MANITOBA RENAL PROGRAM

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SUBJECT

 Accessing and Locking Hemodialysis Central Venous

Catheter

SECTION

30.20 Vascular Access

CODE

30.20.02

AUTHORIZATION

 Professional Advisory Committee, Manitoba Renal Program

 Nursing Practice Council, St. Boniface Hospital

EFFECTIVE DATE

May 1999

REVISION DATE

January 2009

January 2012

May 2016

October 2016

March 2017

January 2018

PURPOSE:

1. To access non-tunneled or tunneled central venous catheter (CVC) for Hemodialysis in the management of

acute or chronic renal failure. The CVC may also be accessed for blood sampling as ordered by a physician.

POLICY:

1. Registered Nurses and Licensed Practical Nurses in the Manitoba Renal Program who have received

instruction and have demonstrated competency to the renal educator or delegate may utilize a CVC.

2. A physician’s order must be obtained prior to initial use of a CVC to ensure proper placement.

3. Following recommendations by The Canadian Association of Nephrology Nurses and Technologists

(CANNT) and the Center for Disease Control (CDC) the Manitoba Renal Program will follow the “scrub the

hub” cleansing technique when accessing Hemodialysis Central Venous Catheters.

“Scrub the Hub” will be performed prior to initiating hemodialysis and again prior to replacing a new cap at

the end of treatment.

For accessing bloodlines during treatment (eg. to flush ports or reverse lines) and to start reinfusion

continue to cleanse the outer connection prior to disconnecting. Rationale: when blood is present in the

lines we don’t want the pump stopped for an extended period of time while scrubbing and allowing to dry.

The risk of contamination to the ends of the bloodlines/CVC ports is increased during these procedures as

they are being held open, unattached for an extended period of time at the same time as manipulating

syringes, bloodlines and ports.

EQUIPMENT:

For Initiating Dialysis

 Clean towel or sterile drape

 Disposable gloves

 2 packages 2% chlorhexidine (CHG) with 70%

Alcohol wipes

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 2 – 10 mL syringes containing 0.9% NaCl, one of

these may contain heparin/saline prime as ordered

by a physician

 2 – 10 mL syringes

 1 package of sterile gauze 10 X 10 cm

 2 procedure masks

For Discontinuing Dialysis

 Clean towel or sterile drape

 Disposable gloves

 4 packages 2% chlorhexidine (CHG) with 70%

Alcohol wipes

 1 package of sterile 10 X 10 cm gauze

 1 unsterile 10x10cm gauze for wrapping (optional)

 2 procedure masks

 2 sterile luer-lock caps

 2 – 3 mL syringes for instillation of prescribed

locking solution

 2 syringes containing 10 – 20 mL of 0.9% NaCl

 Label with appropriate instillation information

PROCEDURE:

KEY POINT:

A. INITIATING DIALYSIS:

1. Perform hand hygiene.

2. Mask (patient and nurse).

 Recommendations from the CSN and KDOQI

clinical practice guidelines.

3. Don clean gloves.

4. Change the dressing as per Procedure

30.20.05 Hemodialysis Central Line Dressing

Change.

 Exit site MUST be visualized prior to initiating

dialysis.

 Dressing changes are preferentially done prior to

initiating dialysis to assess catheter position and to

verify sutures are intact. Notify physician if

indicated.

5. Open drape and place under catheter.

 The drape is utilized to provide a clean (not sterile)

field.

6. Confirm that cannula clamps on catheter are

closed.

 The use of the clamp on the silastic portion of the

catheter ensures that the line is not open to

atmospheric pressure during any of the

connections and disconnections.

7. Remove one luer-lock cap from the catheter

and using a rotating motion, scrub the hub with

a new 2% CHG with 70% Alcohol wipe for 30

seconds.

 For practical reasons, pads or similar products

might be preferred over other forms of antiseptics

(e.g. swab sticks) for disinfecting the catheter as

they are pliable and allow for vigorous cleaning of

small spaces.

8. Allow the hub to dry completely while

continuing to hold the catheter lumen.

