Haemodialysis Access

Title of Guideline (must include the word “Guideline” Guidelines for Haemodialysis Access in
(not protocol, policy, procedure etc)
Children

Contact Name and Job Title (author) Roy Connell – Clinical Nurse Specialist
Diane Blyton – Renal Nurse Educator

Directorate & Speciality Family Health; Renal

Date of submission May 2014

Date on which guideline must be reviewed (this should August 2016

be one to three years)
Explicit definition of patient group to which it applies
(e.g. inclusion and exclusion criteria, diagnosis)
Children and Young People treated with
haemodialysis under the care of the
Children’s Renal Unit, QMC Campus.

Abstract This guideline describes the Assessment,

care and management of access for
haemodialysis in paediatric patients.

Key Words Haemodialysis, Central line, Fistula, Child,

Young Person, Renal.

Statement of the evidence base of the guideline – has 1b

the guideline been peer reviewed by colleagues?

Evidence base: (1-5)

1a meta analysis of randomised controlled trials
1b at least one randomised controlled trial
2a at least one well-designed controlled study
without randomisation
2b at least one other type of well-designed quasi-
experimental study
3 well –designed non-experimental descriptive
studies (ie comparative / correlation and case
studies)
4 expert committee reports or opinions and / or
clinical experiences of respected authorities
5 recommended best practise based on the clinical
experience of the guideline developer
Consultation Process Children’s Renal Unit guideline review.
Paediatric Clinical Guidelines Group
Target audience Clinicians and healthcare professionals
caring for children and young people
treated with haemodialysis at Nottingham
University Hospitals NHS Trust

This guideline has been registered with the trust. However, clinical guidelines are guidelines
only. The interpretation and application of clinical guidelines will remain the responsibility of
the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised
when using guidelines after the review date.

Roy Connnell 1 of 19 August 2013 1

Index Page

Introduction 3

A. Central Venous Catheters 4

A1. Temporary 4
A2. Long-term. 4-5

B. Pre Operative guidelines 5

B1. CVL/Fistula 5
B2. CVL 5
B3. Fistula 5

C. Intra operative Guidelines 5

D. Post Operative Guidelines 6

D1. CVL 6
D2. Fistula 6

E. Exit Site Care 7

F. Line locks for CVLs. 7-8

G. Alteplase locks for CVL 8

G1. Assessment and contraindications 8
G2. Dose 9
G3. Administration 9
G4. Equipment 9
G5. Observation 9

H. Central line occlusion/Decreased function 10-11

I. Fistula Occlusions 11
I1. Mild Ischaemia 11
I2. Severe Ischaemia 12

J. Central Line Infections 12

J1. Investigations 12
J2. Central line related bacteraemia 12
J3. Antibiotic treatment 13

K. Fistula Infections 13

L. Exit Site Infection 13

M. Tunnel Infections 14

N. Fistula Stenosis 14

References 15
Appendices 16-18
Roy Connnell 2 of 19 August 2013 2
Introduction

These guidelines are to ensure the correct management of central venous

catheters and arteriovenous fistulas for Haemodialysis and other extracorporeal
therapies, from insertion/formation, for children under the care of the Paediatric
Renal Unit.

Central venous lines not named in section A in these guidelines should be

managed in accordance with the guidelines from the patient’s speciality.

The central venous lines discussed in this guideline differ from the standard
Hickman lines/Broviac catheters used for “IV access” or TPN, in that their design
differs (multiple lumens and multiple, tapered perforations) and their use differs
(3 times a week access and reliable high flows (up to 300ml/min) required from
both lumens).

The strength of heparin used in central venous lines should be carefully

observed.

The maximum concentration that should be used is Heparin 100 units/ml.

Higher concentrations can be dangerous to the patient even if used only as a
lock.

If a child is attending another department, and their catheter may be used

(e.g. Interventional radiography, or theatres), the line lock should be replaced
with Heparin 10 units/ml whilst the patient is off the ward.

