China's First Continuous Renal Replacement Therapy Expert Consensus On Prevention And Control Of Nosocomial Infection Released!
Jul 27, 2023
At present, there is still a lack of international guidelines or consensus on the prevention and control of nosocomial infection in continuous renal replacement therapy (CRRT). Since nosocomial infection prevention and control in CRRT is different from intermittent hemodialysis, the Kidney Branch of Sichuan International Exchange Promotion Association and West China Hospital of Sichuan University established an expert consensus group for CRRT nosocomial infection prevention and control. Systematic retrieval, data analysis, and expert argumentation were carried out for the subject content. The expert consensus group constructed 5 CRRT medical staff occupational protection, CRRT catheter-related infection, CRRT blood/waste sample collection, CRRT machine disinfection, CRRT consumables use, and waste disposal. The theme aims to strengthen the awareness of medical staff on the prevention and control of CRRT nosocomial infection, standardize the clinical operation of CRRT, and prevent nosocomial infection.
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occupational protection
1 Standard protection
①Medical staff should dress neatly, wear personal protective equipment according to the protection level, and wear disposable medical masks and surgical caps (level I recommendation, level D evidence).
②Sterile gloves should be worn during aseptic operations that may cause blood exposure, and clean gloves should be worn when touching patients' blood, body fluids, secretions, excretions, and contaminated items (level I recommendation, level D evidence), and strict implementation Hand hygiene.
③ It is recommended to establish health records for staff, conduct regular (in principle, at least once a year) physical examinations and detection of hepatitis B virus, hepatitis C virus, Treponema pallidum, and human immunodeficiency virus markers, and manage and store physical examination data.
2 isolation protection
① When treating air-isolated patients, medical staff should wear medical protective masks, sterile gloves, goggles, and long-sleeved isolation gowns (level I recommendation, level D evidence).
② When treating patients who need droplet isolation, personal protective equipment should be worn according to the protection level, especially when treating patients with severe acute respiratory syndrome and new coronavirus infection, they should wear disposable work caps, medical protective masks, protective masks, and disposable masks. Latex gloves, protective clothing, disposable shoe covers, and strict hand hygiene (level I recommendation, level D evidence).
3 special patients
For patients with fever who are quarantined at home or who have close contact with those who are quarantined at home, and suspected patients, medical staff will carry out protection according to the second level of protection, and terminal disinfection will be carried out after CRRT; Personnel should be protected according to the requirements of the second level of protection; when performing CRRT on patients in the negative pressure isolation ward, medical staff should be protected according to the third level of protection.
CRRT catheter-associated infection
1 Catheter placement and maintenance
Operators should be trained before catheterization, including the principles of using dialysis catheters and the standardized operation of dialysis catheterization (level I recommendation, level A evidence).
2 Principles of Sterility
The principle of asepsis and hand hygiene procedures should be strictly implemented during the whole process of catheterization (level I recommendation, level B evidence).
3 Disinfection principles
① Before catheterization, disinfectant should be used to clean the skin at the catheterization site to avoid skin preparation to reduce skin damage (level II recommendation, level B evidence).
② Chlorhexidine ethanol disinfectant (chlorhexidine>0.5%) can be used for skin disinfection (with the puncture point as the center, circular disinfection from the inside to the outside, the disinfection range should be ≥15cm×15cm). After disinfection, re-contact with the skin puncture point and the surrounding disinfected area should be avoided. If the patient has contraindications to the use of chlorhexidine, tincture of iodine, povidone-iodine, or 70%-80% ethanol can be used (grade I recommendation, level A evidence).
③ It is recommended to perform central venous catheterization under the guidance of ultrasound to reduce the number of repeated punctures and mechanical damage and improve the success rate of puncture (level I recommendation, level B evidence).
4 Maintenance after catheter placement
① After catheterization, sterile gauze or sterile transparent or translucent dressing should be used to cover the catheterization site (Class I recommendation, Level A evidence).
②If the puncture site secretes a lot of body fluid, it should be covered with sterile gauze. Transparent or translucent dressings should be changed every 5-7 days, and sterile gauze dressings should be changed at least once every 2 days (level I recommendation, level B evidence).
③The transparent dressing covering the tunnel or implanted catheter should not be replaced more than once a week (unless the dressing is contaminated or loose) until the catheter site is healed (level II recommendation, level B evidence).
④ When the dressing is wet, loose, or stained, it should be replaced immediately (grade I recommendation, level A evidence).
