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HEMODIALYSIS CATHETERS, CARE AND MAINTENANCE Ranjith Kumar Inbasekaran B.Sc in Renal Dialysis Technology Tutor & Dialysis Technologist B N Patel Institute of Paramedical and Science 1 Ranjith Kumar Inbasekaran

Hemodialysis Catheters, Care and Maintenance

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HEMODIALYSIS CATHETERS, CARE AND MAINTENANCERanjith Kumar InbasekaranB.Sc in Renal Dialysis Technology Tutor & Dialysis Technologist B N Patel Institute of Paramedical and Science

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Catheters More than 10 million central venous catheterizations

are performed each year around the world 85% new patients on HD Target % on new Catheters 6 months port can implanted

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MaterialsPoly Urethane Polytetrafluroeth elene (PTFE) Polyethelene Polyvinylchloride (PVC) / Polychloroethene Silicone and its elastomers Rigid at room temperature Becomes soft at body temperature More rigid than polyurethane Does not becomes soft at body temperature More thrombogenic than polyurethane More rigid than polyurethane Does not becomes soft at body temperature More thrombogenic than polyurethane More rigid than polyurethane Does not becomes soft at body temperature More thrombogenic than polyurethane Very soft and flexible requires surgical placement Extremely soft at body temperature, with thicker walls Very less thrombogenic

Less thrombogenic

Inert to infusatesDissolved if alcohol is used for cleaning

Commercially known as Teflon

Easy breakage, problem of leachingProgressive hardening of the catheters

Suitable for prolonged useDissolves if iodine is used for cleaning

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Lumen Configuration

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Hub, Port Type

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Size Catheter lumen size: 9-16 French in diameter. 1 French = 1/3 mm Length Temporary catheters:

Right Jugular vein: 15 Cm Left Jugular vein: 20 Cm Femoral Vein: 20-24 Cm Length Permanent catheters: 70 Cm in overall length

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Tip

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Insertion- modified Seldinger approach

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SitesFemoral Patient discomfort Easy insertion particularly in unstable patients Subclavian Patient comfort Technical expert required Internal jugular Patient discomfort Technical expert required

Low insertion complicationsShort functional life Limited patient mobility Infection is the major problem No post insertion radiograph is required

Risk of serious insertion related complicationsExtended functional life Risk of delayed complications Central Venous Stenosis is the major problem Post insertion radiograph is required

Risk of serious insertion related complicationsExtended functional life Risk of delayed complications Catheter difficult to secure Post insertion radiograph is always required

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Insertion Complication

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Insertion Complications Air embolism Bleeding Brachial plexus injury Cardiac arrhythmia Cardiac tamponade Hematoma Hemothorax

Pneumothorax AV fistula Arterial PunctureRanjith Kumar Inbasekaran 17

Care Ask the patient to keep the catheter and dressing away

from getting wet. Educate patient to do emergency dressing in case of wet dressing Mupirocin ointment or Povidone Iodine 10 % application at exit site Prophylactic antibiotic locks: Gentamycin lock, Vancomycin lock

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Maintenance Change of catheter caps every 72 hours Change of dry gauze dressing every 48 hours Change of transparent film every 7 days Use of Chloroprep and Biopatch

Line up slit in biopatch with catheter

Blue side to the sky

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Cont Use 1000-5000 IU/mL heparin for catheter lock. Use 10 mL or larger syringe, not smaller Use only for HD, Not for other infusions Should only be handled by dialysis staff, no body else Always keep hub closed, either with cap or syringe Use positive pressure flush to keep line from clotting.

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Late Complications- Infectious

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Infectious complications Exit site infection Tunnel Infection Blood stream infection

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Risk Factors Long term catheterization Previous history of CRB Recent surgery Diabetes mellitus Iron overload Immunosupression Malnutrition

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Infectious complications Causes Substandard Care of catheter Excess Manipulation Reduced Staff to Patient ratio Prolonged catheterization period During placement Entry site contamination Hematogenous spread Contamination of tubing/injection ports

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Infections Signs and symptoms: Tenderness and erythema along tunnel Fluctuance along tunnel Loss of adhesion of anchoring cuff

Purulence at exit site Redness at the exit site Pus at the exit site Fever Chills Nausea, vomiting and Fatigue

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Infection Prevention Hand hygiene Maximal sterile barrier precautions Chlorhexidine/Betadine skin antisepsis Optimal exit site care

(device and site of insertion) Patient education, Staff continuing education programs Catheter removal as early as possible Monitoring of practices by vascular access coordinator or a experienced dialysis staffRanjith Kumar Inbasekaran 26

Chlorhexidine-Impregnated Patch (BIOPATCH) and Conventional DressingIntervention % of Local Infection (among 401 subjects) 16.4 29.3 % of Catheter related blood stream Infections (among 589 subjects) 2.4 6.1 Biopatch Use Control

44% reduction in the incidence of

local infection 60% reduction in the incidence of CR-

BSIs Statistically significant reduction in

skin colonizationRanjith Kumar Inbasekaran 27

Infection Treatment: Mupirocin ointment Vancomycin 20-30 mg/Kg + Gentamycin 2-3 mg/Kg for 2-3 weeks Blood culture, removal if indicated

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Late Complications- others

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Late Complications- others Kinked catheter Fibrin sheath formation Catheter thrombosis Extravessation

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Catheter Removal Should be removed by experienced dialysis staff or

under supervision Position patient with head as low as possible. Remove sutures and pull line with steady motion as patient holds breath or during expiration. Assure tip is present. Hold pressure until bleeding stops, apply dressing.

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Patient education Serious infection is increased five to 10 fold Experiencing a painful complication from infection

(osteomyelitis, septic arthritis, endocarditis, or epidural abscess) Inadequate dialysis, associated problems Increased hospitalizations Mortality in the first year of dialysis is significantly increased

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My view Catheters are life saving, no doubt in it. But they do cause22% infectious complications, with septic arthritis, endocarditis and osteomyelitis 2. 43% higher cardiovascular related death rate than fistulas in some studies 3. AVF after 90 days with 29% reduction in all-cause mortality compared to catheters 4. Greater all cause and infection related hospitalizations 5. Reduced dialysis adequacy, poorer quality of life and greater costs1.Ranjith Kumar Inbasekaran 33

What we can do Keep preventive measures in mind always. Make plans to remove catheters soon. Team Work Early referral to nephrologist Patient education

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Reference Oxford text book of dialysis Text book of Dialysis therapy- Allen Nissessenson BARD, Hemostar, Biopatch Manufacturer info Infection control in dialysis Hyun Chul Kim, MD British Renal Society KDOQI Guidelines Students Manual RK, B N Patel Institute

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Thank You

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Special thanks to Prof. Raman Patel, FRCS (Lon) Prof. Himanshu Patel, MD, DM, DNB Prof. Soundararajan, MD, DM Dr. Thiagarajan M.Sc Ph.D Mr. Jagadeeshwaran M.Sc MSW

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Visit Gujarat

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