptoms and signs associated with serious air embolism are non-specific and canPERMITTED be difficult to diagnose. Affected patients can suffer cardiovascular and pulmonary symptoms including tachyarrhythmia, chestPERSONAL pain, cardiovascular collapse, dyspnoea, continuous coughing, hypoxemia, and respiratory distress. Neurological COMMERCIAL symptoms include seizures, loss of consciousness,FOR altered mental status, and hemiparesis/ hemiplegia.PRINTING In many cases, patients may exhibit sudden onset of a combinationFOR of signs and symptoms. Although much of the literature discusses arterial infarcts as a result of air embolism, it is worthNOT noting that intravascular air can also cause venous infarcts.125 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Management When venous air embolism is suspected, appropriate management must be started promptly while waiting for the results of diagnostic tests. It is paramount to locate the source of air entrance in order to stop further emboli generation. Intensive supportive care should be initiated at once in a closely monitored setting. Most often the affected patients are critically ill and thus adequate oxygenation by high- flow oxygen is essential, with consideration of mechanical ventilation in the case of life-threatening respiratory failure. Aggressive fluid resuscitation and vasopressinMEMBERS administration are often needed to maintain hemodynamic ONLY stability. Once the diagnosis of venous air embolismBY is confirmed, more definitive therapy can be considered, especially if the patient is haemodynamically unstable or complicatedUSE by end-organ damage. However, apart from the above supportiveREPRODUCTION measures, specific recommendations pertaining to the management of 118 established venous air embolism still have not been firmly 119 established].126,127 In the case of embolicPERMITTED obstruction at the right ventricular outflow tract, an assumption of the ‘Durant’s position’ (laying the patient on the left side)PERSONAL together with a head-down inclination has been suggested as the initial management step. However, the ideal position assumedCOMMERCIAL by an affected patient remains controversial, FORas recent animal studies have demonstrated a lackPRINTING of clinical improvement despite relocating air bubbles to the apex of theFOR right ventricle by means of postural changes. It has been suggested that if a patient is in the Trendelenburg position at the time when air is in the systemic venous system, the buoyantNOT air emboli can migrate into the veins of the lower extremities, causing peripheral venous obstruction and tissue ischaemia. As a consequence, cyanosis, numbness and pain can occur. However, the outcome of this complication may Catheter Related Complications

not be life or limb-threatening if the peripheral circulation is still in good order. In order to remove the trapped air, intra- cardiac aspiration has been recommended. However, the effectiveness of this option is questionable, since evaluation of this aspiration procedure has been carried out mostly in animal and laboratory studies. In humans, attempts to aspirate air in haemodynamically compromised subjects have often yielded disappointing results.128 The management consideration for cerebral air embolism, involving a retrograde or paradoxical pathway, is different. The affected patient should be placed flat and MEMBERSsupine, rather than in a Trendelenburg position, to avoid potentialONLY exacerbation of any cerebral oedema. Moreover, inBY the case of paradoxical cerebral air embolism, a head-down inclination is ineffectual in preventing the air bubbles from beingUSE propelled into the cerebral vasculature. Among all of the proposedREPRODUCTION therapeutic options, however, hyperbaric oxygen treatment is probably the 118 only one that has been proven to be effective for both venous 119 and arterial air embolism, particularly in patients with cerebral involvement. The PERMITTEDhigh barometric pressure reduces the volume of air emboli and maintains high oxygen content in the blood to optimize oxygenationPERSONAL of ischemic tissues. As a result, cerebral oedema can be alleviated with a resultant reduction in intracranial pressure.COMMERCIAL If the treatment is started within one to six hours, a FORmore favourable outcome has been observed. BecausePRINTING of the paucity of evidence-based data for the treatment of venous air embolism,FOR the role of preventive measures in avoiding iatrogenic venous air embolism has assumed much greater importance. Trendelenburg positioning, Valsalva manoeuvre,NOT prompt needle/catheter occlusion, and tight intravenous connections help to avoid this complication during CVC placement. Prior to CVC removal, patients should be placed in the supine position. The CVC should be removed Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

during exhalation, when intrathoracic pressure is greater than atmospheric pressure. Firm pressure should be applied for at least one minute following removal.123

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9. CVC monitoring and surveillance 9.1 Dialysis efficiency Dialysis efficiency is monitored in several ways. During the haemodialysis treatment (blood flow, arterial/venous pressure, recirculation and transmembrane pressure), by the nutritional status (haemoglobin, albumin), observing and documenting patients status (hydration status, mineral bone disease, general well-being, etc.) and by calculating dialysis dose Kt/V and Urea Reduction Ratio (URR). CVC performance (maximum blood flow rate,MEMBERS blood resistance and recirculation) should comply with delivery ONLYof an adequate dialysis dose without altering the patient’sBY treatment schedule (frequency, dialysis duration) 129 . Monitoring the various pressures throughoutUSE the extracorporeal circuit is important in guarding against or detectingREPRODUCTION clotting, disconnection, kinking or obstruction of blood tubing, or dysfunction of the vascular access.130 PERMITTED 9.2 Blood flow 124 Blood flow131 is the amountPERSONAL of blood moved from the patients’ 125 vascular access to the dialysis machine and back to the patient during 1 minute. It is measuredCOMMERCIAL by mL/min. Blood flow with a tunnelled CVCFOR132 should be at least 300 mL/min even up to 400PRINTING mL/min. FOR A higher blood flow equates to improved haemodialysis treatment131. Two problems can occur in the modern volumetric haemodialysisNOT machines: • The pump segment elasticity in the haemodialysis tubing influence the amount of blood moving through CVC Monitoring and Surveillance

it. When the segment is getting warmer during the treatment, there is a slight decrease in blood flow. • When the blood pump flow increases, the pre-pump pressure becomes more negative. The pump segment does not fill properly with blood and the measurement of the blood flow is less accurate. Blood flow deterioration caused by catheter dysfunction is usually progressive and can easily be measured and documented: • Start dialysis • Decrease arterial pressure to -250mmHgMEMBERS ONLY • Measure blood pump speed afterBY 5 minutes • Document the result

• Compare the results to previous/futureUSE treatments REPRODUCTION A decline of <10% in blood flow under the same negative arterial pressure should not be of any concern. A decline of >10% can indicate catheter dysfunction and should be treated accordingly. PERMITTED

124 The blood flow PERSONALmeasurement should be done from 125 the first use of a new catheter. COMMERCIAL FOR 9.3 ArterialPRINTING and Venous Pressures Arterial PressureFOR Arterial Pressure monitors the pre-pump arterial (negative) pressureNOT inside the bloodlines. Pre-pump pressure is the main indicator of vascular access function. But this figure does not stand alone. Arterial pressure negative more than -250 mmHg with a blood flow of 300mL/min indicates mal function of the CVC.130 Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

Venous Pressure Venous pressure monitors the positive pressure of the bloodlines post dialyser. A high venous pressure indicates an obstruction either of the bloodlines (kink, closed clamps, clots in the drip chamber) or malfunction of the CVC.