⑤ Catheters or catheterization sites should be prevented from being contaminated by body fluids (level IV recommendation, level D evidence).
5 retention time
Duration recommendations for non-tunneled and Dacron sheathed dialysis catheters (NCCs):
① In principle, neck vein NCC should not be used for more than 4 weeks (level I recommendation, level D evidence);
② Femoral vein NCC should not exceed 1 week in principle (Class I recommendation, Level D evidence);
③Long-term bedridden patients can be extended to 2 to 4 weeks depending on the situation (level I recommendation, level D evidence).
6 Conduit Fitting Maintenance
①Although routine prophylactic antibiotic lock is not recommended, for patients with long-term indwelling catheters, although aseptic techniques are performed to the greatest extent, there are still multiple catheter-related bloodstream infections (CRBSI) history, antibiotics can be used prophylactically Solution lock (level II recommendation, level B evidence).
② Routine maintenance evaluates whether the gauze wrapping the catheter is loose or falls off, opens the dressing wrapping the end of the central venous catheter, and evaluates whether the catheter is discounted, whether the clip is in a clamped state, and whether the external part of the catheter is broken (level IV recommendation, level D evidence).
7 Catheter replacement and extubation
① Catheters should not be replaced routinely to prevent catheter-related infections (level I recommendation, level B evidence).
②The catheter should not be removed simply because of fever, and the necessity of catheter removal should be comprehensively evaluated according to the clinical manifestations.
③ For catheters suspected of being infected, it is forbidden to use a guide wire to replace the catheter in situ (grade I recommendation, level B evidence).
④ When there is no obvious infection, a guide wire can be used to guide the replacement of a dysfunctional catheter (grade I recommendation, level B evidence).
⑤When replacing the guide wire, sterile gloves should be changed before touching the new catheter (level II recommendation, level B evidence).
⑥It is not recommended to apply an antibacterial ointment on the intubation site, as it may lead to fungal infection and antimicrobial drug resistance (Class I recommendation, Level A evidence).
⑦ When it is not needed, the catheter should be removed as soon as possible (the time is not specified), but if the aseptic technique is proper, the catheter can be left in place for a maximum of 14 days (level II recommendation, level B evidence).
⑧ When there are signs of CRBSI or thrombosis, remove the catheter instead of resetting it (Class II recommendation, Level of Evidence B).
⑨ After the catheter is pulled out, the blood vessel puncture point is compressed to stop bleeding, and the local area is sterile bandaged.
CRRT blood/waste sample collection
1 collection site
The collection site can be divided into patient body and extracorporeal circulation circuit sampling.
Internal sampling: the radial artery is the most commonly used for arterial blood collection, the dorsal pedal artery is an alternative, and the femoral artery is not recommended; the elbow vein is usually used for venous blood collection, and the back of the hand, wrist, popliteal fossa, and lateral malleolus veins are optional.
Extracorporeal circulation circuit sampling: the sampling point before the filter is located at the front end of the blood draw (red); the sampling point after the filter is located on the return blood vessel after the filter (blue); the waste liquid sampling point is located on the waste liquid line (yellow); For waste bag sampling, use a new waste bag and mix the waste before collecting. During partial citrate anticoagulation, when the arteriovenous line is directly connected, it is recommended to take samples from the extracorporeal circulation line for blood gas analysis; when the arteriovenous line is connected reversely, this method is not recommended.
2 Disinfection of the collection site
Skin disinfection: refer to the Health Industry Standard of the People's Republic of China "Technical Specifications for Disinfection in Medical Institutions" (level IV recommendation, level D evidence).
3 Requirements and principles for specimen collection in the extracorporeal circulation circuit
① Blood samples related to treatment can be collected, and blood samples not related to treatment are prohibited;
② Minimize the collection of specimens from the extracorporeal circulation circuit to prevent damage to the airtightness of the circuit;
③ When collecting specimens in the extracorporeal circulation circuit, in principle, a needle with a diameter of 20 gauge or smaller should be used (level IV recommendation, level D evidence) and a 1 mL syringe is recommended;
④It is recommended to use dry heparin containing sodium or lithium as an anticoagulant;
⑤ It is not recommended to use arterial blood collection needles and butterfly blood collection needles to take samples from the sampling point before the filter;
⑥ It is forbidden for non-specialist personnel to take samples from the collection port of the extracorporeal circulation circuit.