If you are unsure about any of the contents of these guidelines or the strength of
Heparin, Alteplase or Urokinase to use, please consult a haemodialysis trained
nurse or the paediatric nephrology consultant on-call.

Roy Connnell 3 of 19 August 2013 3

A Central Venous Catheters

A1 Temporary central venous lines

For children receiving short term treatment temporary access may be inserted.

Supplier Name Line size Single/double Heparin Weight

lumen Lock guide.
Gambro Gamcath 6.5fr - Double 0.9ml < 10kg
7.5cm
Gambro Gamcath 6.5fr - Double 1ml < 10kg
12.5cm
Gambro Gamcath 8fr - Double 1.1ml 10 - 20kg
12.5cm
Gambro Gamcath 11fr - Double 1.3ml > 20kg
15cm
Gambro Gamcath 11fr - Double 1.4ml > 30kg
20cm

A2 Long-term central venous lines.

The current long-term central lines of choice are single cuff dual lumen for most
children receiving renal replacement therapy for chronic kidney disease (or any
other on-going extra-corporeal therapies).

Long-term Double Lumen Catheters

Supplier Catheter Size Lock Required Patient Size

(priming volume)

Kimal 8 fr -12cm 0.8 ml per lumen Infant Under 10 Kg

Medcomp 8 fr – 18cm 1 ml per lumen Infant/Child

10-20 Kg

Medcomp 10 fr – 18cm 1.2 ml per lumen Infant/Child

(Split-cath) 10-30 Kg

Medcomp 12 fr – 24cm 1.3ml per lumen Child

30-60 Kg

Kimal 14 fr – 28cm 1.9 ml per lumen Child

Over 60 Kg

Roy Connnell 4 of 19 August 2013 4

Please Note;
These are general Guidelines. The patient’s height and body proportions should
be considered when making the selection.

Single Lumen catheters

Catheter Size Lock required (priming Product code

volume of lumen)

Tesio 10Fr 35cm 1.9ml (1.7ml)

Tesio 7Fr 30cm 1.6ml (1.4ml)

B1 Pre Operative guidelines (CVL and Fistula)

1. Pre operatively Full blood count, Paediatric Renal Profile, Group and Save and
clotting screen should be sent urgently.
2. A nasal swab should be sent for culture and sensitivity, to determine if the child is a
carrier of Staphylococcus Aureus.
3. If MRSA positive discuss treatment with the microbiologists.
4. If the child has chronic renal failure and is to receive dialysis; If not already
completed the pre-dialysis investigations should be completed.

B2 Pre Operative guidelines (CVL)

1. Prior to theatre the nurse will mark on “non dominant arm” with statement “avoid
IVs in this arm if possible” (non-dominant arm is saved for potential fistula formation
in the future).
2. Please see the section on heparin below for guidance on patients going to theatre
with central line in situ.

B3 Pre Operative Guidelines (FISTULA)

1. If an AV fistula is chosen as access an appointment should be made with the
appropriate surgeon.
2. Assessment of appropriate sites should be made. Venograms/other
investigations should be undertaken at this stage as required.
3. Whenever possible the wrist in the non-dominant arm should be used as the
first site. Then the brachial site should be used (National Kidney Foundation
2000).
4. A date should be set for surgery, and then a programme of preparation can
be undertaken by named nurse and play specialist.

C Intra operative Guidelines (CVL)

1. The appropriate sized central line and the Mini gastrostomy button (if applicable)
will be sent to theatre with the child.