9.4 Recirculation Daugirdas133 defines re-circulation “whenever the blood leaving the dialyser outlet returns to the inlet without having traversed first the peripheral urea-rich tissues”.MEMBERS Recirculation is measured by urea based or non-urea based ultrasound, thermal dilution techniques. Recirculation excidingONLY 10% using the urea based technique, 5% using theBY ultrasound technique and 15% using the thermal dilution technique should prompt USE be investigated. REPRODUCTION In 2003 Sefer et al.134 measured the percentage of urea recirculation in haemodialysis by a dual-lumen central venous catheters of various locations. They found that when haemodialysis is deliveredPERMITTED using the correct blood lines connection, the measurements have shown 5% recirculation 126 for jugular and subclavianPERSONAL catheters, and 5-10% for femoral 127 catheters. COMMERCIAL However, in casesFOR when the venous lumen of the catheter is used as an arterial lumen, and vice versa, urea recirculation is belowPRINTING 10% for jugular catheters; whereas in femoral catheters the percentage FORis > 20%. Recirculation is not a major problem unless short femoral lines are usedNOT (< 30%). In other CVCs, recirculation is no more than 3%.132 CVC Monitoring and Surveillance

9.5 Transmembrane Pressure Transmembrane pressure (TMP) is the difference in hydrostatic pressure between the blood compartments across the dialysis membrane and the dialysate compartment that determined the ultrafiltration (UF) and convection during the treatment. The number is always negative in the beginning of the treatment and changes to more positive during the treatment as part of the blood compartments are clotted.130 CVC malfunction might stop the blood pump several times during the treatment, blood clots block the blood compartment and TMP is more positive. Thus insufficientMEMBERS blood pump speed and low arterial pressure indicate CVC malfunction.ONLY BY

9.6 Urea Reduction Ratio and Kt/V USE Urea reduction ratio (URR) is a measure of REPRODUCTIONthe proportionate reduction in blood urea nitrogen over the course of dialysis. It is calculated as: URR=100%×(predialysisPERMITTED BUN−postdialysis BUN)

126 PERSONALpredialysis BUN 127 The pre- and post- ureaCOMMERCIAL levels can be input in any of the following five FORmeasurement units: PRINTING• mg/dL • g/L FOR • g/dL • mg% • NOTmg/L It is an alternative expression of the R term in the Daugirdas135 equation for spKt/V. For example, if a patient started dialysis Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

with a BUN of 100 mg/dL and finished dialysis with a BUN of 30 mg/dL, R would equal 0.3 and URR would equal 70%. As thereby implied, there is an inherent mathematic correlation between URR and spKt/V. Discrepancies between URR and spKt/V derive from three primary sources: 1. URR is not directly indexed to body size 2. URR does not directly account for urea generation during dialysis 3. URR does not account directly for convective urea losses. MEMBERS ONLY Nonetheless, the two are largely consideredBY interchangeable, and both are endorsed by guideline committees as valid markers of dialysis adequacy. USE The urea reduction ratio or the urea reductionREPRODUCTION percentage (URP) can be used to monitor dialysis efficiency based on pre- and post-dialysis urea nitrogen levels which are measured on a routine basis, each month or every 12-14 dialysis sessions. PERMITTED

128 By providing insight PERSONAL on the amount of dialysis when the 129 clearance of urea exceeds the urea generation rate, the URR shows whether the setCOMMERCIAL dialysis rate is able to remove waste products fromFOR the body. This efficiency is expressed as a percentage.PRINTING URR values lowerFOR than 60% indicate high levels of urea build up and increased adverse outcome. In some cases nutritional deficiency can worsen the status of the patient.135,136 NOT The Kt/V is mathematically related to the URR and is in fact derived from it, except that the Kt/V also takes into account two additional factors: CVC Monitoring and Surveillance

• urea generated by the body during dialysis • extra urea removed during dialysis along with excess fluid The Kt/V is more accurate than the URR in measuring how much urea is removed during dialysis, primarily because the Kt/V also considers the amount of urea removed with excess fluid. Consider two patients with the same URR and the same post dialysis weight, one with a weight loss of 1 kg during the treatment and the other with a weight loss of 3 kg. The patient who loses 3 kg will have a higher Kt/V, evenMEMBERS though both have the same URR. ONLY The fact that a patient who loses moreBY weight during dialysis will have a higher Kt/V does not mean it is better to gain more water weight between dialysis sessionsUSE so more fluid has to be removed, because the extra fluid puts a strainREPRODUCTION on the heart and circulation. However, patients who lose more weight during dialysis will have a higher Kt/V for the same level of URR. A linear equation hasPERMITTED been developed and been shown to give reliable results for spKt/V when applied to HD administered 3 137 128 times per week : PERSONAL 129 spKt/V=-ln(R-0.008 xCOMMERCIAL T)+(4-3.5 x R)x0.55xWeight loss/V FOR R isPRINTING the ratio of post dialysis to pre dialysis BUN; V is body water volume andFOR Weight loss is expressed in the same units; and T is treatment time in hours. However, for other schedules including twice or up to 7 treatmentsNOT per week, the results stray from Kt/V values assessed by formal urea modelling. The errors are largely due to differences in the effect of urea generation between treatments. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

A recent change to the above established formula accounts for this variable and effectively eliminates these errors138: spKt/V=-ln(R-GFAC x T)+(4-3.5 x R)x0.55xWeight loss/V This equation differs from the above by substitution of GFAC (G factor) for the constant 0.008. GFAC is a term that reduces R to its estimated value in the absence of urea generation and ranges from 0.0045 to 0.0175, depending on the frequency of treatments, but mostly on the preceding inter dialysis interval (PIDI). Values can be obtained from a table in the original publication and can be roughly estimated asMEMBERS 0.175 divided by the PIDI in days. ONLY On average, a Kt/V of 1.2 is roughly BYequivalent to a URR of about 63 percent. Thus, another standard of adequate dialysis is a minimum Kt/V of 1.2. USE REPRODUCTION The Kidney Disease Outcomes Quality Initiative (KDOQI) group has adopted for thrice-weekly HD in patients with low residual native kidney clearance (Kru < 2 mL/min), the target single pool Kt/V (spKt/V)PERMITTED dose 1.4 volumes per dialysis, minimum dose 1.2, as the standard for dialysis adequacy. Like 130 the URR, the Kt/V mayPERSONAL vary considerably from treatment to 131 treatment because of measurement error and other factors. So while a single lowCOMMERCIAL value is not always of concern, the average Kt/V FOR should be at least 1.2. In some patients with largePRINTING fluid losses during dialysis, the Kt/V can be greater than 1.2 with a URRFOR slightly below 65% in the range of 58 to 65%. In such cases, the KDOQI guidelines consider the Kt/V to be the primary measure of adequacy.139 These dialysisNOT adequacy guidelines were determined on the basis of studies in large groups of patients. These studies generally showed that patients with lower Kt/V and URR numbers had more health problems and a greater risk of CVC Monitoring and Surveillance

death. However, the HEMO study showed that a Kt/V greater than 1.2 did not result in improved outcomes.140 If a patient’s Kt/V is always above 1.2 and the URR is close to 65 percent, then the patient’s treatment is meeting adequacy guidelines. The patient’s URR may be a few points below 65 if the person has large fluid losses during dialysis.

