Emergency Department: Emergent Accessing of Hemodialysis

Catheter in the Patient with Poor Venous Access

Introduction:
To provide guidelines for registered nurses (RN) in the Emergency Department related to
accessing and maintaining dialysis catheters in emergent situation the Emergency Department
in patient with poor venous access until another type peripheral or central access can be
obtained. The hemodialysis catheter will be accessed to administer intravenous (IV)
medications and/or fluids and obtain lab specimens.

Scope:
An Emergency Department Provider’s order is to be obtained to access and infuse a HD
catheter for non–dialysis purposes. Only Emergency Department RNs who have been trained
and demonstrated competency may access a HD catheter. A dialysis catheter may be
accessed after two unsuccessful peripheral IV attempts.

Table of Contents

I. Care of Hemodialysis Catheter........................................................................................... 1-2

II. Procedures.......................................................................................................................... 2-5

III. Nursing
Considerations……………………………………………………………………………5

I. Care of Hemodialysis Catheter

A. Assessment

1. The Emergency Department RN will assess the catheter approximately every four hours for
the following:

a. Clamps are closed on all lumens not being used for infusion.

b. Needle-free HD connectors are secured to the line and warning labels are in place when
catheter is not accessed.

c. Luer lock caps are in place when catheter is accessed. Do NOT access catheter for infusion
through a needle-free HD connector. Change to luer lock cap for infusion.

d. White universal disinfecting caps are in place if needle-free HD connector is present.

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e. Catheter exit site assessed for signs of inflammation/infection, proper position, and ensure
sutures are in place.

f. Dressing is clean, dry, and intact.

B. Documentation

1. Document the following approximately every four hours:

a. Type and location of catheter.

b. Description and skin integrity of exit site.

c. Exit site dressing status and dressing change due date.

d. Status of catheter lumens: infusing, flushed, or locked with heparin

C. Flushing Protocol

1. Follow the EHR Order: UCH Adult Central Line Flushing Protocol- Mahurkur Dialysis
Catheter

2. Dialysis catheters should NEVER be flushed without aspirating due to the high concentration
of heparin used to heparin lock the catheter.

D. Dressing Change 1. Change exit site dressing per Lippincott Procedure: Central Venous
Access Device Dressing Change

1. Dressing should be changed every 7 days or if visibly soiled.

2. If dressing is changed in should be label with time, date, and initials.

II. Procedures

A. Initiation of Fluid, Medication, or Cap Change

1. A complete opening of the dialysis catheter system using sterile technique

a. Gather supplies: 2 sterile drapes, 2 10 mL syringes, 2 10 mL NS flushes, 4% chlorhexidine

(CHG) solution, 4 sterile 4x4 gauze pads, 1 pair of sterile gloves, 2 masks, 2 sterile luer lock
caps, and primed primary IV tubing setup with IV pump.

b. Perform hand hygiene and explain procedure to patient.

c. Place mask on self and patient.

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d. Place all supplies on sterile drape and place the second drape on the patient’s chest under the
HD catheter.

e. 10 mL NS flushes are not sterile and should be placed to the side of the sterile drape.

f. Pour 4% CHG solution on 2 of the sterile 4x4 gauze pads.

g. Don sterile gloves.

h. Scrub the catheter from the clamp to the end of the venous cap with the 4% CHG soaked
gauze. Do not wipe the catheter line, 4% CHG solution may cause cracking of the catheter
material.

i. Wipe connection with dry sterile 4x4 gauze pad. Assure clamp is closed.

j. Remove the needle-free HD dialysis cap.

k. Attach sterile luer lock cap. Remember the lumen is heparinized and must be aspirated before
flushing.

l. Attach a 10 mL syringe, unclamp lumen, remove at least 5 mL of blood/heparin, disconnect

syringe and then discard in sharps container.

m. Flush catheter with 10 mL NS flush, attach primary IV tubing to luer lock cap, and begin
fluid/medication infusion.

i. Repeat steps g-m on second HD catheter lumen if additional access is needed.

n. Maintain NS infusion at a minimum rate of 20mL/hour at all times to maintain catheter

patency. Must have Healthcare Provider order for carrier fluid infusion. EHR Order: Adult
IP/ED Carrier Fluid(s) RN Standing Order (aka Carrier).

B. Heparinization of HD Catheter

1. If patient is not require. HD catheter will need to be heparinized with heparin 5000 units/mL
concentration per EHR Order: UCH Use of dialysis catheters for non-dialysis personnel.

a. Gather supplies: 10 mL syringe, alcohol wipes, gloves, 2 masks, and appropriate heparin dose.

b. Perform hand hygiene and explain procedure to patient.

c. Place mask on self and patient.

d. Don gloves

e. Identify the catheter lumen length which is located on the side of each lumen.

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i. This indicates the amount of heparin to be instilled into each lumen post procedure (e.g.
catheter lumen volume is 1.3 mL; instill 1.3 mL of heparin).

f. Draw up appropriate amount of heparin.

g. Instill heparin to fill catheter lumen; do not instill more than lumen indicates.

h. Clamp catheter lumen before disconnecting syringe.

i. Clamping the catheter lumen before disconnecting the heparin syringe prevents backflow of
blood into the catheter tip and helps prevent clotting.

i. Apply universal disinfecting caps (white universal disinfecting cap for needle-free HD cap or
green universal disinfecting cap for luer lock cap).

j. Ensure catheter lumen is labeled with type and volume of locking solution.

3. If luer lock/needle-free HD caps are removed, heparinizing the HD catheter requires sterile
technique. Refer to Procedure A for accessing catheter using sterile technique.