Roy Connnell 5 of 19 August 2013 5

2. Cefuroxime 30mg/kg (max dose 750 mg) should be given prophylactically at
induction.
3. The line is usually inserted into the internal jugular vein and held by a single cuff
and sutures. The central line is sutured onto the skin at the hub. Sutures in the
exit site should be avoided.
4. Manufacturers guidelines state that on insertion the arterial lumen should be
towards the patient’s midline, and the venous lumen should lie distal to the midline.
It has been shown that by doing so, line longevity and optimal flow characteristics
are obtained.
5. The line is flushed in and out in theatre to ensure patency. A 10ml syringe (or
larger) should be used when a CVL is accessed (Conn 1993)
6. It is then flushed and locked with Heparin 10units/ml 0.2ml more than lumen
volume, for example for 12.5f x 28cm the line will be locked with a volume of 1.7ml
each lumen. See heparinisation section below, as the lock will be changed once
the patient arrives on the ward post operatively.
7. Ensure pain relief is written up and commenced post operatively.
8. X-ray confirmation will be completed to determine positioning before use.

D1 Post Operative Guidelines (CVL)

1. The heparin will be changed once the patient arrives back on the ward, from
the10 units/ml inserted in theatre to Heparin 100 units/ml.
2. Oral fluids are usually allowed post operatively with agreement from the
paediatric surgeon.
3. The sutures are removed after 3-4 weeks (although they can be removed as
early as 2 weeks, or as late as 6 weeks at the discretion of an experienced
renal nurse).
4. If the hub on the line is uncomfortable for the patient, it can be carefully
removed after the sutures have come out.

D2 Post Operative Guidelines (FISTULA)

1. The patient should be maintained on IV fluids at maintenance (if on a fluid
restriction divide the total fluid restriction by 24 hours for a more appropriate
estimation of maintenance fluids). This reduces the risk of postoperative
thrombosis of the fistula. This should continue until surgical review has taken
place.
2. Ensure adequate pain relief is written up and given regularly post operatively
3. Routine observations should be made. The arm should be kept warm and
regular observations should be made to check for patency.
4. Before discharge the named renal nurse will give the patient information
about care of the fistula at home.
5. Providing it is safe to do so, the patient should remain 1 litre (or approx 5%)
over their target weight for three weeks after surgery. This can then be
gradually reduced each dialysis session.
6. After two weeks post surgery the patient should be given information on
exercising the limb to promote development of the fistula. The fistula should
not be exercised before this time.
7. The Fistula will be assessed for potential sites for inserting needles 6-8 weeks
following surgery, and the fistula can then be used if appropriate.

Roy Connnell 6 of 19 August 2013 6

8. For the first needling attempts one needle of small gauge (17 gauge) should
be inserted and used for return only. This aids in fistula development. Only
nurses trained in accessing fistulas should do this.
9. When established the largest needle possible should be inserted. This
improves flow and prevents high pressures that can cause cell damage.

E Exit Site Care (CVL)

1. The exit site will be cleaned in theatre and covered with an absorbent Mepore
dressing and immobilised well (a butterfly of tape around the line, supported
by a strip of tape over the top). Dressing will be sent to theatre with CVL.
2. The exit site dressing is then to be left unchanged (unless excessive oozing)
for one week. It should be immobilised well and excessive movement
avoided (this should be emphasised to the child and family as it takes 6
weeks before tissue in growth secures the catheter).
3. If dressing change is required during the first week this should be done using
aseptic technique.
4. Chloroprep® (Chlorhexidine Gluconate 2% and Isopropyl alcohol 70%) should
be used to clean the exit site on advise from the Infection control department.
The use of Betadine and hydrogen peroxide is not recommended for
cleaning, as this is toxic to fibroblasts (Twardowski & Prowant 1998).
5. With long-term catheters;
 Shallow baths (not submerging exit site) can be taken, but not showers.
This is especially important during the first 6 weeks.
 Swimming is not usually recommended though can be discussed on an
individual patient basis.
 The family should receive appropriate verbal and written advice on care of
the catheter at home, and emergency advice should the catheter be
dislodge. This should be done before they are discharged .
 A school/nursery visit, if appropriate, should be arranged to ensure health
and safety concerns are addressed.
 Consider the use of prophylactic nasal Mupirocin in patients
considered to be at a higher risk of developing exit site infections,
ie: developmental delay, tendency to fiddle with line, young age,
previous infection etc. (Weekly application to both nostrils 3 times in
one day).