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10. Reporting of Central Venous Catheter Dysfunction CVC dysfunction and catheter related infections can lead to an increase in mortality and morbidity of haemodialysis patients. Haemodialysis CVC dysfunction result in significant causes of catheter loss and interrupted haemodialysis sessions. Catheter dysfunction can be defined as the failure to attain or maintain adequate blood flow. Blood flow problems can be initially related to mechanical issues, although, frequent and prolonged problems are often related to thrombosis. Attention to monitoring for dysfunction andMEMBERS infection, the two major clinical complications of catheter use,ONLY as well as prompt intervention to salvage the functionalityBY of the CVC, are essential in preventing or minimizing potential morbidity

and mortality. USE REPRODUCTION 10.1 What, When and Why to report All problems that may affect the patency, integrity and survival of the CVC should bePERMITTED reported. Early detection and immediate referral for intervention following reported dysfunction or infection will assist inPERSONAL prolonging the longevity of the CVC access and most importantly may prevent further complication. Current guidelines recommendCOMMERCIAL that CVC and exit site monitoring andFOR surveillance are part of the dialysis care providedPRINTING to patients with ESRD in order to identify and 134 intervene at an FORearly stage. 135 Complications related to CVC dysfunction, integrity and infectionNOT must be reported as described in Table IV. Reporting of Central Venous Catheter Dysfunction Why to report

Air may be sucked into the catheter due to the negative pressure within the chest during inspiration particularly if the patient is sitting up leading to possible air embolism prevent air entering the To patient and to reduce catheter contamination and prevent infection enhance education on best To practice and reduce risk of air entering the CVC MEMBERS ONLY BY

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If air enters the patients venous system: during catheter use PERMITTEDcatheter integrity failure (fracture/hole in the lumen) the catheter accidently cut clamp/cap failure dialysis lines not connected securely during dialysis PERSONAL

Table IV. Reporting of Central Venous Catheter Dysfunctions Reporting of Central Venous IV. Table COMMERCIAL FOR PRINTING 134 What to Report When to report FOR 135 Mechanical failure of catheter Catheter fracture Chest pain Dyspnoea Tachycardia/irregular pulse Hypotension Evidence of air in the lumen on aspiration Air entering the catheter lumen due to procedure failure

NOT Identified Problems Air in the catheter lumen Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter Why to report The catheter could cause The damage to the vein wall. damaged site could develop platelet/ clot formation leading to a thrombosis. Patients who develop thrombosis have an increased risk of pulmonary embolism and infection Immediate reporting can trigger Doppler/ultrasound to check catheter position and prevent further complications i.e. damage to the vein wall and platelet/ clot formation (thrombosis) MEMBERS ONLY BY

USE REPRODUCTION During patient assessment prior to commencement of haemodialysis During catheter patency check when evident aspiration problems are identified PERMITTED PERSONAL COMMERCIAL FOR PRINTING 136 What to Report When to report FOR 137 Swelling of neck, chest, arm or leg Skin discoloration numbness Tingling Skin temperature changes Coughing Pain on the side of insertion Palpitations Inability or difficulty aspirating from the catheter

NOT Identified Problems Thrombosis Catheter malposition Reporting of Central Venous Catheter Dysfunction 113 113 Why to report Catheter loss of patency can be caused by malposition of the catheter against a vessel wall, a kink in the catheter and the formation of fibrin or clot formation in the catheter Immediate reporting can trigger Doppler/ultrasound to check catheter position and prevent further complications from malposition i.e. damage to the vein wall and platelet/ clot formation (thrombosis). The ultrasound can also determine kinking of the catheter MEMBERSRegular monitoring of the catheter blood flow rate (Qb) and negative arterial pressure during haemodialysis (PA) can identify potential catheter dysfunction and facilitate early intervention ONLY BY

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During catheter access any aspiration problems from the catheter When the catheter lumen is kinked or twisted PERMITTEDWhen a clot or fibrin sheath is present in the catheter lumen PERSONAL COMMERCIAL FOR PRINTING 136 What to Report When to report FOR 137 Inability to flush the line Inability to aspirate/ infuse from the catheter Poor blood flows during dialysis treatment

NOT Identified Problems Catheter loss of patency blockage

Esto de aquí arriba es una ñapa, pero por tiempos no me voy a poner a investigar cómo quitar el encabezado de esta página y la anterior no... Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter Why to report Immediate reporting can facilitate urgent correction (many CVCs can be re- secured) and prevent possible infection and risk of bleeding, air embolism and further catheter migration When removing dressings be careful not to pull the line Immediate reporting can facilitate urgent correction (many CVCs can be repaired) and prevent possible infection prevent possible To complications such as infection/air embolism MEMBERS ONLY BY

USE REPRODUCTION During patient assessment pre- dialysis and when attending CVC dressing When there is any leakage from the catheter During dialysis PERMITTEDcommencement PERSONAL COMMERCIAL FOR PRINTING 138 What to Report When to report FOR 139 Catheter appears longer at the exit site is visible Cuff Broken Clamps Cracking/Holes in lumen

NOT Identified Problems Catheter migration Catheter damage Reporting of Central Venous Catheter Dysfunction 113 Why to report Urgent medical intervention can decrease patient morbidity and costs associated with hospitalisation Urgent medical intervention can decrease patient morbidity and costs associated with hospitalisation Unknown cause possibly due to an inflammatory response to a foreign body. The inflammation can cause thickness and redness of the skin around the catheter at change of dressing A exit site. type may be necessary MEMBERS ONLY BY

USE REPRODUCTION During exit site dressing and if patient has pyrexia When a patient has one hour pyrexia up to after catheter has been flushed/dialysis commencement and if patient presents with pyrexia During exit site dressing PERMITTED PERSONAL COMMERCIAL FOR PRINTING 138 What to Report When to report FOR 139 Redness and tracking at exit site. Purulent discharge at exit site Pyrexia of unknown origin/rigors Skin colour changes at the exit site e.g. Pink/red Thickening of skin at exit site

NOT Identified Problems Exit site infection Catheter related infection Skin granulation at the exit site

10.2 Reporting responsibilities Before each haemodialysis treatment, the nurse must perform an assessment of the patient and their CVC, report and record the findings and adjust the haemodialysis treatment plan if required. Every dialysis clinic should have an established protocol to report any CVC dysfunction to the physician responsible for the patient. This ensures timely management of the dysfunction and may prevent catheter loss, interruption to the haemodialysis session and reduce the incidence of catheter related bloodstream infection (CRBSI).113 MEMBERS ONLY Each dialysis clinic should have BYa database to collect information related to catheter dysfunction including patency, 75 infection and integrity. For better assessment,USE bimonthly multidisciplinary meetings should take placeREPRODUCTION to discuss the data of those patients presenting with dysfunctional factors which may require further investigation.

