What do you do in your unit for catheter dressing and exit site care. Do you use the DOQI Guidelines? If not what do you do different and why?
?'s
No dressings
Do patients change their own at home- what about bathing or swimming
How often do you change the dressings
Do you track and trend infections- exit site as well as + blood infections

I was speaking to our unit sister today and telling her about this website. She asked if I could find out what people were using to clean catheter exit sites for haemodialysis. But as you asked first I'll write what we do. We use a alcoholic betadine solution to clean the exit site (using aseptic technique) and then use a sandwich dressing (one under catheter and one over) with tegaderm , a clear breathable membrane. We change this at each dialysis session. We also use the betadine solution to clean the catheter ports before use.

Dressing procedures really vary. Some use Betadine, Hibiclens (chlorexidine gluconate) or a new item a spray from Amuchina. Dressing vary from dry gauze to the type you are using. Some units are letting patients go without dressing and can shower. Would like to see what others use and comments on why it�s good and way it�s bad. What do you think of the tegaderm in the sandwich dressing? Any problems and how are your infection rates? Do you use the same for cuffed as well as non-cuffed catheters?

What is the tegaderm in the sandwich dressing? Can you please explain it and who makes it?

Sorry I don�t know who makes Tegaderm dressing- if someone knows please post. The procedure I am familiar with uses op-site or the clear plastic like dressings. You place one dressing down on the skin below the catheter exit and another dressing above the catheter exit site. The two dressings are pressed together with the catheter extension between the dressings. The extension sites of the catheter may or may not be fully covered by the dressing. This sandwich dressing was widely used with the old non cuffed temporary subclavian catheters. I personally never liked this dressing technique because it was so hard to remove from the catheter. You had to pull at the sandwiched portion with the catheter inside. Often staff would even take scissors to the dressing to cut the dressing away from the catheter. This is a big risk incase they nick the catheter. The plastic type dressing can be rough on the skin and often were moist or wet under the dressing when removed. Sometimes with the sandwich technique a gauze pad was placed inside the dressings. This was tough to do without ruining the dressing. With the tunnel cuffed catheters the extension sets are longer and I did not routinely use the sandwich dressing in recent years.
Maybe others using the sandwich technique could better comment.

I believe 3M makes the Tegaderm dressing. McKesson-General Medical and FUSA distribute Tegaderm. If anyone wants more info on where to get it, call me at work:

847-647-8505

or e-mail at joe@tubeguy.com


Joe

Joe,
You are too cool! All dialysis units should have someone like you working in the unit. Thanks for the info!

I have heard that using occlusive dressings like Tegaderm is frowned upon these days because they have found that the moisture that collects at the catheter insertion site has been contributing to infections. I heard this at the ANNA meeting. A surgeon from Florida spoke of this in a presentation he gave at a dinner meeting. I think his name was Caredi or something like that. It was a great talk !
Anybody know of any publications discussing infections with occlusive dressings ? Anybody have any personal experience with this problem ?

Sally- Dr. Caridi from Univ. of Florida gave a great talk! I when to dinner with him after the talk and he told me how much he enjoys talking to nurses because we laugh at his silly slides but also learn and remember the information. He references the same articles used in the DOQI Guidelines- Dr. Maki�s work. The dressing protocol in the DOQI is based on the studies that showed a higher infection rate with the plastic like occlusive dressing. That�s why the DOQI guidelines have the dry gauze dressing. The proidone iodine ointment is also based on Maki�s work. His studies used all types of central venous catheters and mostly hospitalized patients. Maki�s work was used by the CDC for the 1st time ever that guidelines for hemodialysis catheters were written by the CDC. Done at the same time as the DOQI and I talked with the CDC to make the DOQI Guidelines match the CDC. You can read the CDC guidelines on the web site. The name is Guidelines for Prevention of Intravascular Device-Related Infections at www.cdc.gov/ncidod/hip/iv/iv.htm The guidelines are based on the studies that were available when written (now 2-3 years old). The literature was lacking good clinical studies done in out pt dialysis units and most were done on non-cuffed temp. catheters.
Would like to hear from anyone currently doing a study in their unit comparing infection rates with dressing protocols. You can do this in any unit. Get baseline infection rates on all catheter patients. Then develop 2 or 3 different dressing protocol. Divide the patients into different dressing groups (make sure you divide them equally and use a random way such as machine station number or pods/ you don�t want to bias the study by selection certain �best� patients for the new dressing protocol) Use the different dressing protocol and track results. Track all exit site infection (all C+S cultures done on exit site drainage), all blood cultures done on any of the catheter patients and all suspected then documented infections and source of the infections. With in a 3 month time span you should see a different in infection rates. Most tunneled cuffed catheters will have an infection in a one year time period. In 3 months the infection rate should be <3%. The removal rate of catheters is > to 50% at 1 year due to infection. Track if the infection result in catheter salvage or catheter removal. Also track the organism that causes the infection and look for any trends. The easily way to do this is with an infection tracking log. Have the staff log all C+S cultures sent with the source note and current vascular access in place and the access being used, all blood cultures with reason why cultures are done such as fever/chills. When the final cultures are back the log tracks the results as Positive (with organism listed) or negative and how the infection was treated. Also logs when cultures return to normal. Can track if Vanco is given when a C+S is done � look to see how many Vanco�s are given for negative cultures. Lots of ways to look at this basic but very important issue.

Wow, tracking a catheter for over a year? How long do your clients have those catheters in?

Here, Uldall/Cook cuffed and tunnelled catheters are utilized, usually at the start of treatment or for emergent needs (like with fistula/graft problems). They're usually removed when the access is ready and being used consistently.

We dress the catheters, with sterile technique, using Betadine to cleanse, ETOH to rinse, betadine ointment at the exit site covered by 2-2x2's and finally a clear Tegederm. We cleanse the ports before cap removal with a Betadine soak and scrub.

I have often wondered why we keep completely healed catheter sites dressed, knowing that the cuff not only holds it in place but provides a barrier. I know of some dialysis clinics that don't dress them after they are completely healed, and it makes sense to me. I don't know what their infection rate is...