F Line locks for CVLs

Line locks schedule for haemodialysis patients.

Heparin 100units/ml x 2 per week (or on all days when only having only one day gap if
receiving more frequent HD).

Alteplase 2mg/2ml x 1 per week (or on days when having two or more day gap if
receiving less frequent dialysis).

Nb: See Alteplase section before prescribing or administering.

Roy Connnell 7 of 19 August 2013 7

1. Catheter lumens should be flushed with 3-5ml 0.9% Sodium Chloride after
blood sampling and between administration of intravenous therapies. The
flush volume is determined by the child’s fluid status and size of child and
CVL.
2. The line locks listed in the table above should be used following the advice
given for each. The volume required for each CVL is identified in section A
and should equate to the volume of the internal aspect of the CVL + 0.2ml.
3. If a child is attending another department, and their catheter may be used
(e.g. Interventional radiography, or theatres), the line lock should be replaced
with Heparin 10 units/ml whilst the patient is off the ward. The 100 units/ml
strength should be re-inserted as soon as possible once the patient returns to
ward.
PLEASE NOTE: It is the responsibility of the medical staff to request
and prescribe this change in advance of the patient going to theatre.
This dose will be written up on the once only section of the drug card
and clearly communicated to the nursing staff.
4. Line locks should always be aspirated before the catheter is used. If it cannot
be aspirated, it can be flushed in, in the following circumstances:
 When a child is to commence dialysis and an experienced nurse is
accessing the catheter. In small children the child’s ACT (activated
clotting times) should be monitored and heparinisation during
dialysis modified as necessary.
 If a senior member of the medical team is consulted, and other
access for treatment is not available. This action should be
documented in the patient’s notes to ensure the bolus of heparin is
noted.
 See Alteplase section for more specific advice.
5. If a lumen is being accessed for treatment other than haemodialysis and the
lock cannot be aspirated, the second lumen if available should be accessed
instead.
6. Any problems with function should be reported and documented in the
patient’s notes and treatment given as below, to prevent complete occlusion.

NB: The maximum strength of heparin to be used is 100 units/ml

G Alteplase (Actilyse) locks for CVL.

G1 Assessment and contraindications.

Absolute contraindications for the use of Alteplase line locks are:

 significant bleeding disorder at present or within the past 6 months

 manifest or recent severe or dangerous bleeding
 less than 24 hours post insertion of CVL and 1 week post renal
biopsy

Relative contraindications include those listed below; cases should be

discussed with a consultant paediatric Nephrologist.
Roy Connnell 8 of 19 August 2013 8
  known history of or suspected intracranial haemorrhage
 suspected subarachnoid haemorrhage or condition after
subarachnoid haemorrhage from aneurysm
 severe uncontrolled arterial hypertension
 bacterial endocarditis, pericarditis
 acute pancreatitis
 documented ulcerative gastrointestinal disease during the last 3
months, oesophageal varices, arterial-aneurysm, arterial/venous
malformations
 neoplasm with increased bleeding risk
 severe liver disease, including hepatic failure, cirrhosis, portal
hypertension (oesophageal varices) and active hepatitis
 Major surgery or significant trauma in past 3 months

As with all thrombolytic agents, the expected therapeutic benefit should be

weighed up particularly carefully against the possible risk, especially in patients
with small recent traumas, such as biopsies puncture of major vessels,
intramuscular injections, cardiac massage for resuscitation.

G2 Dose

Alteplase 1mg in 1ml should be prescribed in an appropriate volume to fill the

internal aspect of the central venous line plus 0.2ml.

There is no limit to the number of administrations if given as a lock into central

venous line and previous dose has been withdrawn as directed in section F.