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11. Patient Education for Central Venous Catheter Care Patient education is one of the most important elements in managing a CVC at home. Living with a catheter and commencement of haemodialysis can be a very traumatic event for patients and their family, which can often result in stress and depression. To reduce this risk patients and their family should be provided with as much information as possible, along with on-going evaluation regarding their ability to manage CVC care at home.

MEMBERS The patient education must be centred on the care ONLY and management of the CVC atBY home: including personal hygiene, protecting the catheter from

harm and complication management.USE REPRODUCTION It is important to consider the psychological aspects of living with a CVC in a patient’s day to day life. Often patients with a CVC have commenced haemodialysis following late referral and emergency starts,PERMITTED or following dialysis access failure/ revision which can bePERSONAL stressful events to cope with. The impact of CVC dysfunction and catheter related infections on patient outcomes haveCOMMERCIAL been well explained. Therefore early detection of anyFOR signs or symptoms and immediate referral for interventionPRINTING will assist in preventing further complications. To facilitate this, aFOR focus on patient education that is timely and has an emphasis on infection prevention, is paramount.75 The multi-disciplinary healthcare team, the patient, the family and/or theNOT main caregiver all have an important role to play. 144 The healthcare team must deliver standardised education, 145 delivering the same information with consistency141, while patient education provides an opportunity to reduce catheter Patient Education for Central Venous Catheter Care

related infections and allows the patient to feel empowered, secure and independent. Including the patient, the family and/ or the main caregiver from the beginning ensures they have the same knowledge and can provide further support for the patient. Individualised or patient centred education is also important, every patient has different needs which should be assessed and the education delivered to suit those needs.142 This includes interpreter and disability services (deaf, blind, physical impairment). The teaching process should start with information that the patients already know,MEMBERS and then move to what the patients do not know. It is important to ONLYclarify what the patients have already been told and dispelBY any misconceptions. Another important aspect of patient education is to teach them

step by step, from simple concepts to complexUSE ones. Education material needs to have plain, simpleREPRODUCTION language that is easy to understand. Studies have shown that only 50%141 of the education delivered is retained by patients, therefore it is important to provide hand-outs such as brochures, flyers or handbooks that PERMITTEDcan also be taken home and reviewed. Evaluation of the patient’s knowledge following education is essential to ensure comprehension,PERSONAL while ongoing education will provide reinforcement of that knowledge. COMMERCIAL FOR 11.1PRINTING Protect the lifeline – things to consider in the patient´s daily life FOR It is very important to consider risk factors associated with catheter complications and infections. The location of the catheterNOT143, the duration of catheter retention, the age of the 144 patient and any comorbidity such as diabetes, along with 145 cognitive impairment and the patient’s home environment, can all increase the risk of developing a catheter related Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

infection. With this in mind identifying ‘High Risk’ patients prior to discharge is essential. Educating the patient, the family and/ or the main caregiver will assist in mitigating risks144, whilst some patients may benefit from additional community services support. When a patient has a CVC inserted, they need to be informed about how important it is for them to adhere to all aspects of CVC care.141 They should be reminded that the CVC requires checking every day for the proper fixation of the dressing, any signs of leakage and any symptoms of skin intolerance to the dressing. MEMBERS ONLY Educate patients to: BY • Recognise signs and symptoms of redness and discharge around the catheter exitUSE site (for intact clear dressing) REPRODUCTION • Recognise signs and symptoms of infection • Remind them to check that their dressing is intact and to ensure that the CVC exit site and the dressing are kept clean andPERMITTED dry • Remind them PERSONALto check that the clamps are closed and the caps are in situ and if a dressing had to be changed • Recognise if theCOMMERCIAL catheter has become longer in length • RecogniseFOR signs and symptoms of swelling of their PRINTINGneck, arm or leg (femoral catheter) Educate patient,FOR family and/or main caregiver on the importance of hygiene in order to prevent migration of bacteria to the catheterNOT which could lead to infection. 146 Advise patients to: 147 • Wash their hands and maintain body hygiene • Avoid touching the CVC Patient Education for Central Venous Catheter Care

• Wear clean clothing • Refrain from scratching near or around the catheter dressing • Avoid coughing or sneezing in the direction of the CVC • Avoid getting overheated to prevent sweating • Avoid dirty environments that could contaminate clothing and skin • Avoid contamination with urine or excrements (femoral CVC) Teach patient, family and/or main caregiverMEMBERS the importance of protecting the CVC from external damage. ONLY The patients must be aware not to: BY • Wear clothing that could place pressure on the CVC USE • Wear clothing that could pull on the CVCREPRODUCTION • Use sharp implements or scissors near the CVC

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11.2 CVC daily care It is of the utmost importance that patients are educated on daily care of the CVC to preserve the catheter and to prevent complications.113

Dos and Don’ts for CVC daily care Dos Maintain good body hygiene at all times Protect the CVC from harm by avoiding MEMBERSactivity that may cause damage to the CVC ONLY Maintain home environment free fromBY excess dust, dirt and contaminants When taking a bath or shower preventUSE getting the CVC lumens and exit site wet by covering them withREPRODUCTION a waterproof material, such as plastic wrap sealed with tape The clamps must be clamped at all times when CVC is not in use Don’ts PERMITTED Do not let the CVC dressingPERSONAL get wet Do not submerge the CVC dressing or catheter lumens underneath the water COMMERCIALin a bath or swimming pool Do not touchFOR the open end of the CVC if the cap has been dislodgedPRINTING / removed FOR Never use sharp implements such as scissors or pins, near the CVC dressing or lumens NeverNOT unclamp the clamps on catheter or remove the caps 148 Do not to touch the CVC exit site if the dressing lifts, contact 149 the dialysis unit for advice Patient Education for Central Venous Catheter Care

11.3 Managing incidents & complications at home Patients relatives and main caregivers should be educated and informed on how to recognise the following complications and any responses that may be required. It should be clear to patients that when they feel that ‘something is wrong’ they should contact their dialysis unit immediately. Patients must be taught to recognise the following signs: Signs of infection • Redness and tenderness around the catheter exit site • Drainage, exudate or odour aroundMEMBERS the catheter exit site ONLY • Warm to touch near the catheterBY • Fever, rigors, sweating or chills USE REPRODUCTION It is imperative to advise the patient, the family and/or the main caregiver to contact the dialysis unit or seek medical treatment immediately in the event of any of the above symptoms. CVC infection can lead to centralPERMITTED line associated bloodstream infection which PERSONALif not treated urgently can have severe consequence to the patient. COMMERCIAL FOR PRINTING FOR

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Thrombosis • Swelling of the face, neck, chest, or arm on the side where the catheter is inserted (or leg if femoral catheter) • Tingling sensation in the arm or leg • The limb becomes cold to touch • The limb becomes mottled or has skin discolouration