C. Obtaining Blood Cultures from HD Catheter

1. Emergency Department RNs are allowed to draw blood cultures from a HD catheter when
dialysis personnel are not available.

2. The following must be considered:

a. Clarify with the Healthcare Provider that one set of blood cultures needs to be obtained from
the dialysis catheter.

b. Emergency department RNs are NOT allowed to draw blood cultures from HD catheters on
emergency department patients on different units.

3. Because the luer lock/needle-free HD cap is removed to access the catheter, sterile technique
is required when obtaining blood cultures.

a. Gather supplies: blood culture kit, new cap (needle-free HD connector or luer lock), 2 2%
chlorhexidine (CHG)/70% isopropyl alcohol (IPA) applicators, 2 sterile drapes, 30 mL syringe,
4% CHG solution, 4 sterile 4x4 gauze pads, 1 pair sterile gloves, 2 masks, and 1 needle-free
blood transfer device.

b. Perform hand hygiene and explain procedure to patient.

c. Place mask on self and patient

d. Place all supplies on sterile drape and place the second drape on the patient’s chest under the
HD catheter.
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e. Blood culture kit is not sterile, place to the side of sterile drape.

f. Scrub tops of blood culture bottles with 2% CHG/70% IPA applicator.

g. Pour 4% CHG solution on 2 sterile 4x4 gauze pads.

h. Don sterile gloves.

i. Scrub the catheter from the clamp to the end of the IV tubing connection with the 4% CHG
soaked gauze. Do not wipe the catheter line, 4% CHG solution may cause cracking of the
catheter material.

j. Wipe connection with dry sterile 4x4 gauze pad. Assure clamp is closed.

k. Remove needle-free HD cap or luer lock cap and attach new sterile luer lock cap.

l. Wipe new cap with 2% CHG/70% IPA applicator vigorously for 30 seconds and allow to dry.

m. Attach 30 mL syringe, unclamp lumen, and draw back at least 22 mL of blood from HD
catheter.

i. Do NOT flush or waste prior to aspiration of blood.

n. Attach syringe and using sterile technique collect specimens per Lippincott Procedure: Blood
Culture Collection

o. Refer to Procedure C to heparinize HD catheter lumen.

Definitions:

Healthcare Provider: A credentialed or licensed practitioner who has ordering privileges and
prescribing authority.

Luer Lock Cap: A needle free intravenous connector that can be used on all peripheral, arterial,
and central venous catheters for the administration of IV fluids, medications, and blood products.

Needle-free Hemodialysis Connector: a closed luer-lock access connector that creates

mechanically and microbiologically closed system while allowing unobstructed blood flow for
hemodialysis.

Temporary Double Lumen Dialysis Catheter: a short-term dialysis catheter containing two
lumens for the purpose of hemodialysis and apheresis. The catheter emerges from the skin at the
site of entry into the jugular vein. Intended for use in hospitalized patients.

Temporary Triple Lumen Dialysis Catheter: a short-term dialysis catheter containing two lumens
for hemodialysis and apheresis and one central IV lumen for IV medication infusion and/or

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blood draws. The catheter emerges from the skin at the site of entry into the jugular vein.
Intended for use in hospitalized patients.

Tunneled Double Lumen Dialysis Catheter: long-term dialysis catheter containing two lumens
for the purpose of hemodialysis and apheresis. The catheter is placed in the jugular vein but
emerges from the skin in the subclavian area. It is tunneled to prevent migration and accidental
withdrawal.

Universal Disinfecting Cap: alcohol-containing cap that twists onto IV needless connectors for
disinfection and protection. Dialysis universal disinfecting caps will be white.

References:

Agharazii, M., Plamondon, I., Lebel, M., Douville, P., Desmeules, S. (2005). Estimation of
heparin leak into the systemic circulation after central venous catheter heparin lock. Nephrology
Dialysis Transplantation, 20, 1238-1240. (LOE III)

Centers for Disease Control and Prevention. (n.d.). Hemodialysis central venous catheter scrub-
the-hub protocol" [Online]. Accessed February 2017 via the Web at
http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Central-Venous-Catheter-STH-
Protocol.pdf (LOE V)

Counts, Caroline (ed) (2008) Core Curriculum for Nephrology Nursing. 5th ed.

Pitman Publishing, New Jersey: Jannetti, Inc. (LOE VI)

Cox, S., Hazelett, S., Kropp, D. (2008). Effectiveness of Chloraprep® in reduction of blood
culture contamination rates in the Emergency Department. Journal of Nursing Care Quality,
23(3), 272-276. (LOE III)

Dinwiddie, L., Bhola, C. (2010). Hemodialysis catheter care: Current recommendations for
nursing practice in North America. Nephrology Nursing Journal, 37, 507-519. (LOE V)

Dunning, K., Gaslin, T., Mathew, A., Ying, J. (2009). Central catheter blood sampling: The
impact of changing the needleless caps prior to collection. Journal of Infusion Nursing, 32(4),
212-218. (LOE III)

Merrill, K., Sumner, S., Linford, L., Taylor, C., Macintosh, C. (2014) Impact of universal
disinfectant cap implementation on central line-associated bloodstream infections. American
Journal of Infection Control, 42(12), 1274-1277. (LOE IV)

Smith, N. (2010). Prevention of hemodialysis central line-associated bloodstream infections in

acutely ill individuals. Nephrology Nursing Journal, 37(5) 523-528. (LOE V)

The current version of this policy can be viewed on The Source. Printing is discouraged.
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