If lock volume cannot be withdrawn and discarded, a maximum of two

administrations per day, with a minimum time of 2 hours between doses, should
be adhered to.

G3 Administration

Pre-made (frozen) syringes of Alteplase (Actilyse) 2mg in 2ml are kept as stock
on the Haemodialysis unit.

One syringe should be used for each lumen being locked.

The syringes should be taken out of the freezer 30 minutes prior to use, to allow
adequate defrosting.

To ensure the correct dose is given, the Pre-made syringes (2mg in 2ml) should
be reduced to the appropriate volume required, prior to administration. The
concentration and volume should be correctly prescribed on the patients drug
chart.

Alteplase should be given as a central venous line intra-catheter lock directly into
the appropriate lumen as an IV push and CVL clamped under pressure.
Roy Connnell 9 of 19 August 2013 9
G4 Equipment

 Resuscitation equipment.
 Anaphylactic shock drug box
 Oxygen either piped or bottled.

G5 Observation

No unwanted effects are produced when administered correctly as drug should

mainly fill the internal aspect of the central venous line with a minimal amount
(0.2ml) entering the patient’s circulation.

The patient should be kept under close observation for one hour if it has been
necessary to administer the Alteplase lock due to inability to withdraw and
discard.
If, in this situation, the patient is below 15kg it is recommended that the initial
heparin bolus, when connecting to the haemodialysis machine, be omitted.
Activated clotting times (ACT) should also be tested after 30 minutes to ensure
correct anticoagulation of the haemodialysis circuit. (The therapeutic dose of
Alteplase for the treatment of intravascular thrombosis is 100-500 micrograms /
kg/ hr for 3-6 hours).

If given into vein can cause:

 Nausea.
 Vomiting.
 Bleeding.
 Hypotension.
 Body temperature increase.
 Allergic reaction: - Rash, flushing, anaphylaxis.

Adverse reactions documentation to be completed and forwarded to pharmacy.

Document when Alteplase has to be flushed in.

H Central Line Occlusion/decreased function

Definition

Central line dysfunction is defined as “failure to attain and maintain an extra

corporeal blood flow sufficient to perform haemodialysis without significantly
lengthening the haemodialysis treatment”. Blood flow should be minimally 3-
5ml/kg/min and should be adequate to delver the prescribed dialysis dose.
For children not receiving haemodialysis this may be indicated by difficulties
aspirating from the catheter lumens, or flushing.

Treatment

Roy Connnell 10 of 19 August 2013 10

  The algorithm detailing the course and order of treatment with Urokinase
should be followed in order to get the best results. (See appendix).
 Below are details of how to prepare and administer the locks and infusion
detailed in the algorithm.

Urokinase as a lock.

This should go into each lumen of the line and be left in situ for 30 minutes.
Dose:

 Child under 10kg – 2,500units per lumen.

 Child over 10kg - 5,000units per lumen.

Nb: These doses are different to those described below for push locks.

Mixed with Sodium Chloride 0.9% to volume of line lock required.

Urokinase as an infusion.

Should be made up to 20ml with 0.9% sodium chloride and given over 30
minutes to 1 hour.
Dose:

 Child under 10kg – 2,500units per lumen.

 Child over 10kg - 5,000units per lumen.

Urokinase as a push lock.

Should be given directly into the lumen required.

Dose:

 Child under 10kg – 5000units made up to double CVL lock volume.

 Child over 10kg – 12500units made up to double CVL lock volume.

Administer lock volume plus 0.2mls. Leave for 2 minutes. Then administer 0.2mls
every 2 minutes (clamping in between) until volume fully infused. Cap off and
leave lock for 10 minutes.

