1.

GENERAL POLICY STATEMENT:

1.1 Gensan Medical Center Renal Dialysis Unit ensures that there are standard
procedures aimed to reduce the incidence of infection.
1.2 Gensan Medical Center Renal Dialysis Unit ensures the patency and integrity of the
catheter is maintained.

2. DEFINITION OF TERMS:
2.1 Cuffed tunnelled dialysis cathether (perm cath)- these are double catheters made of
silastic that are inserted surgically into the jugular, subclavian and femoral. They are
tunnelled under the skin and have a cuff that is tunnelled subcutaneously.
2.2 Non-Cuffed catheter or double lumen catheters- these are made of plastic polymers
and are used for temporary dialysis. They are inserted under strict aseptic technique
percutaneously using a guide wire into a large vein (usually femoral, jugular or
subclavian).

3. POLICY:
3.1 All renal dialysis unit staff nurse shall be trained according to Hospital standard when
starting and ending hemodialysis therapy.
3.2 All Renal Staff nurses shall be equipped and competent in using hemodialysis central
venous line catheter.
3.3 All renal Staff Nurses may apply suture for non-tunnelled catheters ONLY IF the
suture is not intact or loose.
3.4 Use of Hemodialysis catheters for other purposes shall be restricted where no
alternatives vascular access is feasible.
3.4.1 Internal Jugular Catheters (non tunnelled) are suitable ideally for 4 weeks of
use.
3.4.2 Femoral catheters are usually used for a maximum of 5 days.
3.4.3 Tunneled catheter can be used for 1 year.

4. PROCEDURE:
4.1 Preparation of tunneled and non-tunneled catheter:
4.1.1 Identify the patients. Explain the procedure.
4.1.2 Gather all equipments/materials needed.
4.1.2.1 Working Gloves 1 pair
4.1.2.2 Sterile gloves 1 pair
4.1.2.3 Mupirocin Ointment
4.1.2.4 Sterile Gauze 4x4 1 pack
4.1.2.5 Chlorhexidine Spray
 4.1.2.6 Sterile kidney basin
4.1.2.7 Micropore
4.1.2.8 Sterile Eyesheet
4.1.2.9 10cc syringe, 5 cc Syringe
4.1.3 Arrange sterile supplies needed for the catheter care over sterile towel.
4.1.4 Perform hand hygiene. Wear appropriate PPE.
4.1.5 Wear clean gloves and remove the dressing over the catheter and examine exit
site for drainage, pain, redness and whether the catheter is secured with
sutures or not.
4.1.6 If sutures are not intact, apply a suture to secure the catheter (for non-tunneled
only).
4.1.7 Clean the exit site of the catheter using gauze with chlorhexidine from the
insertion site outward. Let it dry.
4.1.8 Apply mupirocin ointment in the insertion site put on top sterile dry gauze
then cover with adhesive tape.
4.1.9 Remove gloves and perform hand washing.
4.1.10 Don sterile gloves. Place sterile towel under the catheter.
4.1.11 Wrap the lumen with sterile gauze with chlorhexidine.
4.1.12 Remove caps from lumen and clean the catheter hub with alcohol. Connect
5cc syringe and aspirate indwelling Heparin according to the lengths and
patient’s catheter.
4.1.13 Check the patency of each port using 10cc syringe simultaneously to assess
for good inflow and backflow. Secure the caps while aseptically soaked in a
basin with hydrogen peroxide.
4.1.14 Kept 10cc syringe in place. Catheter lumen must kept sterile. Never leave
catheter lumen open to air as there is risk of air embolism and infection.
4.1.15 If patent, catheter is ready to use.
4.1.16 If not, notify the Nephrologist if any observation such as:
4.1.17.1. Inability to infuse, these may be due to mechanical obstruction (kink,
malposition).
4.1.17.2. Inability to withdraw blood, these may be due to thrombotic obstruction.
It is a “Fibrin Sheath” growing around the catheter in the vessels lumen.
4.1.17.3. In case of discharges, tenderness, pain in the catheter site, fever and
chills.
4.1.17 Disinfect the end of the arterial limb using sterile gauze with chlorhexidine
and aseptically connect to arterial lumen port of the catheter.
4.1.18 Open the catheter arterial clamp and the clamp of arterial bloodline while the
venous line aseptically attached a receptacle then start the blood pump to start
treatment time.
 4.1.19 Take intra HD vital signs and monitor for intradialytic complications. Notify
MD if any abnormalities occur.

