Reflections on Safe PD Catheter Exit Site Care from a 29-year PD Nurse
First came Ford versus Chevy. In the 60’s, a more specific Mustang versus Camaro. Then, in the 80’s, BMW versus Mercedes. Now it’s internal combustion versus electric cars. We seemed to be faced with having to “take sides” in life with many decisions. Most boil down to personal preference—what you believe will most appropriately meet your wants and needs. In the dialysis community, it’s hemodialysis (HD) or peritoneal dialysis (PD). Both are effective treatment modalities. There are pros and cons for both, so it comes down to choosing the one that has more “pros” on a person’s check-off sheet.
For those who choose peritoneal dialysis, the goal of the team—the patient, nephrologist, nurse, social worker, and dietitian—is to keep the patient in an optimal state of health on that modality for as long as possible. Unfortunately, there is a significant rate of modality failure in this patient group.
PD-related peritonitis is the most frequent reason for peritoneal dialysis catheter (PDC) removal and patient drop-out from PD. The relationship between PDC exit site infection (ESI) and peritonitis was first noted in the 1980’s, when it was found that patients with ESI were more likely to develop peritonitis than patients who did not have an ESI.1 Reducing ESI leads to reduced peritonitis—which leads to less modality drop-out. Sounds like a plan.
With that lengthy introduction done, I would like to take this opportunity to share a bit of my 29 years experience as a PD nurse doing my best to figure out how to keep my patients’ exit sites as healthy as possible. There have been a lot of failures along the way, a lot of different products used, but after nearly 3 decades, there are a lot of things that seem to make it all work.
Once a patient is discharged following PDC placement, the first few weeks are fairly simple. The patient/care partner is provided with verbal and written discharge instructions and a phone number to call if they have any questions. The basics:
Keep dressing dry
Report any increasing pain or discomfort, and any bleeding
Take stool softeners to avoid constipation, call if no BM in 2 days
No lifting over 10 lbs
Return in 1 week for catheter flush and dressing change
This continues for 2 to 4 weeks to allow the tissue ingrowth into the Dacron cuffs of the PDC, and for exit site healing.
Once the post-op period is past, the work begins. Daily exit site care and catheter immobilization in the home setting are essential to PDC survival, and it’s up to the well-trained patient to do it. Our PD unit provides not only the training, but all supplies necessary to the patient: hand sanitizer, gloves (for a care partner), impervious pads (Chux), masks, skin disinfectant, tape of patient choice, gauze, dressings, immobilization device of choice. We will provide whatever they need to keep the PDC protected.
Daily exit site care consists of
Showering with a mild liquid pump soap (note: antimicrobial is not recommended for use by the FDA2)
Gentle drying of the exit site and catheter
Spraying with sodium hypochlorite 0.057%
Patting dry after a 2 minute contact time
Applying a small dollop of sodium hypochlorite 0.057% gel
Covering with an air-permeable telfa dressing
What? No gentamicin cream or mupirocin ointment? Is this heresy?
We are all familiar with the current recommended practice for prevention of PD catheter related infections. This routine catheter exit site care includes prophylactic topical application of gentamicin 0.1% cream and/or mupirocin 2% ointment.3 However, we are now becoming increasingly aware of newly surfacing antibiotic resistance. The concept of “antibiotic stewardship” should be high on our radar. Is there an effective antimicrobial alternative to traditional antibiotics?
Sodium hypochlorite 0.057% has been tested and proven to kill the pathogens that are the most common causes of ESI. In the commercially available liquid and viscous hydrogel forms, it has exceptionally rapid broad spectrum fungicidal, sporicidal and bactericidal properties. These include the pathogens:
Clostridium difficile spores
The antibiotic resistant strains CRE, MRSA, and VRE4
The products we use are Anasept® Antimicrobial Skin & Wound Cleanser and Anasept® Antimicrobial Skin & Wound Gel. This is a new idea for many. Maybe it’s time to think beyond the box.
We have had the majority of our 800+ patients using sodium hypochlorite 0.057% for their daily exit site care for over a decade with excellent results. It is reassuring to know that within 2 minutes all pathogens on treated skin are killed, and the gel will continue protecting the exit site area until the next dressing change—all without the use of traditional antibiotics. I suspect we’ve all seen the patients with exit sites clogged with dried antibiotic cream or ointment. The sodium hypochlorite gel has the opposite effect—as a clear hydrogel, it remains moist and actually helps lift off dry skin and exudate. Food for thought, I hope.
Finally, the critically important immobilization issue. A perfect exit site can be quickly reclassified as equivocal or infected with a simple tug on the catheter. We have 3 rules:
Never get anything sharp in contact with the catheter
Never tape the catheter down with any tension on it
Never let it dangle
To minimize the risk of tension at the exit site, we have the patient tape the catheter to the abdomen with a little dip or loop in it to allow for body movement. To prevent dangling, I have tried tapes, binders, belts, nets, tube tops pulled low, even the double-underwear trick. What has been most successful is the Secure Way device (www.secureway.org). The plastic device clamps on to a transfer set (Baxter or Fresenius) and is suspended on a necklace. All of our patients use it in the shower because it holds up the catheter without the use of any tape, allowing for thorough cleansing of the abdomen. Many of our patients use it during the day, too, to keep the catheter protected with minimal taping and nothing constrictive around the waist. Some patients use it at night on the cycler because it snaps over the transfer set in the open position, preventing accidental disconnection by the restless or confused patient. I use it on all inpatients as an added deterrent for the patient or anyone else in contact with the patient to leave it alone.
My second choice for catheter stabilization for both the shower and daytime use, is the Hyginet/Surgilast tubular elastic dressing retainer (available from Amazon). The patient cuts a 12-18 inch length and slides it around the waist. It holds the catheter in place with minimal taping, and the catheter can be easily repositioned for comfort. The patient can wash and reuse a piece until the elastic gets stretched out.
PD exit site care is an evolving process. PD professionals need to continue to work together to be innovative, and to share best practices. I appreciate this opportunity to share my experience with you today.
1Piraino B, Bernardini J, Sorkin M. The Influence of Peritoneal Catheter Exit-Site Infections on Peritonitis, Tunnel Infections, and Catheter Loss in Patients on Continuous Ambulatory Peritoneal Dialysis. Am J Kidney Dis. 1986 Dec;8(6): 436-40
2U.S. Food & Drug Administration Antimicrobial Soap? You Can Skip It, Use Plain Soap and Water (2019).https://www.fda.gov/consumers/consumer-updates/antibacterial-soap-you-can-skip-it-use-plain-soap-and-water Accessed July 16, 2020.
3 Szeto C-C, Li PK-T, Johnson DW, Bernardini J, Dong J, Figueiredo AE, Ito Y, Kazancioglu R, Moraes T, Van Esch S, Brown EA. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int. 2017 Mar-Apr;37(2):141-154, doi: 10.3747/pdi.2016.00120
4A New Dimension in Exit Site Care [Brochure]. (2019). San Dimas, CA: Anacapa Technologies.