 Always handle the catheter hubs aseptically. Once

disinfected, do not allow the catheter hubs to touch

non-sterile surfaces. During this time ensure that

the catheter remains clamped.

 Allow to air dry for at least one minute. No

wrapping, no fanning, no blowing.

 Antiseptics should be allowed to dry for maximal

effect.

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 If hub is not dry, it may be difficult to disconnect

blood line at the end of the treatment.

9. Attach an empty sterile 10 mL syringe.

10. Open cannula clamp and aspirate 3-5 mL of

blood to confirm patency and to withdraw

previously instilled locking solution. Close

clamp. Discard syringe.

 Dark blood should freely enter syringe.

Occasionally clots may be aspirated.

 Blood specimens may be drawn following

aspiration of locking solutions. Never aspirate

with a syringe less than 5 mL.

11. Attach a new sterile syringe containing 10 mL

0.9% NaCl. Open clamp and instill into the

catheter port. Close clamp.

 Blood should never be allowed to dwell in the

catheter lines. Repeat flush with saline if

necessary.

12. Open sterile 10x10 gauze and place under

catheter port.

13. Repeat Steps 9-13 for the other lumen of the

catheter. If patent, give heparin prime as per

physician’s order.

 Heparin prime dosages of at least 1000 units may

alternatively be given via heparin pump on the

Fresenius after initiation of dialysis.

14. Initiate dialysis as per Procedure 30.10.01 Use

of Fresenius 5008 Delivery System or

30.10.03 Initiation and termination of

Treatment using the Fresenius 5008

ONLINEplus ™ System

 Administer heparin prime through heparin pump on

delivery system if not already done.

15. Instruct patient to keep catheter connections

exposed during treatment.

 To observe for accidental disconnect.

B. CARE OF CLOTTED/SLUGGISH

HEMODIALYSIS CATHETER:

1. If unable to aspirate, attempt to flush with 0.9

NaCl.

 Do not use a syringe less than 10 mL.

2. If flush is unsuccessful, clamp line, disconnect

syringe and instill alteplase per physician’s

order and Procedure 30.20.08 Alteplase for

Clearing Hemodialysis Catheter Thrombosis

Using the Push (30 min) Method.

 Refer to physician order re: Instillation of

Alteplase.

3. If the flush is successful.

a. If a heparin lock is instilled, hold heparin

bolus/prime and flush line with 10 – 20 mL

0.9% NaCl.

b. If a 4% sodium citrate lock or an alteplase

lock is instilled, administer heparin

bolus/prime.

 The patient will receive the lock as a bolus.

 Orders to instill heparin 1000 units/mL, 4% sodium

citrate or alteplase are found on the Chronic

Hemodialysis Physician’s Order Sheet (W-00109).

4. Attach bloodlines and initiate treatment.

C. DISCONTINUING DIALYSIS:

1. Perform hand hygiene.

2. Mask (patient and nurse).

3. Don clean gloves.

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4. Open the drape and place under the catheter

and bloodlines.

 The drape is utilized to provide a clean (not sterile)

field.

5. Using 2% CHG with 70% Alcohol swab, scrub

connection sites for 30 seconds.

 For practical reasons, pads or similar products

might be preferred over other forms of antiseptics

(e.g. swab sticks) for disinfecting the catheter as

they are pliable and allow for vigorous cleaning of

small spaces.

6. Place on sterile gauze and allow to dry

completely.

 Allow to air dry. No wrapping, no fanning, no

blowing.

7. Return blood as per procedure 30.10.01, Use

of the Fresenius 5008 Delivery System or

30.10.03, Initiation and Termination of

Treatment using the Fresenius 5008

ONLINEplus™ System

8. Proceed with lock procedure.

I. Procedure for Locking Hemodialysis Catheter

1. Confirm clamp is closed. Attach a syringe

containing 10 –20 mL 0.9% NaCl into the

CVC port used for supply and infuse. Close

clamp.

 Either arterial or venous port can be used for

supply. Select the port to which arterial blood line

was attached.

