Strategies For Identifying And Maintaining Infection in Vascular Access For Hemodialysis
Jan 04, 2023
Hemodialysis is inseparable from good vascular access maintenance. Ensure safe, unobstructed, and long-term use of vascular access for dialysis is the primary task of hemodialysis medical staff and dialysis kidney friends. According to Eur Vasc Endovasc research, the incidence of hemodialysis vascular access infection is 4.1% of the total infection risk of arteriovenous fistula, and the total infection incidence rate is 0.018/100 access days.
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The most common accesses for hemodialysis are autogenous arteriovenous fistula, artificial vascular arteriovenous fistula, and central venous catheter. Clinicians choose the same as long-term access for maintenance hemodialysis according to the comprehensive conditions of patients. Long-term maintenance and use in dialysis treatment. According to a multi-center study in Australia, the incidence of infection in the three major vascular access systems, bloodstream infection calculated based on 100 patient-months, the long-term catheter infection rate is 2.6%, graft artificial vascular fistula is 0.76%, and autologous arteriovenous internal fistula is 0.27%.
Therefore, regardless of the clinical maintenance of vascular access, active prevention of infection complications is the key content of hemodialysis clinical care and our daily health education, which requires the joint efforts of doctors, nurses, patients, and their families.
1. Instruct patients and family members to identify symptoms of pathway infection
Hemodialysis clinical medical staff and family members of dialysis patients should be aware of the judgment of infection symptoms. Hemodialysis channels will have characteristic clinical manifestations before infection. To give judgment, early detection, and early treatment.
The specific performance is——
Erythema, induration, swelling, pain, bleeding, exudate, ulceration, etc. appear in the local vascular access, and some patients also have chills and chills, which generally occur in patients with central venous catheters. Compared with intravascular fistula, the symptoms of catheter infection tend to be more characteristic of chills, fever, and chills. Some patients will develop fever and systemic inflammatory syndrome, and low-grade fever after dialysis.
Regardless of the manifestation, as long as the body is abnormal, the dialysis kidney friend and family members need to inform the doctors and nurses in the hemodialysis room in time to prevent early infection. Under the new situation of the new coronavirus infection management, we still need to learn to distinguish some symptoms from the new coronavirus infection, such as high fever, runny nose, nasal congestion, pain, etc., but this also needs to go to the hospital in time for differential diagnosis and symptomatic treatment due to treatment.
Afraid of cold and shivering during dialysis, urgently check the axillary temperature for low or high fever, indicating the presence of access infection. The main risk factor is long-term dialysis with catheters. Autologous fistula and artificial blood vessels are usually caused by a regional puncture, tumor-like expansion, and needle holes Caused by local infection of the internal fistula such as ulceration.
The differential diagnosis can be based on clinical features, urgent blood samples, chest CT, etc.
For the prevention of infection in vascular access for dialysis, the focus is on early detection and timely treatment.
2. Possible factors of hemodialysis vascular access infection
1) Possible factors of autologous fistula/artificial vascular fistula infection
patient reason
For autogenous arteriovenous fistula and artificial vascular fistula, the patient factors mainly include not paying attention to the hand hygiene of the fistula side limbs, and not having a good habit of washing hands with soap under water before puncture; the self-protection awareness is not strong during home care, and the puncture site is dirty. Humidity, leading to pollution, such as bathing, sweating, etc.; long-term use of adhesive plasters and band-aids, causing skin allergies at the venous puncture site, damage, ulceration, and skin infection caused by scratching with hands; dialysis kidney friends due to poor body resistance and malnutrition, anemia, etc., tumor-like expansion, regional puncture, or needle hole rupture in the dialysis internal fistula, resulting in redness, swelling, heat, and pain in the fistula body.
medical factors
The irregular aseptic operation, incomplete hand hygiene and skin disinfection at the puncture site; contamination of the puncture site after needle withdrawal; improper selection of the puncture site, repeated puncture at the same puncture site; poor puncture technique, repeated puncture at the puncture site and hematoma at the puncture site; The nurses did not observe and evaluate the arteriovenous fistula skin enough, and did not conduct timely education and care for the early allergies, redness, swelling, and damage of the arteriovenous fistula skin. Sometimes there is even redness and swelling at the puncture site. Contamination of skin disinfectant, expired use, iodophor bottle not capped in time or aseptic operation was not strictly implemented, resulting in contamination.
2) Possible factors of central venous catheter infection
patient factors
During hemodialysis treatment, a small amount of protein will be lost in the process of removing toxins from the patient's body. The digestive function of elderly dialysis patients is impaired, and the intake of protein, vitamins, and dietary fiber is reduced, resulting in malnutrition and low body resistance. Especially in diabetic patients, the risk of infection is higher than that of the general population due to disorders of glucose metabolism, low immune function, and reduced defense function. Advanced age, hypoalbuminemia, low hemoglobin level, malnutrition, diabetes, and use of immunosuppressants are risk factors for hemodialysis catheter infection.