1. If 1st line treatment is unsuccessful the following investigations should be

explored;
 Chest X-ray to determine positioning.
Roy Connnell 11 of 19 August 2013 11
  Contrast study may be undertaken following discussion with a Consultant
Paediatric Nephrologist (National Kidney Foundation 2000).
2. Central Line malpositioning may be corrected by surgical repositioning, or
exchange of the catheter over a guide-wire. A thrombosed/occluded line
would need to be exchanged over guide-wire or replaced.
(National Kidney Foundation 2000).
3. If patients have repeated occlusions a Thrombophilia screen should be
performed. Aspirin and warfarin should be considered as treatment.

I Fistula Occlusions

I1 MILD Ischaemia

Defined as, “subjective coldness, paresthesias, and reduction in skin

temperature but no loss of sensation or motion” National Kidney
Foundation 2000.
1. Written information on all aspects of caring for their fistula, should be given to
the patient when discharged after surgery.
2. Patients are taught to check their fistula 4 times a day for patency. If they
have concerns they are instructed to contact the ward.
3. The patient should have weight, height and blood pressure measurements
and be assessed for volume. Blood pressures should not be completed
on the fistula limb.
4. The limb should be checked to ensure that no restrictive items (clothing,
jewellery) are present, which could impede flow.
5. Fistula limb should be kept warm.
6. If signs of volume depletion are present supportive fluids should be
prescribed, consideration should be made to urine output and fluid
restrictions.
7. Diarrhoea and vomiting is a risk to maintaining fistula patency, patients are
encouraged to contact the unit if they are unwell, and IV fluids may be needed
to maintain hydration.
8. Further investigations should be undertaken. A Fistulagram may be required
to investigate for signs of stenosis, which is a threat to patency (National
Kidney Foundation 2000).

I2 Severe Ischaemia
 This complication is very difficult to treat. Surgical opinion should be
sought.

J Central Line Infections

Standard = Where central lines are used the rate of infection should be less
than 1 every 12 patient months averaged over 3 years

J1 Investigations

If a catheter is suspected to be infected the following investigations should be

performed;
Roy Connnell 12 of 19 August 2013 12
 1. Temperature, pulse, respirations and blood pressure.
2. Urgent C-reactive protein.
3. Blood culture from the line. The waste blood (line lock) can also be sent
for blood cultures as this may give an indication of the source of the
infection. The bottle should be clearly marked to indicate which lumen the
sample was taken from (e.g. venous or arterial/ red or blue )
4. Full blood count and differential (Urgently).
5. A swab of the exit site should be obtained and sent for culture and
sensitivity.
6. A nasal swab should also be sent for repeated infections.

J2 Central Line related bacteraemia

Characterised by positive blood cultures, pyrexia >38OC, and rigors (particularly

when on dialysis).
1. The child should be assessed specifically looking for signs of endocarditis
and osteomyelitis.
2. If the child/young person is systemically symptomatic of infection,
intravenous antibiotics should be commenced immediately.
 IV Vancomycin. (Single dose) Refer to high risk injectables guide.
 IV Gentamicin. Refer to high risk injectables guide.
Please note if patients have repeated infections, the use of Gentamicin
should be discussed because of the risk of ototoxicity.
3. Antibiotic treatment should be changed according to sensitivities.
4. See below for guidance on frequency and dosage.
5. Taurolock solution may be used as a line lock in selected cases; this
decision will be made by a consultant paediatric Nephrologist. Taurolock
contains a mixture of cyclo-taurolidine (antimicrobial agent) and an
anticoagulant.

NB Repeat line cultures should be performed a week after the antibiotic

course is completed.

J3 Antibiotic treatment.