An untreated thrombosis can result in an increased risk of a patient developing pulmonaryMEMBERS embolism and infection. It is important to educateONLY patients relatives and main caregivers BYto report any of these symptoms to their dialysis clinic as soon as 113 possible. USE REPRODUCTION Catheter Leakage • Bleeding from the exit site • Leakage of PERMITTEDfluid from the CVC lumen ends (cap) It is not uncommon afterPERSONAL insertion to have minimal bleeding around the CVC exit site following insertion usually this ceases after 24 hours. If a patientsCOMMERCIAL notices bleeding from the exit site or if the catheterFOR has been accidently pulled this may cause bleeding.PRINTING The patient should apply pressure and a cold pack over the dressingFOR and contact the dialysis clinic immediately. If fluid is noticed leaking from the end of the catheter lumens, the patient or the relatives or the main caregiver should check that the NOTcatheter lumen are clamped and the catheter caps are 150 in place and that there is no damage to the catheter. Advise 151 the patient to close the clamps if open, reposition the caps if necessary or if damaged to ensure the catheter is clamped Patient Education for Central Venous Catheter Care

between the hole and the patient. Then wrap the catheter in sterile gauze and seek medical attention immediately

Catheter dislodgement or damage • Broken clamps • Holes in the catheter lumens • CVC appears longer or cuff is visible • CVC accidental removal MEMBERS Immediate reporting of the above findings is necessary to prevent life threatening complicationsONLY such as infection and risk of bleeding,BY air embolism and further catheter migration. Patients relatives USE and main caregivers must be advisedREPRODUCTION to seek urgent medical attention and contact the dialysis clinic immediately.

First line managementPERMITTED and patient advice includes: • CVC accidentalPERSONAL removal – immediately apply pressure to the exit site using a clean cloth • Broken clampsCOMMERCIAL – ‘kink’ the lines or apply a plastic scissorFOR clamp (never metal clamp) PRINTING• Holes in the catheter lumens – clamp or kink the catheterFOR lumen between the hole and the patient • CVC appears longer – tape the catheter to the skin to NOTprevent further dislodgement 150 151 MEMBERS ONLY BY

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12. Recommendations CVC is not the most recommended vascular access for haemodialysis treatment. Morbidity and mortality of patients with CVC is higher than with patients with peripheral VA. Carefully managed CVCs can extend patient life with wellbeing. In order to give our patient this opportunity we should remember: • We should always advocate peripheral VA where possible. • Any temporary CVC should beMEMBERS changed for a tunneled cuffed CVC as soon as possible to prevent ONLY complications BY • Once a patient has a CVC, the most important component of patient survival USEis patient and family/ main caregiver education. If care REPRODUCTIONand attention is given to the CVC this form of vascular access will have longevity • Aseptic treatment of the CVC in the dialysis unit by renal expertsPERMITTED is extremely important. The healthcare team must treat the patient in the correct way always remembering PERSONALto follow strict aseptic procedures and being responsive to the early detection and escalation of any complicationsCOMMERCIAL or concern related to the patients care FOR PRINTING• All complications must be discussed with the patient, family FORand their main caregiver. This discussion must include why the complications have happened and what can be done to prevent them in the future NOT(common complications are CVC occlusions, air embolism and CRBSI and CVC exit site infections) 154 155 • Aseptic technique is the most important duty of the nurse treating a patient with CVC. The immune Recommendations

system of the haemodialysis patients is weaker than the general healthy population which increases their susceptibility to all infections. Always escalate immediately any concerns about patients care to the senior nurse on duty and to the patient’s physician. Above all always document any concerns as well as the assessment and care provided.

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13. Conclusions To a large extent, the success of long-term haemodialysis depends upon the patient having trouble-free vascular access. VA-related complications remain a serious clinical problem, with VA failure being a major cause of morbidity, hospitalisations and mortality. The creation of an arteriovenous anastomosis, the number of HD patients with autologous AVFs is declining. The major cause for this observation is the change in the demography of the haemodialysis population with increasing numbers of very old patients accepted for renal replacement therapy, with multiple comorbidities includingMEMBERS obesity, chronic heart failure, diabetes mellitus, peripheral vascularONLY disease and hypertension. Central venous cathetersBY play an important role in the treatment of chronic haemodialysis; they represent

a means for immediate vascular accessUSE in cases of urgently needed renal replacement therapy. CVC representsREPRODUCTION a good choice, especially when a permanent access via an AVF becomes dysfunctional. Nowadays bedside implantation is possible even in the emergency room. CVCs are often usedPERMITTED as a bridge to a permanent vascular access, either because the patient starts dialysis without a mature fistula or PERSONAL graft, or because an existing permanent access has failed. Insertion of a CVC for HD is a relatively straightforward procedureCOMMERCIAL for both temporary and permanent catheters. TheFOR universal availability of ultrasound and fluoroscopicPRINTING guidance has resulted in recommendations from NKF-KDOQIFOR regarding the use of both technologies for placement of cuffed, tunnelled catheters. There are well- established guidelines for selection of an insertion site for CVC. TheNOT preferred site is the right internal jugular vein, low 158 in the neck and close to the jugular bulb so that there is little 159 chance for catheter kink when tunnelling to the chest wall. Conclusions

The connection of a patient via CVC requires competent staff members, with knowledge of the haemodialysis principles, plus knowledge of catheter usage and associated risks. Nurses, in particular, play a crucial role in the management of CVC. The exit site of the CVC must always be inspected at each dialysis treatment, so that an infection can be detected and be confirmed by swabbing and bacterial culture in case of any suspicion. Patients should be included in the process of caring and should be educated to respect the integrity of the dressing and to maintain it dry and respect strict hygienic measures. Also, both, the patients and/or the caregivers should know what to do in case of the exit site dressing isMEMBERS compromised. ONLY CVCs are associated with an increasedBY risk of adverse events, including infection, dysfunction caused by obstruction,

occlusion of a central vein, lower accessUSE life span and unpredictable blood flow. CVC dysfunctionREPRODUCTION and catheter related infections can lead to an increase in mortality and morbidity of haemodialysis patients. Dialysis CVC dysfunction result in significant causes of catheter loss and interrupted haemodialysis sessions.PERMITTED Attention to monitoring for dysfunction and infection, the two major clinical complications of catheter use, as well as promptPERSONAL intervention to salvage the functionality of the CVC, are essential in preventing or minimising potential morbidity and mortality.COMMERCIAL The impact of FORCVC dysfunction and catheter related infections on PRINTINGpatient outcomes have been well researched and explained. ThereforeFOR early detection of any signs or symptoms and immediate referral for intervention will assist in preventing further complications. To facilitate this, a focus on patient educationNOT that is timely and has an emphasis on infection 158 prevention, is paramount. 159 MEMBERS ONLY BY

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14. Appendix 14.1 Table of abbreviations

ANTT Aseptic non-touch technique AVF Arteriovenous fistula AVG Arteriovenous graft

CARI Caring for Australasians with Renal Impairment

CRBSI Catheter-related bloodstream infection CRRT Chronic renal replacement therapyMEMBERS CVAD Central Venous Access Device ONLY BY CVC Central venous catheters