Catheter-related factors
Colonization of the local skin flora of the patient and invasive catheterization can increase the risk of infection of the dialysis central venous catheter. Because the catheterization physician is not skilled in catheterization and repeated punctures, pathogenic bacteria can invade the deep part through the puncture needle, and repeated punctures will also Cause severe local irritation and damage, increasing the risk of infection. The indwelling site and indwelling time of the central venous catheter are closely related to catheter infection. Theoretically, the femoral vein skin fold is deep and close to the perineum, and the surrounding skin has more parasitic bacteria, easily polluted by excrement and has a greater risk of infection.
medical factors
The air cleanliness of the operating environment, air exposure time at the catheter port, hand hygiene, and aseptic operation will affect the occurrence of catheter-related infections. The hemodialysis center is an outpatient treatment environment with an intensive personnel flow. Under dynamic conditions, including any personnel tidying up items, frequently opening doors, personnel walking, and cleaning work, etc. will increase the number of planktonic bacteria in the air. If the catheter opening is exposed to the air for too long, bacteria may contaminate the catheter through sedimentation or pass through the nozzle. Enter the body and cause catheter-related infection.
3. Strategies for prevention and treatment of hemodialysis vascular access infection
Infection is rare for autogenous arteriovenous internal fistula. In clinical practice, when local symptoms such as redness, swelling, heat, and pain appear, avoid re-puncture at the infected site, palpate the skin temperature, observe the patient's systemic symptoms, and generally perform external surgery. Anti-infection principle treatment, early detection, and early treatment.
For graft artificial vascular access, if an internal fistula infection occurs, the affected area is generally relatively large, and the effect of simple anti-infection treatment is not good. If early detection and intervention are not performed, most of the graft vessels must be partially or completely surgically removed, and suitable ones should be selected. Antibiotics are used for anti-infection treatment. At this time, the patient needs to undergo transitional dialysis with the insertion of a central venous catheter.
For central venous catheters, the catheter site is the main factor that causes CRBS. To meet the blood flow requirements of hemodialysis, the order of central veins to be inserted into the Cuff catheter is as follows: right internal jugular vein, right external jugular vein, left internal jugular vein, left external jugular vein, subclavian vein, or femoral vein. Related literature reported that the infection rate of femoral vein catheterization reached 19% within 1 week, and the infection rate of internal jugular vein catheterization within 3 weeks was only 5.4%.
For the prevention of long-term catheter infection, antibiotic ointment can be used for local dressing changes at the catheter port. Mupirocin (Biodobang) is used when local redness, swelling, heat, and pain appear at the catheter port, but long-term use may produce drug resistance, such as later use If there is no effect, re-evaluation is required. One point worth paying attention to here is that long-term use of antibacterial ointment may lead to changes in the properties of the catheter. Bactroban will degrade polyurethane catheters, and the negative effects of long-term use should be avoided.
Another strategy for preventing long-term catheter infection is to use antimicrobial drugs to lock the catheter, that is, to use antibiotics + heparin to lock the catheter. The specific method is the second edition of the vascular access expert consensus courseware. The way of skin cleaning and disinfection before dialysis catheter operation has a great influence on catheter infection.
In addition, no matter what kind of vascular access, when there is dysfunction, there may be repeated tube or needle adjustment behaviors. Any exposure and disconnection will increase the risk of access infection. It is necessary to strictly evaluate the access function before using the machine to avoid After the machine, there is a long time of adjusting the tube and needle.
Summary
In clinical work, it is not difficult to find that the infection rate of the autologous arteriovenous fistula is low, the risk of graft internal fistula and catheter infection is high, and access infection is often the deepest blow to graft blood vessels, while for central venous catheter, It is the key factor causing the hospitalization and death of dialysis patients, and some dialysis patients have to face the outcome of unplanned extubation.
No matter what kind of vascular access is used or faced, the following principles must be kept in mind to do a good job in the prevention of access infection: strict hand hygiene timing, rational use of clean gloves, wearing masks when getting on and off the machine, strict aseptic operation, etc. The most important factor in preventing infection of dialysis vascular access. The core principle of prevention and control is early diagnosis and timely treatment. This reminds us doctors and nurses of the importance of health education, and we need to tell dialysis patients to identify and judge whether there are abnormalities in their pathways and intervene after timely feedback.
Because the incidence of dialysis catheter infection in clinical practice is higher than that of the other two types of vascular access, we need to do a good job in the maintenance of the catheter during, after the catheter, during the treatment, and after the treatment and choose the appropriate catheter. The site, strict principles of aseptic operation, wearing masks and gloves, the timing of hand hygiene, etc. In addition, it is to choose the appropriate sealing technology to maintain good catheter function.
The "Guidelines for the Prevention and Control of Vascular Catheter-Related Infections (2021 Edition)" (hereinafter referred to as the "Guidelines") issued by the General Office of the National Health and Health Commission once again standardized the requirements for catheter placement, emphasizing the operator's skill training and operating environment requirements. Indications for catheterization, and a series of cluster management measures mentioned above.
Remember the most critical sentence: early identification, early treatment, avoiding serious unplanned extubation or closure of the fistula, hospitalization for the reconstruction of access, or intubation transition dialysis, which may even be life-threatening.
for more information:ali.ma@wecistanche.com
