Sodium Hypochlorite For Catheter Care

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More than 20% of the world's population use a catheter for dialysis, despite guidelines limiting their use. Although the structure and design of the catheters differ by manufacturer, the material used in central venous catheters and peritoneal dialysis catheters are the same across manufacturers. Given the long-term use of these catheters in the dialysis population, the good compatibility of the antiseptics and disinfectants used on the catheters is imperative to prevent failure and cracking of the catheter material. Tensile strengths of commercially available catheters were measured after exposure to commonly used disinfectants. The tensile strength was then compared between the catheters by analyzing the displacement vs. force (N) curves produced during the evaluation. A total of 44 catheter lumens were evaluated. The electrolytically produced sodium hypochlorite solution, Alcavis 50/ExSept Plus, was the only solution shown to be compatible with all three catheter materials resulting in a deviation of less than 10% for each of the different catheter types. Electrolytically produced sodium hypochlorite solutions were the only solutions in this study that did not alter the physical properties of any of the catheters after long-term exposure.

Copyright © 2007 S. Karger AG, Basel

Long-term implanted catheters continue to be an important tool for the administration of dialysis. In the United States, for example, there is a prevalence of 20% catheter use for hemodialysis (HD), while all peritoneal dialysis (PD) patients require an implanted catheter [1]. This results in more than 90,000 dialysis patients in the United States using a long-term catheter. Prevalence of long-term catheter use throughout the world may be even greater dependent on the proportion of patients on PD and availability of vascular surgical teams to prepare fistulas [1, 2].

Patients with either a HD central venous catheter (CVC) or PD catheter (PDC) are at an elevated risk of skin infection at the exit site of the catheter or below the skin in the catheter tunnel. CVCs are at risk of bacteremia, if bacteria are introduced into the lumen of the catheter and migrates into the blood stream. Similarly, PDCs are at risk of peritonitis if bacteria enter the inner lumen of the catheter and reach the peritoneal cavity.

Proper handling of the catheter and aseptic technique are required to reduce risks of infection. Routine dressing changes, antisepsis at the exit site, cuffed catheters, proper disinfection prior to accessing and careful manipulation of the catheter are powerful tools for reducing exit site, tunnel and blood stream infections. Maki showed that in the short-term, approximately 1 week, bac-teremia is likely a result from the insertion procedure with a lesser risk from hub contamination [3]. However, Sitges-Serra and Linares et al. suggest that the risks of bacteremia are greatest as a direct result of hub contamination. This was their conclusion in a study population that had catheters in place on average for approximately 3 weeks [4, 5].

Several studies have demonstrated that the use of electrolytically produced sodium hypochlorite (ESH) solutions for the chronic care of implanted dialysis catheters (CVC and PDC) can reduce the rate of infection. Benefits of the use of ESH for exit site antisepsis for CVC care has recently been demonstrated by Astle and Jensen [6], while Mishkin et al. [7], Wahdwa et al. [8] and Mendoza [9] have demonstrated the benefits of ESH for routine PDC exit site care. Furthermore, advantages using ESH solutions in reducing bacteremia and peritonitis rates have also been demonstrated by Astle et al. [6] and Mishkin et al. [7].

The benefits of ESH for routine long-term catheter care at the exit site and connection sites (ex. hub and cap disinfection and transfer set change disinfection) have been clinically demonstrated. However, a common obstacle of good catheter care is the compatibility of an antiseptic or disinfectant with the catheter material. The Center for Disease Controls' Guideline for the Reduction in Intravascular Catheter Related Infections, recommendations for the routine care of 'Dialysis CVC' states: 'ensure the cleaning solutions are compatible with the catheter materials' [10].

CVC and PDC exit site care is performed thrice weekly and daily, respectively. Disinfection of the catheter hubs and connectors is also performed before and after every treatment. Given a life expectancy of a catheter of 6 months, this results in a minimum of 78 applications of the antiseptic or disinfectant to both the skin and catheter material. It is imperative that the antiseptic or disinfectant be safe and effective to the patient as well as compatible with the catheter materials. There is ample evidence that ESH solutions are safe, non-irritating and non-sensitizing, and effective [6, 7, 11-13]. The compatibility of the catheter materials with different antiseptics and disinfectants will be reviewed.

PDCs are usually made out of silicone as are the transfer sets used with PDCs. CVCs however are usually made from one of three different materials: (1) silicone (similar to PDC); (2) Tecoflex® polyurethane (Noveon), or (3) Carbothane® polyurethane/polycarbonate copolymer (Noveon) [14]. Although the structure and design of the catheters differ by manufacturer, the material used in CVC and PDC catheters are the same across manufacturers.

The safety testing of catheters is similar around the world and follows ISO 1055501:1995(E) guideline. The use of antiseptics and disinfectants on catheters potentially affect the safety of the catheter by degrading the structural integrity of the catheter material, (ex. lumen) or the integrity at each juncture of the catheter (ex. luer connector to extension, extension to hub, hub to lumen, etc). ESH is listed as a recommended disinfectant/antiseptic by numerous catheter manufacturers, having passed the ISO standards above, for all three available catheter materials. This makes ESH unique in that it is the only antiseptic routinely used that is compatible with all materials. As a rule of thumb, it is recommended that povidone iodine only be used with polyurethane based catheters and alcohol containing products only be used with silicone based products. The newer material Carbothane copolymer claims to be compatible with all antiseptics and disinfectants commonly used.

A modified evaluation of the ISO standards was performed in order to compare the affects of ESH on the three different materials used for dialysis catheters. In addition, we evaluate the affects of different antiseptics on dialysis catheters to assess changes in physical properties such as lumen strength.

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