4.2 Initiation of Dialysis Treatment

4.2.1 Follow the procedure

4.2.2 Never the catheter open during the procedure. Cover it with sterile green towel all
the time.
4.2.3 Whenever catheter needs to be manipulated, strict aseptic/sterile tip technique
should be observed.

4.3 Care tunneled/non-tunneled catheter post dialysis

4.3.1 Gather equipment/materials needed on a clean area.

4.3.1.1 1pc 20cc syringe
4.3.1.2 1 pc 5cc syringe
4.3.1.3 Working Gloves 1 pair
4.3.1.4 Sterile gloves 1 pair
4.3.1.5 Sterile Gauze 4x4
4.3.1.6 Sterile kidney basin
4.3.1.7 Micropore
4.3.1.8 Chlorhexidine Spray
4.3.1.8 Heparin lock

4.3.2 Arrange sterile supplies needed for the catheter care over sterile towel observing
aseptic technique
4.3.3 Perform hand hygiene. Wear appropriate PPE.
4.3.4 Don sterile gloves. Using 5cc syringe, aspirate heparin according to the length of
each lumen.
4.3.5 Infuse heparin mixed with NSS observing the appropriate amount and technique
depending on the catheter size flushing quickly but smoothly to ensure that Heparin
reaches the distal end of the lumen. Clamp immediately.
Note: Flushing or clamping slowly may cause heparin to exit the catheter from the
proximal inlet holes leaving the distal holes unprotected from thrombus.
4.3.6 Ensure that the clamps on both lumens are closed and covered with sterile luer lock
caps.
4.3.7 Clean exposed lumen with gauze soaked in chlorhexidine. Let it dry.
4.3.8 Wrap catheter lumen with dry sterile gauze then cover with sterile adhesive
dressing.
4.4 In case of catheter infection:
4.4.1 Infection may result from contamination of the catheter connectors, lumen
contamination during dialysis or infused solutions. Patient should be observed of the
following signs and symptoms:
4.4.1.1 Fever and chills – degree of fever may increase during dialysis.
4.4.1.2 Erythema and/or crust but no purulent discharge in the exit site.
4.4.1.3 If there is presence of pus in the exit site or if pus can be expressed from
the tract of the catheter
4.4.2 Two sets of blood culture (aerobic and anaerobic) must be taken before the use of
parenteral or systemic antimicrobial therapy as order.
4.4.3 Blood culture must be drawn from the peripheral vein (1set) and from the catheter
port (1set).

Note: Observe sterile technique when obtaining blood sample for culture.
4.4.4 Give the appropriate antibiotics according to the result of the culture.
4.4.5 Blood culture should be drawn during the treatment and one to two weeks after
completion of antibiotic therapy.
4.4.6 If there is no progress, removal of catheter. On removal, the catheter tip should be
cultured.
4.4.7 A new catheter maybe inserted at another site, ideally after several days when blood
cultures have returned negative.

4.5 Home Care:

4.5.1 Encourage the patient to take a bath before coming to the Dialysis Unit, where
antibacterial ointment and a new dressing will be applied.
4.5.2 Instruct the patient to observe for any signs of bleeding on the catheter exit site. If
seen, patient is advised to go directly to the Emergency Room.
4.5.3 Advise patient to keep dressing dry and not to immense in bath water.

5. ACCOUNTABILITIES:
5.1 All nursing staff are responsible for assessment, care and dressing of the catheter exit
site and appropriate documentation of management and treatment.
5.2 Nephrologist are responsible for ensuring the correct position of the catheter post
insertion.
6.FORMS/EQUIPMENT:
6.1 Sterile gauze 4x4
6.2 Povidone-Iodine
6.3 Surgical Mask
6.4 Nonsterile and sterile gloves
6.5 Chlorhexidine
6.6 5cc, 10cc, 20cc
6.7 Surgical adhesive tape
6.8 sterile towel
6.9 Sterile luer lock caps
6.10 Sterile pick up forceps
6.11Heparin
6.12 0.9% NSS
6.12 Sterile Eyesheet