1. Vancomycin (Single dose) Refer to high risk injectables guide.

o This can be administered into the haemodialysis circuit so that the
end of the infusion coincides with the end of dialysis.
o Dose should be repeated when level is below 10mg/l (UK Renal
Pharmacy Group 2004). If the child is receiving haemodialysis the
clearance of Vancomycin to this level takes approximately 5 – 7
days. This is dependant on the child’s residual renal function.
o Post dialysis levels should be taken to ensure therapeutic level is
maintained.
o When level is below 10mg/l further dose can be given.
2. Gentamicin (Single dose) Refer to high risk injectables guide (post dialysis
if receiving haemodialysis). The dose should not be repeated unless the
trough level is below 2mg/litre.
 Levels should be taken pre-haemodialysis to ensure that a level is
available for the end of treatment enabling further dosing if needed.
Roy Connnell 13 of 19 August 2013 13
 However adjustment should be made for clearance during the
treatment, as Gentamicin is removed during dialysis.

Antibiotic treatment should be adjusted in line with culture results and

advice from microbiology.

K Fistula Infections

1. Signs and symptoms of an infected fistula are;

o Redness around needling sites or surrounding area.
o Oozing of pus from needling sites.
o Pain/tenderness.
o Pyrexia/general malaise.
2. Swab and blood culture should be sent immediately for analysis.
3. If fistula able to be needled infected sites should be avoided, otherwise
alternative access should be considered.
4. Treatment with a broad-spectrum antibiotic should be commenced
immediately, until sensitivities become available, liaise with microbiology if
appropriate.

L Exit site infections

Exit site infections are characterised by: Purulent discharge, erythema, and pain
around the exit site.

1. Uncomplicated infections should be treated with 7 days Flucloxacillin

orally (Clarithromycin if allergic to penicillin) until sensitivities are available.
2. Reassessment is then required, as a further treatment may be required.
3. If a recurrent Staphylococcal infection is detected, Microbiology should be
consulted for advice. A nasal swab should also be repeated.
4. Topical treatment should be considered, Mupirocin ointment and Fucidin H
cream are the current first line treatments. These can be used in
combination with oral or IV antibiotics.
5. MRSA infection should be managed according to NUH MRSA guidelines
6. Line removal is a major risk for dialysis dependent children but should be
seriously considered for recurrent infections, MRSA or candida infection.
7. Consider the use of a Biopatch for patients requiring line replacement due
to recurrent exit site infections. (This should be sent to theatre with the
patient).
Consider the use of prophylactic nasal Mupirocin in patients considered to
be at a higher risk of developing exit site infections,
ie: developmental delay, tendency to fiddle with line, young age, previous
infection etc. (Weekly application to both nostrils 3 times in one day).

NB: Over-granulation of the exit site increases the risk of infection. Therefore,
Maxitrol ointment should be used to treat the over granulation tissue until it has
resolved. Silver-Nitrate sticks should be used with caution on the CVL exit site
and surgical opinion is advised prior to use.

Roy Connnell 14 of 19 August 2013 14

M Tunnel infections.

Tunnel infections are characterised by erythema and inflammation along the line
of the tunnel.

1.Treat initially with;

 IV Vancomycin (Refer to high risk injectables guide)
 IV Gentamicin. (Refer to high risk injectables guide)
2. Until sensitivities are available. See below for guidance on frequency of
dosage.
3. Rifampicin can be considered in some cases, but this should be done after
consultation with Microbiology.
4. Tunnel infections are difficult to treat and line removal should be
considered in persistent or recurrent infections Consult with Consultant
Paediatric Nephrologist and Microbiologist.

N Fistula stenosis

1. Stenosis in or near the fistula can lead to problems with flow through the
fistula.
2. This increases the possibility of clotting within the vessel.
3. Transonic monitoring of the fistula should be performed to monitor for
abnormal fistula flow and recirculation.
4. Any problems with flow during dialysis should be investigated, as stenosis
could be implicated.
5. Surgical review should be sought, as revision may be required.

Roy Connnell 15 of 19 August 2013 15

 References

BMA, RPS, RCPCH & NNPG (2005) British National Formulary for Children. BMJ
Publishing Group Ltd., London.