CVP Central venous pressure USE REPRODUCTION DVT Deep vein thrombosis ECG Electrocardiogram EJ External jugular ePTFE ExpandedPERMITTED polytetrafluoroethylene ERBP EuropeanPERSONAL Renal Best Practice ESRD End Stage Renal Disease COMMERCIAL HCAIs FORHealthcare-Associated Infections HCWPRINTING Healthcare Workers HD FORHaemodialysis IJ Internal jugular IJV NOT Internal jugular vein IVAD Implanted Venous Access Devices 162 163 KDOQI Kidney Disease Outcomes Quality Initiative Appendix

Kt/V Dialysis adequacy LMW Low molecular weight heparin National Kidney Foundation Kidney Disease NKF-KDOQI Outcomes Quality Initiative PPE Personal Protective Equipment PVD Peripheral vascular disease RA Right atrium MEMBERS RN Registered Nurse ONLY BY RRT Renal replacement therapy

SC Subclavian cannula USE REPRODUCTION spKt/V Single pool Kt/V SVC Superior Vena Cava TMP Transmembrane pressure UF UltrafiltrationPERMITTED UPS UnplannedPERSONAL start URP Urea reduction percentage COMMERCIAL URR FORUrea reduction ratio VA PRINTINGVascular access VAE FORVenous air embolism WHO World Health Organization NOT 162 163 MEMBERS ONLY BY

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15. Bibliography 1. Gonda SJ, Li R., Principles of subcutaneous port placement. Tech Vasc Interv Radiol. 2011 Dec;14(4):198-203. doi: 10.1053/j. tvir.2011.05.007. 2. Mimi Bartholomay et al., Nursing Management of Venous Access Devices: Implanted Central Venous Access Devices (Ports). http:// www.mghpcs.org/EED_Portal/Documents/Central_Lines/CL_ Module4.pdf 3. Volker Mickley. Central venous catheters: many questions, few answers. Nephrology Dialysis Transplantation, Volume 17, Issue 8, 1 August 2002, Pages 1368–1373, https://doi.org/10.1093/ ndt/17.8.1368 Published: 01 August 2002 4. Overview of Central Venous Catheter. http://advancedrenaleducation.MEMBERS com/content/overview-central-venous-catheters ONLY 5. Swindle MM, et al. Vascular access portBY (VAP) usage in large animal species. Contemp Top Lab Anim Sci. 2005 May; 44(3):7-17. 6. Cohen AB, et al. Silicone and polyurethane tunnelled infusion catheters: a comparison of durability andUSE breakage rates. J Vasc Interv Radiol. 2011 May; 22(5):638-41. REPRODUCTION 7. Bander, S.J., Woo, K. et al. Central catheters for acute and chronic hemodialysis access. https://www.uptodate.com/contents/central- catheters-for-acute-and-chronic-hemodialysis-access 8. Vascular SurgeryPERMITTED University of Southern California Department of Surgery Keck School of Medicine of USC, Areas of Expertise, Vascular Access. http://www.surgery.usc.edu/vascular/vascularaccess.html. Accessed Jul 27, 2016.PERSONAL 9. Parisotto, MT, and Pancirova, J, eds. Vascular Access Cannulation and Care: A NursingCOMMERCIAL Best Practice Guide for Arteriovenous Fistula. 2nd ed.; 2015.FOR ISBN: 978-84-617-0567-2. https://www.edtnaerca.org/ PRINTINGacademy/publications 10. Parisotto, MT, ed. Vascular Access Cannulation and Care A Nursing Best PracticeFOR Guide for Arteriovenous Graft. 2nd ed.; 2016. ISBN: 978- 84-617-4687-3. https://www.edtnaerca.org/academy/publications 11. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines forNOT hemodialysis adequacy, update 2006. Am J Kidney Dis, 2006. 48 Suppl 1:S2-90. 166 167 12. Ravani, P, Palmer, SC, Oliver, MJ, et al. Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol, 2013. 24(3):465-73. Bibliography

13. Michael R. Clarkson, Ciara N. Magee and Barry M. Brenner, eds. Pocket Companion to Brenner and Rector’s The Kidney Book 2nd Edition 2011 14. Konner, K. History of vascular access for haemodialysis. Nephrol Dial Transplant, 2005. 20(12):2629-35 15. Quinton, W, Dillard, D, and Scribner, BH. Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs, 1960. 6:104-13. 16. Seldinger, SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol, 1953. 39(5):368-76. 17. Aitken, EL, Jackson, AJ, and Kingsmore, DB. Early cannulation prosthetic graft (Acuseal) for arteriovenous access: a useful option to provide a personal vascular access solution. J Vasc Access, 2014. 15(6):481-5. MEMBERS 18. Brescia, MJ, Cimino, JE, Appel, K, et al. Chronic hemodialysisONLY using venipuncture and a surgically created arteriovenousBY fistula. N Engl J Med, 1966. 275(20):1089-92. 19. Gracz, KC, Ing, TS, Soung, LS, et al. USE Proximal forearm fistula for maintenance hemodialysis. Kidney Int, 1977. 11(1):71-5.REPRODUCTION 20. Thomas, GI. A large-vessel applique A-V shunt for hemodialysis. Trans Am Soc Artif Intern Organs, 1969. 15:288-92. 21. Flores Izquierdo, G, Ronces Vivero, R, Exaire, E, et al. [Venous autologous graft for hemodialysis (original technic). Preliminary report][Article in PERMITTEDSpanish]. Arch Inst Cardiol Mex, 1969. 39(2):259-66. 22. May, J, Tiller, D, Johnson, J, et al. Saphenous-vein arteriovenous fistula in regular dialysisPERSONAL treatment. N Engl J Med, 1969. 280(14):770. 23. Chinitz, JL, Tokoyama, T, Bower, R, et al. Self-sealing prosthesis for arteriovenous fistulaCOMMERCIAL in man. Trans Am Soc Artif Intern Organs, 1972. 18(0):452-7.FOR 24.PRINTING Soyer, T, Lempinen, M, Cooper, P, et al. A new venous prosthesis. Surgery, 1972.FOR 72(6):864-72. 25. Baker, LD, Jr., Johnson, JM, and Goldfarb, D. Expanded polytetrafluoroethylene (PTFE) subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Trans Am Soc ArtifNOT Intern Organs, 1976. 22:382-7 166 26. Uldall PR, Dick RF, Woods F, Merchant N, Martin GS, Cardella 167 CJ, Sutton D, Veber GA de. A subclavian cannula for temporary vascular access for hemodialysis or plasmapheresis. Dial Transplant 1979;8:963-8. Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

