How to deal with the old Dialysis line in line exchanges in IR?

Tish88 · Nov 17, 2012

There are a few questions I would ask first before answering.

1. Is the catheter infected prior to the exchange? Is there a tunnel track infection present and/or positive blood cultures?

2. Are you exchanging over a wire?

3. How is the radiologist placing a catheter if he does not touch the original catheter?

If there is a tunnel infection present, you will need to change the tunnel and not go over a wire. It will be like a newly placed catheter. You don't want to place a new line into an area that already has an infection.

Secondly, if the patient has positive blood cultures, you should have the patient receive dialysis then pull the catheter. Give the patient at least 48 hours on antibiotics and be catheter free. If this is impossible, place a temporary femoral line during that time and then on the 3rd day place a tunneled catheter.

This is what we do if there is no signs of infection and will be exchanging over a wire.

1. The catheter dressing is removed and the skin and catheter are cleaned with adhesive remover and all adhesive is removed.

2. The heparin is removed.

3. The patient is then taken to the procedure room.

4. The scrub tech puts on sterile gloves. The entire skin, neck, chest area and the catheter itself is chlora-prepped. The caps are then removed. The hubs are then chlora-prepped, since you will be putting a guidewire down one of your lumens. We use a minimum of 2 chlora-prep scrubs and more if needed.

5. Once this area is prepped, a sterile towel is laid on the patient's chest and the catheter lays on this. Then the patient is covered with a sterile drap and we are ready to do the exchange.

6. Both the doctor and scrub nurse don 2 sets of sterile gloves. Once the wire is in position and the old catheter is removed, the one set of gloves are removed (the dirty ones that touch the old catheter). Now you still have clean sterile gloves on. The wire is then cleaned with betadine. Now you can place the new catheter over the wire.

I hope this helps. By using this technique, our outcomes are infection free!

iluvivt, BSN, RN · Nov 18, 2012

That was a great answer Tish88 and I agree. I cannot stress enough how critical it is for a good outcome to research each case prior to exchanging any catheter not jut Dialysis catheters because an exchange may be the last thing you want to do. Have blood cultures been taken from the catheter and a peripheral site indicating that the catheter is the source of the infection? If this is a tunneled CVC or HD catheter ,is there a tunnel infection? Do? Does another MD only suspect an infection? Why are you exchanging the catheter..many times it is for suspected infection and if that is the case you should not use it for an exchange unless there are extenuating circumstances,such as the pts MD does not really think the source is the CVC but they want a new one anyway...(Yes this happens)

Please read this http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

It is worth the long read and gives very clear cut directions

penelope3000 · Nov 18, 2012

Thank you for your input. Yes we are doing as you say regarding confirmed infections. (pulling out the existing line, waiting 48hrs and reinserting new line) The cases that we recently had were for blocked, malfunctioning lines, or exposed cuff. We have been doing much the same as you describe. We use a non scrub nurse and another tech to clean the old tube with a dressing tray while the scrub nurse prepares the procedure tray. Cleaning the tube really well with chlorhexidine. The assistant holds the tube up (with sterile gloves on) as this part can be very awkward. We take off the old caps, clean the ends and put clean ones on. Then we wrap a sterile gauze around the clamps, thin enough so the radiologist can feel them to manipulate them (secured with steristrips) and then he/she can hold on to the tube without actually touching it. The radiologist and scrub nurse change gloves after the old tube is removed. This is all vey time consuming but but not as much as an infected line. We do a lot of these and we are trying to be as consistent as possible. The radiologist is convinced that 2 recent line infections were due to us because it was within 48 hours of us putting them in. I will certainly read the pdf.

Thanks!