2. On completion of blood return, clamp the

venous blood line and catheter lumen and

detach blood line from the catheter. Attach a

syringe containing 10 –20 mL 0.9% NaCl to

the port used for return and infuse. Close the

clamp on the lumen.

 Ensure Blood Pressures are stable prior to

disconnecting venous blood line from access.

3. Attach the syringe containing locking solution

ordered by Physician, open the clamp and

instill using positive pressure. Close the

clamp.

 Positive pressure is maintained if the port is

clamped simultaneously with the completion of

instillation.

4. Remove syringe from port and using a

rotating motion, scrub the hub with a new 2%

CHG with Alcohol 70% swab for 30 seconds.

 For practical reasons, pads or similar products

might be preferred over other forms of antiseptics

(e.g. swab sticks) for disinfecting the catheter as

they are pliable and allow for vigorous cleaning of

small spaces.

 If using an antiseptic that leaves a residue (eg

Chlorhexidine), avoid allowing large amounts of

antiseptic to enter the lumen of the catheter to

avoid potential toxicities to the patient.

5. Allow the hub to dry completely while

continuing to hold the catheter lumen.

Allow time to air dry for at least one minute. No

wrapping, no fanning, no blowing.

 If hub is not dry, it may be difficult to remove CVC

cap next treatment.

 Always handle the catheter hubs aseptically. Once

disinfected, do not allow the catheter hubs to touch

non-sterile surfaces. During this time ensure that

the catheter remains clamped.

6. Attach sterile luer-lock cap.

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7. Repeat steps 3-6 with second port.

D. Procedure for Accessing the CVC for blood sampling only

1. Perform hand hygiene.

2. Mask (patient and nurse).

 Recommendations from the CSN and KDOQI

clinical practice guidelines.

3. Don clean gloves.

4. Open drape and place under catheter.

 The drape is utilized to provide a clean (not sterile)

field.

5. Confirm that cannula clamps on catheter are

closed.

 The use of the clamp on the silastic portion of the

catheter ensures that the line is not open to

atmospheric pressure during any of the

connections and disconnections.

6. Remove one luer-lock cap from the catheter

and using a rotating motion, scrub the hub with

a new 2% CHG with 70% Alcohol wipe for 30

seconds.

7. Allow the hub to dry completely while

continuing to hold the catheter lumen.

 Always handle the catheter hubs aseptically. Once

disinfected, do not allow the catheter hubs to touch

non-sterile surfaces. During this time ensure that

the catheter remains clamped.

 Allow to air dry for at least one minute. No

wrapping, no fanning, no blowing.



8. Attach an empty sterile 10 mL syringe.

9. Open cannula clamp and aspirate 3-5 mL of

blood to confirm patency and to withdraw

previously instilled locking solution. Close

clamp. Discard syringe.

 Dark blood should freely enter syringe.

Occasionally clots may be aspirated.

 Blood specimens may be drawn following

aspiration of locking solutions. Never aspirate

with a syringe less than 5 mL.

10. Attach a sterile vacutainer or empty sterile

syringe and obtain specimens as needed.



11. Once blood sample is obtained, close clamp

and remove syringe or vacutainer. Attach a

syringe containing 10 –20 mL 0.9% NaCl to the

port. Open clamp and instill. Close clamp.

12. Attach syringe containing locking solution

ordered by Physician and instill using positive

pressure to the volume of the lumen. Close

the clamp.

 Positive pressure is maintained if the port is

clamped simultaneously with the completion of

instillation.

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13. Remove syringe. Using a rotating motion,

scrub the hub with a new 2% CHG with 70%

Alcohol wipe for 30 seconds.

14. Allow the hub to dry completely while

continuing to hold the catheter lumen.

 Always handle the catheter hubs aseptically. Once

disinfected, do not allow the catheter hubs to touch

non-sterile surfaces. During this time ensure that

the catheter remains clamped.

 Allow to air dry for at least one minute. No

wrapping, no fanning, no blowing.

15. Attach sterile luer lock cap.

16. If second lumen needs to be accessed for

sampling (e.g. blood cultures), repeat steps

5-15.