27. Linos DA, Mucha P, Heerden NA van. Subclavian vein: a golden route. Mayo Clin Proc 1980;55:315-21. Huffman KA, Sherertz RJ, Mattern WD. An appraisal of the subclavian dialysis catheter. Int J Artif Organs 1983;6: 176-7 28. Internal Jugular Vein Cannulation with Two Silicone Rubber Catheters: A New and Safe Temporary Vascular Access for Hemodialysis. Thirty Months’ Experience Article in Artificial Organs · November 1986. DOI: 10.1111/j.1525-1594.1986.tb02587.x 29. Bellinghieri G, Ricciardi B, Costantino G, et al. Exhaustion of vascular endowment in hemodialysis: proposal for a permanent inlet access. Int J Artif Organs. 1998;21(4):201–204. 30. Alexander, J., Corrigan, A., Gorski, L., Hankins, J., & Perucca, R. (2010). Infusion Nursing Society. An Evidence-Based Approach. St. Louis: Saunders Elsevier. MEMBERS 31. Bishop, L., Dougherty, L., Bodenham, A., Mansi,ONLY J., Crowes, P., Kibbler, C., Treleaven, J. (2007). GuidelinesBY on the insertion and management of central venous access devices in adults. International Journal of Laboratory Hematology, 29, 261-278.USE 32. Norwood, MA: Infusion Nursing Society. (2011).REPRODUCTION Policies and Procedures for Infusion Nursing (4 ed.). 33. Infusion Nurses Society. (2016). Infusion Therapy Standards of Practice. Journal of Infusion Nursing, 39(1S) 34. O’Grady, et al., (2011). Guidelines for the prevention of intravascular catheter-related PERMITTEDinfections. American Journal of Infection Control, 39, S1-S34. 35. Pittiruti, M., Hamilton,etPERSONAL al., (2009). ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis, and therapy of complications).COMMERCIAL Clinical Nutrition, 28, 365-377. 36. O’Grady FORNP, et al.; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular PRINTINGcatheter-related infections. Clin Infect Dis. 2011 May; 52(9):e162– 193. Epub 2011FOR Apr 1; 37. Larson SD, Mancini MC. Vascular access, surgical treatment. Medscape Reference. Jan 25, 2010. Accessed Jul 11, 2013. http:// emedicine.medscape.com/article/1018395-overview#showall.NOT 168 38. NKF-K/DOQI: III. NKF-K/DOQI clinical practice guidelines for vascular 169 access: Update 2000. Am J Kidney Dis 37[Suppl 1]: S137–S181, 2001. Lok CE: Fistula first initiative: Advantages and pitfalls. Clin J Am Soc Nephrol 2: 1043–1053, 2007. Bibliography

39. Allon M: Current management of vascular access. Clin J Am Soc Nephrol 2: 786–800, 2007 40. Mendelssohn DC, Malmberg C, Hamandi B. An integrated review of “unplanned” dialysis initiation: reframing the terminology to “suboptimal” initiation. BMC Nephrol. 2009;10:22 41. Metcalfe W, Khan IH, Prescott GJ, Simpson K, MacLeod AM. Can we improve early mortality in patients receiving renal replacement therapy? Kidney Int. 2000;57(6):2539-45. 42. Marrón B, Ortiz A, de Sequera P, Martín-Reyes G, de Arriba G, L41. amas JM, et al. Impact of end-stage renal disease care in planned dialysis start and type of renal replacement therapy-- a Spanish multicentre experience. Nephrol Dial Transplant. 2006;21 Suppl 2:ii51-5 MEMBERS 43. Perl J, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, et al. Hemodialysis vascular access modifies the ONLY association between dialysis modality and survival. J Am SocBY Nephrol. 2011;22(6):1113-21. 44. J.H.M. Tordoir, A.S. Bode, M.M. van Loon. Preferred Strategy for Hemodialysis Access Creation in ElderlyUSE Patients. Eur J Vasc Endovasc Surg (2015) 49, 738e743 REPRODUCTION 45. KDOQI 2006 Updates Clinical Practice Guidelines Blood Press; 2006;33(5) 46. Cho SK, Shin SW, et al. Use of the right external jugular vein as the preferred access site when the right internal jugular vein is not usable. J Vasc Interv Radiol.PERMITTED 2006;17(5):823–829. 47. Trerotola SO, Kuhn-Fulton J, et al. Tunneled infusion catheters: increased incidencePERSONAL of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology. 2000;217(1):89–93. COMMERCIAL 48. Infusion NursesFOR Society, J Infus Nurs. 2011;34(1S) 49.PRINTING Bhola C, Lok C. Central venous catheters: optimizing the suboptimal. NephrologyFOR News and Issues. 2011 April 27, 2011. 50. MacGinley R, Owen A, et al. CARI Guideline: Insertion of catheters. Kidney Health Australia. 2012. Association for Vascular Access. Preservation of peripheral veins in patients with chronic kidney disease.NOT 168 51. National Kidney Foundation. KDOQI clinical practice guidelines and 169 clinical practice recommendations 2006 updates: haemodialysis adequacy, peritoneal dialysis adequacy and vascular access. American Journal of Kidney Disease. 2006;48(S1-S322). Vascular Access Management and Care A Nursing Best Practice Guide for Central Venous Catheter

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73. Webster J, Gillies D, O’Riordan E, Sherriff K, Rickard C. Gauze and tape and transparent polyurethane dressings for central venous catheters (review). The Cochrane Library. 2011(11). 74. McIntyre H, Raw A, Stephenson J, Bradley A, Dawson J, Fay M, et al. NICE quality standard 61: Infection prevention and control. National Institute for Health and Care Excellence; 2014. 75. Chin G. CARI Guideline: Prevention of tunnelled dialysis catheter infection. Kidney Health Australia. 2012. 76. Scheithauer S, Lewalter K, Schroder J, Koch A, Hafner H, Krizanovic V, et al. Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing. Infection. 2014;42:155-9. 77. Timsit J, Mimoz O, Mourvillier B, Souweine B, Garrouste-Orgeas M, Alfandari S, et al. Randomized controlledMEMBERS trial of chlorhexidine dressing and highly adhesive dressing for preventingONLY catheter-related infections in critically ill adults. AmericanBY Journal of Respiratory and Critical Care Medicine. 2012;186(12):1272-8. 78. Safdar N, O’Horo J, Ghufran A, Bearden A, Didier M, Chateau D, et al. Chlorhexidine-impregnated dressing USEfor prevention of catheter- related bloodstream infection: a meta-analysis. CriticalREPRODUCTION Care Medicine. 2014;42(7):1703-13. 79. Bernard Canaud, Leila Chenine, Delphine Henriet, Hélène Leraya. Optimal Management of Central Venous Catheters for Hemodialysis. Lapeyronie Hospital – Nephrology, and Renal Research and Training Institute, Montpellier,PERMITTED France. Conference Paper in Néphrologie - January 2001 80. Ronco C, Cruz DNPERSONAL (eds): Hemodialysis – From Basic Research to Clinical Trials. Contrib Nephrol. Basel, Karger, 2008, vol 161, pp 39– 47 COMMERCIAL 81. DoughertyFOR L, Lister S (eds). (2011). The Royal Marsden Hospital PRINTINGManual of Clinical Nursing Procedures. Marsh. 82. World Health Organization. (2009). WHO Guidelines on Hand Hygiene in FORHealth Care. Geneva: World Health Organization 83. K. B. Laupland, D. Koulenti and C. Schwebel . The CVC and CRBSI: don’t use it and lose it! 2017 Springer-Verlag GmbH Germany, part of SpringerNOT Nature and ESICM 172 84. Centers for Disease Control and Prevention (CDC). Invasive 173 methicillin-resistant Staphylococcus aureus infections among dialysis patients--United States, 2005. MMWR Morb Mortal Wkly Rep, 2007. 56(9):197-9. Bibliography

