Cleansing agents used for hemodialysis catheter care
Lesley C. Dinwiddie
Q: We are trying to simplify our catheter care protocol. Can you review the most commonly used agents for cleaning catheter exit sites and connection ports as well as the types of catheters that have exceptions to some agents?
A: In these days of cost containment, staff shortages, allergies, and increased morbidity due to catheter-related infections, the attempt to simplify care without sacrificing quality is a laudable one. The need to simplify is stymied by the variety of catheter brands and materials used, some of which have chemical adverse effects when exposed to certain cleansing agents. Before detailing these catheter brands and cleansing agents, a review of the most recent, impartial catheter care recommendations is in order. In August 2002, the Centers for Disease Control and Prevention (CDC) updated its guidelines for the prevention of catheter-related infections. These are easily found on the Web at www.cdc.gov/ncidod/hip/iv/iv.htm, but the printed report is Guidelines for the Prevention of Intravascular Catheter-Related Infections (CDC, 2002).
Hemodialysis catheter-related blood system infections (CRBSI) are reported in the guidelines to be seven-fold higher than arteriovenous fistula (AVF) infections, reinforcing the K/DOQI[TM] Guidelines call for increasing the number of fistulas and reducing the number of catheters. Of interest in the CDC report as well, is the fact that tunneled, cuffed catheters (TCC) are less likely to lead to CRBSI than nontunneled, noncuffed catheters. However, the majority of TCC infections are attributed to contamination from the hubs. Another stipulation made by the CDC report is that hemodialysis catheters should not be used for any purpose but dialysis, including lab draws and IV therapy access, except in life-threatening emergencies. In addition, TCCs for hemodialysis are the only catheters for which the CDC recommends routine use of povidone-iodine ointment at the exit site. K/DOQI Guideline 15 recommends either povidone-iodine ointment (a polyantimicrobial gel can be used for those with iodine allergies) or mupirocin ointment. The CDC cautions that the use of mupirocin ointment prophylactically can lead to antibiotic resistance.
The report and guidelines state that povidone-iodine 10% solution (such as Betadine[R]) is the most widely used cleansing agent. This is in keeping with the K/DOQI Guideline 15 recommendation that this solution or chlorhexidine be used to clean exit sites and that catheter hubs should be soaked in povidone-iodine 3-5 minutes and allowed to dry before opening and connecting (National Kidney Foundation, 2001). The CDC report, however, favors chlorhexidine 2% for efficacy of disinfection but states that the 0.5% strength (Hibiclens[R]) equals povidone-iodine 10%. A recent meta-analysis suggests that the incidence of bloodstream infection is significantly reduced in patients with central vascular lines who receive chlorhexidine gluconate versus povidone-iodine for insertion-site skin disinfection (Chaiyakunapruk, Veenstra, Lipsky, & Saint, 2002). The use of alcohol 70% is recognized as an alternative but the chloroxidizing agents, Exsept[R] 5% and Amuchina[R] 50%, are not, even though at least one large dialysis company has approved their use on exit sites and hub connections. The CDC (personal communication, 2002) is not aware of any data on the efficacy of these agents for skin prep with catheter-related infection as the outcome. Hence they were not discussed in the guideline.
Information from some of the largest hemodialysis catheter manufacturers on cleanser/catheter compatibilities disclosed the following: Medcomp[R] has a chart outlining their restrictions. No alcohol including chlorhexidine can be used with the Ash Split[R] or the Bioflex Tesio[R] catheter. This is the case also for the HMP Lifejet[R] and the Diatek Canon[R], which are also made of polyurethane. Povidone-iodine cannot be used with Medcomp Bioflex[R], Hemocath[R], or modified silicone Tesio[R] but can be used on the female luers on all but the Hemocath. Alcohol 70% may be used on all Medcomp luer connections. Medcomp has tested all catheters with the electrolytic chloroxidizing agents and found no incompatibilities. Information provided to Medcomp from Amuchina showed that the kill time with all common bacteria is 1-2 minutes for the Exsept[R] and Amuchina [R] 50% solutions. The Bard company says that any cleansing solution can be used on their silicone Hickmans[R], but Optiflow[R], Hemoglide[R], Flexxicon[R], and Niagara[R] are all made of polyurethane and cannot be exposed to alcohol or alcohol-containing disinfectants such as chlorhexidine. The Bard catheter company does not recommend using any ointments containing polyethylene glycol (PEG) on their polyurethane catheters because of evidence of long-term use causing softening and degradation of the material.
In summary, though not all catheter brands in use are specified here, it would be prudent to avoid alcohol and chlorhexidine use with any long-term polyurethane catheter unless the packaging has specific instructions to the contrary. It should also be noted that these instructions are still confusing and are likely to be changed periodically, therefore the user should always consult the most recent product literature on the catheter. The surgeon or interventional radiologist should be contacted for the literature if necessary.
Centers for Disease Control and Prevention (CDC). (2002). Guidelines for the prevention of intravascular catheter-related infections, 2002. Morbidity and Mortality Weekly Report, Recommendations and Reports, 51(RR-10A), 1-29.
Chaiyakunapruk, N., Veenstra, D., Lipsky, B., and Saint, S. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Annals of Internal Medicine, 136, 792-801.
National Kidney Foundation. (2001). K/DOQI[TM] clinical practice guidelines for vascular access, 2000. American Journal of Kidney Diseases, 27(Suppl. 11), S137-S181.
The Clinical Consult department is designed to provide answers to questions concerning clinical problems and to report innovative clinical practices. Readers are invited to submit questions to be answered by a guest consultant. Questions should provide background information and state specific information requested. Answers will be referenced. Manuscripts that address clinical problems or present innovative ideas are also invited. These should be between 400 and 600 words and contain one to three references. Address correspondence to: Lesley C. Dinwiddie, Clinical Consult Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman NJ 08071-0056; (856) 256-2320. You may also log onto this column at www.nephrologynursingjournal.net (click on Department link) and email your comments to the Department Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses’ Association.
Lesley C. Dinwiddie, MSN, RN, FNP, CNN, is a Consultant for Vascular Access Education and Research, Cary, NC, and Nephrology Nursing Journal Editorial Board member. She is the Clinical Consult department editor and a member of ANNA’s Cardinal Chapter.
COPYRIGHT 2002 Jannetti Publications, Inc.
COPYRIGHT 2007 Gale Group