What are the recommended central line connection and care protocols for a dialysis patient to minimize infection risk?

Central Line Connection and Care in Dialysis Patients

For dialysis patients with central venous catheters, strict aseptic technique with chlorhexidine-based hub disinfection for at least 15 seconds before every connection and disconnection, combined with alcohol-based chlorhexidine (>0.5%) exit site care, represents the evidence-based standard to minimize catheter-related bloodstream infections.

Hand Hygiene and Personal Protective Equipment

• All staff must perform hand hygiene immediately before and after catheter manipulation 1
• Staff should wear gloves and masks while handling the catheter during connection and disconnection procedures 1
• Alcohol-based hand rubs are superior to soap and water, requiring less time and causing less skin irritation while effectively removing microorganisms 1

Hub Disinfection Protocol ("Scrub the Hub")

• Scrub the catheter hub with chlorhexidine-based solution or 70% alcohol for at least 15 seconds before connecting to the dialysis machine 1
• Repeat this "scrub the hub" process at the time of disconnection 1
• The use of 3.15% chlorhexidine gluconate/70% alcohol for hub disinfection has demonstrated a statistically significant 65% reduction in catheter-related bloodstream infections in dialysis patients 2
• If chlorhexidine is contraindicated due to allergy or sensitivity, povidone-iodine solution (preferably with alcohol) is an acceptable substitute 1

Exit Site Care Protocol

• Examine the exit site for signs of infection after performing hand hygiene 1
• Disinfect the exit site with alcohol-based chlorhexidine (>0.5% solution) for at least 60 seconds 1
• Acceptable alternatives include 10% povidone-iodine solution used for 2-3 minutes or 70% alcohol 1
• Prepare the skin with 0.5% chlorhexidine preparation with alcohol before catheter insertion and during dressing changes 1
• Allow antiseptics to dry according to manufacturer's recommendations before catheter manipulation 1

Topical Antimicrobial Application

• Apply povidone-iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session, provided the ointment does not interact with the catheter material per manufacturer's recommendation 1
• If using gauze bandages over the exit site, apply povidone-iodine or triple antibiotic ointment 1
• Alternatively, a chlorhexidine disk (Biopatch) with Tegaderm dressing can be used and must be changed weekly 1

Dressing Management

• Use either sterile gauze or sterile, transparent, semi-permeable dressing to cover the catheter site 1
• Replace dressings if they become damp, loosened, or visibly soiled 1
• Monitor the catheter site visually when changing the dressing or by palpation through an intact dressing 1
• The choice between transparent film versus gauze dressing should be based on clinical judgment, as evidence does not demonstrate a significant difference in infection rates 1

Connection Procedure Step-by-Step

• Place the catheter on a nonsterile pad 1
• Clamp the catheter tubing before removing the catheter cap 1
• Perform hand hygiene and don gloves and mask 1
• Scrub the hub with chlorhexidine or 70% alcohol for at least 15 seconds 1
• Connect to dialysis machine using aseptic technique 1

Antimicrobial Lock Solutions

• Consider prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of multiple catheter-related bloodstream infections despite optimal adherence to aseptic technique 1
• At least 94% of studies evaluating antimicrobial lock solutions demonstrated reductions in catheter-related bloodstream infection rates 3
• Recent multicenter randomized controlled trials showed significantly lower infection rates with antimicrobial lock solutions even when baseline rates were already low 3

Critical Pitfalls to Avoid

• Never use the femoral vein for central venous access in adult patients due to higher infection risk 1
• Avoid the subclavian site in hemodialysis patients and those with advanced kidney disease to prevent subclavian vein stenosis 1
• Do not routinely replace hemodialysis catheters to prevent infection; replacement should only occur when clinically indicated 1
• Do not remove catheters based on fever alone; use clinical judgment regarding infection evidence elsewhere 1
• Ensure adequate scrub time (minimum 15 seconds) and allow proper drying time, as variations in these practices can compromise infection prevention 2

Quality Monitoring

• Implement catheter care protocols with regular auditing of hand hygiene compliance, vascular access care observation, exit site disinfection technique, and hub disinfection practices 1
• All of these measures combined have been shown to decrease bloodstream infection risk in dialysis patients 1
• Adherence to meticulous catheter care protocols can achieve catheter-related bloodstream infection incidence well below one episode per 1,000 catheter days 4