Conn, C. (1993) The importance of syringe size when using implanted vascular
access devices. JVAN 3 (1): 11-18

National Kidney Foundation (2000) NFK K/DOQI Clinical Practice Guidelines I &
II Hemodialysis Adequacy & Vascular Access: Update 2006.
http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqi_uptoc.html#v
a accessed 04/05/06

Renal Association (2002) Treatment of Adults and Children with Renal Failure.
Standards and Audit Measures. 3rd Edition. Royal College of Physicians of
London, London.

Twardowski, Z. & Prowant, P. (1998) Current Recommendations for the Care of

Peritioneal Dialysis Catheters. Presented at 18th Annual Conference on
Peritoneal Dialysis. Nashville, Tennessee, USA. February 23-25 1998

UK Renal Pharmacy Group (2004) The Renal Drug Handbook. Second Edition.
Radcliffe Medical Press, Oxford.

Urokinase Lock Algorithm

Central venous line still
blocked or occluded after
saline flush.

Central venous line aspirates

but is slow and/or intermittent Central venous line Central venous line does not
in flow. does not aspirate or aspirate.
flush.

Flush both lumens with saline Give Urokinase Flush both lumens with
and re-try aspiration infusion. saline and re-try aspiration.

Central venous line aspirates Central venous line still does

but is still slow and/or not aspirate.
intermittent in flow. Re-try aspiration.
Roy Connnell 16 of 19
Contact medical August 2013 16
staff if no
Lock central venous line with improvement or Use push-lock method –
 Thrombophilia Screen
Roy Connnell 17 of 19 August 2013 17
For this test you need;

2 x Adult clotting bottles or 3 x Paediatric clotting bottle

Central Line Samples

Peripheral blood should preferentially be used for thrombophilia screens,

however if it is not possible to get peripheral bloods, the laboratory can correct
for the Heparin in the line. This should be written in the clinical details section.
If patient is receiving haemodialysis, the sample should be obtained prior to
session.

Included in this test are;

 Lupus inhibitor
 Antithrombin III functional activity
 Protein C functional activity
 Factor V Leidin
 Prothrombin gene mutation

The results should then be available within 2-3 weeks.

Looking after your child’s central line

Roy Connnell 18 of 19 August 2013 18

 The central line is a plastic tube in a large vein in the neck.

 As with any wound on the body this is an infection risk.

 We will change the dressing weekly (more frequently if the dressing is coming
off). If you notice any discharge on the dressing please inform the hospital.

 If the dressing starts to come off at home stick some tape over the loose
edges. (we will give you some tape to take home)

 In very rare circumstances the line may come out. If this happens open a
packet of gauze, place over the wound and apply firm pressure until it has
stopped bleeding. If the blood soaks through the gauze place some more
over the top (do not remove the first pack of gauze). When the bleeding
has stopped tape the gauze in place and return to hospital (please inform us
that you are coming).

 It is also very important to be aware of signs of infection, these are:

1. Raised temperature
2. Feeling generally unwell
3. Being sick
4. Diarrhoea
5. Shivering/ being ‘jittery’
If your child has any of these symptoms please phone the ward for advice.

 It is very important to keep the dressing clean and dry. Therefore you cannot
go swimming, have showers or deep baths. Shallow baths are acceptable but
be careful not to get the dressing wet.

 If the dressing does get wet and is coming off/does come off, place some
gauze over the exit site (after washing your hands and being careful not to
touch the side of the gauze that will touch the wound) and tape in place. Then
phone the hospital for further advice.

 Please ensure the line is securely anchored to the skin at all times- this will
minimise movement/infection.

Nottingham Children’s Hospital, QMC Campus 0115 924 9924

Haemo Unit ext- 61414 (direct dial 0115 970 9414)
Ward E17 ext- 61415 (direct dial 0115 970 9408)

Always make sure that you have some gauze and tapes at home in
case of emergencies- just ask if you need some more.

Roy Connnell 19 of 19 August 2013 19