E. Procedure for accessing CVC mid treatment for purposes of irrigation of lumens or reversing lines.

1. Perform hand hygiene.

2. Mask (patient and nurse).

 Recommendations from the CSN and KDOQI

clinical practice guidelines.

3. Don clean gloves.

4. Open drape and place under catheter.

 The drape is utilized to provide a clean (not sterile)

field.

5. Using 2% CHG with 70% Alcohol swab, scrub

connection sites for 30 seconds.

 For practical reasons, pads or similar products

might be preferred over other forms of antiseptics

(e.g. swab sticks) for disinfecting the catheter as

they are pliable and allow for vigorous cleaning of

small spaces.

6. Place on the sterile gauze and allow to dry

completely.

 Allow to air dry for at least one minute. No

wrapping, no fanning, no blowing.

7. Stop blood pump if not done prior. Clamp CVC

clamps and blood line clamps,

 Minimize blood pump stop time in order to prevent

coagulation of blood in the extracorpeal circuit.

8. Maintaining aseptic technique disconnect the

blood line(s) from CVC port(s) and irrigate the

lumens with 10mL sterile saline.

 Do not allow CVC ports/lumens or the open blood

lines to touch non sterile surfaces.

 Minimize “open air” time of catheter ports and

blood lines to decrease risk of infection.

9. Reattach blood lines to CVC port.

10. Open clamps on CVC ports and blood lines.

Start blood pump.

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DOCUMENTATION:

 Manitoba Renal Program Health Record:

o Medical Administration Record

o Integrated Progress Notes if applicable

 In-hospital Unit/Ward Health Record:

о Integrated Progress Notes

REFERENCES:

Canadian Hemodialysis Access Coordinators Network. (2015). Nursing Recommendations for the Management

of Vascular Access in Adult Hemodialysis Patient 2015 Update. Canadian Association of Nephrology

Nurses and Technologists (CANNT) Journal. 25(1), 1 – 46.

Centers for Disease Control and Prevention. (2011). Guidelines for the prevention of intravascular catheter-

related infections, http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol – Centers for Disease Control, National Center

for Emerging and Zoonotic Infectious diseases – Division of Healthcare Quality Promotion.

https://www.cdc.gov/dialysis/prevention-tools/scrub-protocols.html

https://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Central-Venous-Catheter-STH-Protocol.pdf

Covidien. (2014). Palindrome™ Chronic Dialysis Catheter. Cleaning and Handling Guidelines (12MAN0152

08/14). Mansfield, MA: Author.

O’Grady, N.P., et al.(2011). Guidelines for the prevention of intravascular catheter-related infections. American

Journal of Infection Control. 39(4). S1-S34.

National Kidney Foundation. (2006). National Kidney Foundation (NKF) KDOQI (Kidney Disease Outcomes

Quality Initiative) Guidelines: Clinical practice guidelines for vascular access, update 2006: Guideline 3:

Cannulation of Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems.

Retrieved September 2011 from:

http://www.kidney.org/professionals/kdogi/guideline_uphd_pd_va/va_guide3.htm

Nguyen, T.V., & Dikun, M. (2004). Establishing an alteplase dosing protocol for hemodialysis-catheter

thrombosis. American Journal of Health-System Pharmacy. 61, 1922-1924.

Vercaigne, L., (June, 2011). Personal Communication between Kemp, J. and Lajeunesse, R. – re: rTPA

protocols.

Personal Communication (Janine Kemp, Vascular Access Nurse, SOGH and Perry Rod, Covidien Sales Rep).

Cleansing Solutions for Palindrome Catheters, June 2010.

Personal Communication (Janine Kemp, Vascular Access Nurse, SOGH and Adele Yan, Bard Canada Inc.).

Cleansing Solutions for BARD hemostar catheters, June 2010.

APIC (Association for Professionals in Infection Control and Epidemiology) – 2010 Guide to the Elimination of

Infections in Hemodialysis.

McGhie, Kathy. (2016). Antiseptic Use in Hemodialysis Manitoba Renal Program. 3M Health Care Academy

powerpoint presentation November 7, 8 & 9, 2016.