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97. Ullman, Amanda J., et al. “Dressings and securement devices for central venous catheters (CVC).” The Cochrane Library (2015). 98. Lafrance, Jean-Philippe, et al. “Vascular access–related infections: Definitions, incidence rates, and risk factors.” American Journal of Kidney Diseases 52.5 (2008): 982-993. 99. Allon Michael, Daniel J. Sexton, et al. “Tunneled, cuffed hemodialysis catheter-related bacteremia.” UpToDate, Waltham, MA.(Accessed on February 28, 2014.) (2014). Retrieved May 16, 2018. 100. Beathard, GA., and Aris Urbanes. “Infection associated with tunneled hemodialysis catheters.” Seminars in dialysis. Vol. 21. No. 6. Blackwell Publishing Ltd, 2008. 101. Rupam Gahlot, Chaitanya Nigam, Vikas Kumar,MEMBERS Ghanshyam Yadav and Shampa Anupurba. Catheter-related bloodstreamONLY infections. Int J Crit Illn Inj Sci. 2014 Apr-Jun; 4(2): BY162–167. doi: 10.4103/2229- 5151.134184 PMCID: PMC4093967. 102. Almuneef MA, Memish ZA, Balkhy HH,USE Hijazi O, Cunningham G, Francis C. Rate, risk factors and outcomesREPRODUCTION of catheterrelated bloodstream infection in a paediatric intensive care unit in Saudi Arabia. J Hosp Infect. 2006;62:207–13 103. Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis. 2004;44:779–91 104. Nassar GM, AyusPERMITTED JC. Infectious complications of the hemodialysis access. Kidney Int.PERSONAL 2000;60:1–13 105. Beathard GA. Management of bacteremia associated with tunneled- cuffed hemodialysis catheters.COMMERCIAL J Am Soc Nephrol. 1999;10:1045–9. 106. Kovalik EC,FOR et al. A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of PRINTINGinfection. J Am Soc Nephrol. 1996;7:2264–7. 107. Wilcox MH,FOR Tack KJ, Bouza E, et al. Complicated skin and skin structure infections and catheter-related bloodstream infections: non inferiority of linezolid in a phase 3 study. Clin Infect Dis. 2009;48:203– 12NOT 174 108. Lorente L, Jiménez A, Santana M, Iribarren JL, Jiménez JJ, Martín 175 MM, et al. Microorganisms responsible for intravascular catheter- related bloodstream infection according to the catheter site. Crit Care Med. 2007;35:2424–7. Bibliography

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123. Feil M. Preventing central line air embolism. Am. J. Nurs. 2015;115:64– 69. doi: 10.1097/01.NAJ.0000466327.76934.a0. [PubMed] [Cross Ref] 124. Wysoki M.G., Covey A., Pollak J., Rosenblatt M., Aruny J., Denbow N. Evaluation of various maneuvers for prevention of air embolism during central venous catheter placement. J. Vasc. Int. Radiol. 2001;12:764– 766. doi: 10.1016/S1051-0443(07)61451-1 125. Bartolini L., Burger K. Pearls & oysters: Cerebral venous air embolism after central catheter removal: Too much air can kill. Neurology. 2015;84:e94–e96 126. Bothma PA, Schlimp CJ. Retrograde cerebral venous gas embolism: are we missing too many cases? Br J Anaesth 2014; 112: 401–404 127. Mirski MA, Lele AV, Fitzsimmons L et al. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106:MEMBERS 164–177 128. Shaikh N., Ummunisa F. Acute managementONLY of vascular air embolism. J. Emerg. Trauma Shock.BY 2009;2:180–185. doi: 10.4103/0974-2700.55330 129. Jan, Tordoy et. Al. . Catheter PerformanceUSE and care. EBPG on Vascular Access. Nephrology Dialysis Transplantation,REPRODUCTION Volume 22, Issue suppl_2, 1 May 2007, Pages ii88–ii117 130. Bodin, Sandra M. Contemporary Nephrology nursing. ANNA. 2017. Pp. 162-164, 192, 358 131. Measuring catheter flow. Thrombosis associated with chronic hemodialysis vascularPERMITTED catheters. UpToDate 2018 132. Jeremy Levi, Edwina brown, Anastasia Lawrence. Haemodialysis. Hand Book Of Dialysis.PERSONAL Oxford University Press. 2016 133. John, T Daugirdas. Blood based therapies. Handbook of dialysis. Fifth edition. Pp 57-57 COMMERCIAL 134. Sefer S. etFOR al. Recirculation of urea and dialysis efficiency using dual- PRINTINGlumen dialysis catheters in various locations: may the venous lumen of the catheter be used as the arterial lumen and vice versa?. Lijec Vjen2003. jan-Feb;125(1-2):1-5FOR 135. Owen WF, Lew NL, Liu Y, Lowrie EG, Lazarus JM. The Urea Reduction Ratio and Serum Albumin Concentration as Predictors of Mortality in PatientsNOT Undergoing Hemodialysis. N Engl J Med. 1993; 329:1001- 1006. 176 177 Bibliography

136. Kessler E, Ritchey NP, Castro F, Caccamo LP, Carter KJ, Erickson BA. Urea reduction ratio and urea kinetic modeling: a mathematical analysis of changing dialysis parameters. Am J Nephrol. 1998; 18(6):471-7. 137. Daugirdas, J.T. Second generation logarithmic estimates of single- pool variable volume Kt/V: an analysis of error. J Am Soc Nephrol. 1993; 4: 1205–1213 138. Daugirdas, J.T., Leypoldt, J.K., Akonur, A., Greene, T., and Depner, T.A. Improved equation for estimating single-pool Kt/V at higher dialysis frequencies. Nephrol Dial Transplant. 2013; 28: 2156–2160 139. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update DOI:https://doi.org/10.1053/j.ajkd.2015.07.015 140. Eknoyan, G., Beck, G.J., Cheung, A.K…., and for the HEMO Study Group. Effect of dialysis dose and membraneMEMBERS flux on mortality and morbidity in maintenance hemodialysis patients: ONLYPrimary results of the HEMO study. N Engl J Med. 2002; BY347: 2010–2019 141. Sarah Champ, 2013. Standardising patient education on the care of central venous catheters USE 142. Kayyali, Andrea MSN, RN; Singh Joy, SubhashniREPRODUCTION D. AJN The American Journal of Nursing: September 2011 - Volume 111 - Issue 9 - p 61 143. Infection control & hospital epidemiology, Vol.36,No.2 February 2015 p. 214 144. Guimaraes, Mendonza,PERMITTED Correa, Matos 2017, 1129-1133. Nursing Interventions for Haemodialysis patients through Central venous catheter. Journal ofPERSONAL Nursing UFPE COMMERCIAL FOR PRINTING FOR

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