KDOQI Update 2000


III. Prevention of Complications: Infection


Infection Control Measures

Staff and patient education should include instruction on infection control measures for all hemodialysis access sites. (Opinion)

Rationale In hemodialysis patients, poor personal hygiene is a risk factor for vascular access site infections.139 Therefore, hemodialysis patients with poor personal hygiene habits should be taught how to improve and maintain their personal hygiene.

In addition, there is a higher rate of infection in hemodialysis patients when new or inexperienced dialysis staff manipulate the patient’s vascular access.140,141 Because of this, all dialysis staff should be trained in infection control procedures (see Guideline 14: Skin Preparation Technique for Permanent AV Accesses, and Guideline 15: Catheter Care and Accessing the Patient’s Circulation). Documenting educational materials and objectives must be part of the patient’s records and staff orientation records.

Tracking the occurrence of infections can help identify the source and allow corrective action to be taken. Ongoing quality assurance, risk management, or CQI efforts should be in place to monitor the incidence of infection, to evaluate the response to patient and staff education, and to identify future educational needs.


Skin Preparation Technique for Permanent AV Accesses

A clean technique for needle cannulation should be used for all cannulation procedures. (Evidence) (See proposed skin preparation technique in Table III-8 and cannulation technique in Table III-9.)

Table III-8. Skin Preparation Technique for Permanent AV Accesses
1. Locate and palpate the needle cannulation sites prior to skin preparation.
2. Wash access site using an antibacterial soap or scrub (eg, 2% chlorhexidine) and water.
3. Cleanse the skin by applying 70% alcohol and/or 10% povidone iodine using a circular rubbing motion.


• Alcohol has a short bacteriostatic action time and should be applied in a rubbing motion for 1 minute immediately prior to needle cannulation.

• Povidone iodine needs to be applied for 2 to 3 minutes for its full bacteriostatic action to take effect and must be allowed to dry prior to needle cannulation.

• Clean gloves should be worn by the dialysis staff for cannulation. Gloves should be changed if contaminated at any time during the cannulation procedure.

• New, clean gloves should be worn by the dialysis staff for each patient.

Table III-9. Technique for AV Fistula/AV Graft Cannulation146,147

After skin preparation, pull skin taut in opposite direction of needle insertion

• Compresses peripheral nerve endings between epidermis and dermis

• Facilitates smoother incision of skin with less surface area contacting cutting edge of needle

• Enables better stabilization of graft or vessel to be cannulated

Use approximately 45 degree angle of insertion for AV graft and approximately 25 degree angle for AV fistula Less steep angles increase risk of dragging cutting edge of needle along surface of vessel. Steeper angles increase risk of perforating underside of vessel.
Once the vessel has been penetrated, there are basically three methods employed in extant practice:

1. Advance the needle slowly with cutting edge facing top of vessel and do not rotate axis

2. Immediately rotate the axis of the needle 180 degrees and advance slowly with cutting edge facing bottom of the vessel

3. Advance the needle to desired position, then rotate the axis 180 degrees

1. Any manipulation may traumatize the intima of the vessel

2. Rotating the axis avoids traumatizing the top of intima

3. Waiting to rotate axis avoids traumatizing top of vessel while needle is taped in place


Tape the needle at the same angle or one similar to the angle of insertion

Pressing the needle shaft flat against the skin moves the needle tip from the desired position within the vessel lumen

Remove needle at same or angle similar to angle of insertion, and NEVER APPLY PRESSURE BEFORE NEEDLE IS COMPLETELY OUT Avoid trauma to any intima by dragging cutting edge along it. Avoid pressing cutting edge into intima when applying pressure for hemodialysis.