4 CRBSI Specimen Collection
① Timing of blood collection:
Once the possibility of bloodstream infection is suspected, blood should be collected immediately for culture, preferably before antibacterial treatment or 24 hours after antibiotics are stopped, when chills or fever occur.
②Collection method:
A. Keep the catheter: collect at least 2 sets of blood cultures from different sites with a syringe (1 set of blood culture = 1 part of aerobic culture + 1 part of the anaerobic culture), of which at least one set is from a peripheral vein and the other is from a catheter For collection, the time interval between blood collection from the two sources must be less than 5 minutes and they must be submitted for inspection at the same time;
B. Do not keep the catheter: Collect 2 sets of blood cultures as before, and at the same time follow the principle of aseptic operation, take out the catheter and cut off the 5cm catheter tip or proximal end, and send it to the laboratory for examination.
CRRT machine disinfection
1 Disinfection of CRRT instruments and equipment
①Overall principles
Reusable instruments and equipment (such as CRRT machines, infusion pumps, micropumps, etc.) should be cleaned and disinfected after use (level IV recommendation, level D evidence);
The surface of all CRRT instruments and equipment should meet the standard that the average number of colonies is ≤10.0 CFU/c㎡ (level IV recommendation, level D evidence);
Instruments and equipment should be disinfected every day (level III recommendation, level C evidence);
When wiping different patient units, the disinfection medium should be replaced (level III recommendation, level C evidence).
② Selection of disinfection medium
Disposable disinfectant wipes, reusable microfiber wipes, and cotton wipes (level IV recommendation, level D evidence).
③Sequence of disinfection
Disinfect according to the principle of top-down, front-to-back.
2 routine disinfection
①Disinfectant: 500mg/L chlorine-containing disinfectant (level IV recommendation, level D evidence).
②Disinfection frequency: Unused equipment can be disinfected every day (level IV recommendation, level D evidence). Instruments and equipment in use should be routinely cleaned and disinfected once a day or once a day and should be cleaned and disinfected in time when blood, body fluids, etc. are contaminated. After the treatment, it should be cleaned and disinfected.
③CRRT machine cleaning and disinfection requirements
Body: The recommended disinfectant solution is 75% ethanol, 70% isopropanol, or 0.1% sodium hypochlorite;
Screen: If it is a touch screen, use a volatile disinfectant;
Crank: Sodium hypochlorite disinfectant should not be selected;
Pressure sensor: no need for regular wiping, use a dry and clean non-woven cloth to wipe;
Blood leakage sensor: No routine wiping is required, if there is liquid adhesion, use 70% isopropanol to wipe.
④Sterilization of supporting equipment
Infusion pumps and micropumps: use disposable disinfectant wipes or 75% ethanol to disinfect the surface of the equipment once a day, once a shift for high-infection departments;
Infusion stand: Wipe with a chlorine-containing disinfectant containing 500mg/L available chlorine at least once a day, and disinfect in time if there is contamination.
When the environment or the surface of the object is contaminated by the patient's blood and body fluids, first cover the pollutants with a rag or a dry wipe soaked in 2000mg/L chlorine-containing disinfectant, use the covering to absorb and remove the pollutants, and then use a concentration of 500mg/L Wipe and disinfect with rags or disinfectant wipes soaked in chlorine-containing disinfectant (level I recommendation, level D evidence).
3 Special disinfection and equipment storage
Clean and disinfect the machine by the principles of the "Management Standards for Environmental Surface Cleaning and Disinfection in Medical Institutions" (WS/T 512), and select the corresponding disinfection or sterilization method according to the risk of infection after contamination of the items.
In principle, keep dry and ventilated, clean and disinfect regularly, and ensure the external environment required for equipment transfer (level IV recommendation, level D evidence). Fixed-point placement refers to the placement of CRRT equipment in designated areas according to classification (level IV recommendation, level D evidence).
CRRT Consumables Usage and Waste Disposal
1 Principles of using CRRT consumables
The filters and tubing of CRRT should be disposable filters tubing that are within the validity period. They should be used by one person, and re-use is prohibited, and they should be replaced regularly according to the product instructions (level I recommendation, level D evidence).
2 Treatment of medical waste
The treatment of medical waste, including disposable products, special patients (class A infectious diseases or managed according to class A infectious diseases), and medical waste liquid shall be handled by corresponding industry standards, such as "Sewage Discharge Standards for Medical Institutions" (level I recommendation, Level D evidence).