Rationale Cannulation of an access site places the hemodialysis patient at risk for infection via bacterial contamination. Bacteria can be introduced directly into the patient’s bloodstream by needle cannulation, leading to local infection of the access material (blood vessel or PTFE) and/or to bloodstream infection. Bloodstream infection increases morbidity and mortality in ESRD patients and must be prevented. Dialysis staff should comply with OSHA regulations, including hand washing and use of clean gloves during needle cannulation. Washing the access site with soap and water will decrease the patient’s skin microflora that can be introduced inadvertently into the patient’s bloodstream during needle cannulation.142-144

The use of 70% alcohol and/or 10% povidone iodine (see Table III-8)conforms to CDC guidelines for the prevention of intravascular device-related infections and is supported by the literature.142,145

There is no literature to support the use of any specific technique for cannulation. The Work Group recommends the technique described in Table III-9.


Catheter Care and Accessing the Patient’s Circulation

Catheter care and accessing the patient’s circulation should be clean procedures.

A. Hemodialysis catheter dressing changes and catheter manipulations that access the patient’s bloodstream should only be performed by trained dialysis staff. (Evidence/Opinion)

B. The catheter exit site should be examined at each hemodialysis treatment for signs of infection. (Opinion)

C. Catheter exit site dressings should be changed at each hemodialysis treatment. (Opinion)

D. Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter exit site are recommended after catheter placement and at the end of each dialysis session. (Evidence)

E. Manipulating a catheter and accessing the patient’s bloodstream should be performed in a manner that minimizes contamination (see Table III-10). (Evidence)

F. During catheter connect and disconnect procedures, nurses and patients should wear a surgical mask or face shield. Nurses should wear gloves during all connect and disconnect procedures. (Opinion)

Table III-10. Considerations for Accessing the Bloodstream Using Catheters
• The catheter hub caps or bloodline connectors should be soaked for 3 to 5 minutes in povidone iodine and then allowed to dry prior to separation.
• Catheter lumens should be kept sterile.
• To prevent contamination, the lumen and tip should never remain open to the air. A cap or syringe should be placed on or within the catheter lumen, while maintaining a clean field under the catheter connectors.
• Patients should wear a surgical mask for all catheter procedures that remove the catheter caps and access the patient’s bloodstream.
• Dialysis staff should wear gloves and a surgical mask or face shield for all procedures that remove catheter caps and access the patient’s bloodstream.
• A surgical mask for the patient and mask or face shield for the dialysis staff should be worn for all catheter dressing changes.

Rationale Catheter dressing changes and manipulation place the patient at risk for infection. Infection rates increase when catheter dressing changes or manipulations are performed by inadequately trained staff.140,141,148

The use of dry gauze dressing and povidone iodine and mupirocin ointment at the catheter exit site can reduce the incidence of exit site infections,141,149-152 especially in patients who have nasal carriage Staphylococcus aureus. Certain manufacturers have indicated that the glycol constituents of ointment should not be used on their polyurethane catheters. A specific manufacturer’s recommendation from Bard has been issued. Dry gauze dressings rather than transparent film dressings are recommended because transparent film dressings pose a greater threat of exit site colonization.149 In patients with an allergy to povidone iodine, alternate agents such as polyantimicrobial gel can be substituted.

Catheter infection can occur following transmission of hand or aerosolized bacterial contaminants. Staphylococcus aureus is the leading cause of catheter exit site infection and bacteremia in hemodialysis patients. Bacteremia and tunnel tract infections are the leading causes of catheter loss.78,153 Chronic hemodialysis patients are at increased risk of S aureus nasal carriage; the literature reports a 50% to 60% carriage rate in hemodialysis patients.141,154-156 Nasal carriage may result in seeding the skin with autogenous S aureus, leading to catheter site infection, tunnel track infection, or bacteremia. Catheter placement near the patient’s nose and mouth, such as occurs with subclavian or jugular vein catheters, exposes the patient’s catheter exit site to nasal drainage/discharge and infectious airborne droplets. Methicillin-resistant S aureus may be transmitted in this mode. A surgical mask worn by the patient and nurse any time the catheter is accessed reduces the spread of infectious droplets and reduces contamination of the catheter site.





© 2001 National Kidney Foundation, Inc

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