The effectiveness of three procedures for dally peritoneal dialysis. (PD) Clltheter exit site care were evaluated in a prospective randomized study using 23 adult ...
-1i= !3 ( Writer's Award Winner
Peritoneal Dialysis Catheter Exit Site Care Barbara F. Prowant, IA»is M. Schmidt, Zbylot J. 1\vardowski, Cheryl K. Griebel, LaVonne K. Burrows, I.eonor P. Ryan, Roberta J. Satalowich
The effectiveness of three procedures for dally peritoneal dialysis (PD) Clltheter exit site care were evaluated in a prospective randomized study using 23 adult PD patients with well-healed catheter exit sites. This article concludes that daily cleansing of the well-healed, nonin/lllmed exit site with soap and water resulted in a markedly lower infection rate and that this is a safe, simple, and cost-effective procedure.
P
eritoneal catheter exit site infection is a frequent complication of peritoneal dialysis (PD) catheters that results in significant morbidity .and may require catheter removal (Khanna & Oreopoulos, 1985; Vas, 198S). The National CAPD Registry (Lindblad, Novak, Stablein, Cutler & Nolph, 1987) shows a rate of O.S episodes per patient year of observation. The etiology of exit site infections is unclear. Inadequate exit site care and poor personal hygiene are believed to be contributing factors. l.ocal reaction to a foreign body and the mobility of the catheter have also been implicated. Exit site care procedures used for continuous ambulatory peritoneal dialysis (CAPD) patients evolved Barbara F. Prowant, BSN, RN, is a· research associate in the Division of Nephrology. The University of Missouri Health Sciences Center. Columbil4 MO.
Lois M. Schmidt, RN, is a primary caregiver, CAPD progmm, Dialysis Clin~ Inc.. Columbia. Ma Admowledgmeat -Funding for this project WG ]J1'tiVid«J through gnzntsfrom the MISSOuri Kidney Progmm ond Diolysls Clinics, Inc. Columbill. MQ Col1f!SJJOndence and Inquiries should be tlddra.sed to Btubtur1 F. Prowtmt; DMslon qfNephrology MA 436; Uniwnity qf
Missouri Hetllth Sciences ~nter; Columblll. M06S212.
Note - This onick Is th winner of ANNA JoUI7Uil's 1988 Writer's Awtud Contest.
from protocols used previously for intermittent peritoneal dialysis (IPD). The focus of exit site care in IPD was routine cleansing of the site with soap and water. Prior to connecting to and disconnecting from the dialysis machine, the catheter exit site was disinfected with povidone iodine. Sterile dressings were used to cover the exit site at all times (Richard, 1986; 'Ienckhoff, 1974). A number of protocols for cleaning the CAPD catheter exit site are documented in the literature: (a) cleansing with povidone iodine (Clayton, et al., 1980; 'Ienckhoff, 1980); (b) cleansing with soap (Moncrief & Popovich, 198S); (c) cleansing with soap, then povidone iodine scrub (li'avenol Laboratories, 1979); and (d) cleansing with hydrogen peroxide in combination with soap or povidone iodine scrub (Cayton, Quinton,' & Oreopoulous, 1981; Zappacosta & Perras, 1984). After cleaning the exit site, some protocols recommend painting the exit site with povidone iodine and allowing it to air dry (Moncrief & Popovich, 1985; 'Thnckhoff, 1980; Zappacosta & Perras, 1984), or using povidone iodine ointment (Gloor, et al., 1983). Anchoring the catheter to prevent movement is frequently recommended (Clayton, et al., 1981; Gloor, et al., 1983; 1iavenol Laboratories, Inc., 1979; Zappacosta & Perras, 1984). The interval between
catheter care procedures ranged from daily to weekly (Clayton, et al., 1980; Gloor, et al., 1983; Zappacosta & Perras, 1984). Descriptions of catheter care procedures are usually not accompanied by discussion of the underlying scientific principles and no data are given to support effit!lcy. Both air occlusive (Cayton, et al., 1980).and air permeable gauze dressings ('Thnckhoff, 1980; 1i'avenol Laboratories, Inc., 1979; Zappacosta & Perras, 1984) have been recommended as well as the elimination of all dressings (li'avenol Laboratories, Inc., 1979). 1\vo randomized prospective studies document that there is no difference in the incidence of exit site infection between CAPD patients who use dressings and those who do not (Clayton, Quinton, & Oreopoulos, 1982; Starzomski, 1984). This article will present data from a prospective randomized study designed to evaluate three procedures for peritoneal catheter exit site care. and document the effectiveness of each in preventing exit site infection.
Methods Adult home PD patients with wellhealed, noninflamed exit sites were eligible to participate in the study. All potential candidates followed at our outpatient unit and satellite centers were informed of the nature of the study and asked to participate. Sixteen patients refused to participate in the study, most because they were doing well with the existing procedure for exit site care or did not want to change to a more complex procedure. Other reasons for refusal included allergies to tape and povidone iodine. Procedures. Each subject who gave
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informed consent to participate in the protocol was randomly assigned one of three exit site care procedure groups: Method 1 - wash exit site with soap, rinse with tap water and dry with clean towel or gauze pads. Method 2 - wash, rinse and dry exit site as above, then paint a l-inch circle around the catheter with povidone iodine and allow to air dry. Method 3 - cleanse exit site with hydrogen peroxide using cottontipped applicators, dry, apply povidone iodine ointment with a sterile cotton-tipped applicator, and cover with sterile gauze dressing secured with tape. Patients were asked to perform exit site care daily and whenever the exit site became wet or dirty. Dressings over the catheter exit site were optional for patients using methods 1 and 2, however, all patients were required to secure the catheter to avoid tension or pulling. Except for soap, all supplies were provided by the clinic. Use of antibacterial soap was recommended, and patients used either bar or pump soaps. Povidone iodine scrub was used in some instances. A comprehensive patient education program was developed so that all patients were taught to perform exit site care and report complications in a consistent manner. Patient education included topics such as: (a) definitions related to the catheter exit site, (b) characteristics of a healthy exit site, (c) procedures for care, (d) symptoms and treatment of exit site complications, (e) sequelae of exit site infection, and (f) principles related to exit site care. Figure 1 shows a page from the flip chart teaching tool and patient pamphlet (Bartelt, et al., 1986). A healthy exit site was defmed as the absence of redness, tenderness, scab, or crust. Exit site infection was defmed as erythema with exudate. Infection was confmned by the differential cell count on exit site smear (Prowant et al., in press) and culture results. All inflamed and infected exit sites were reevaluated weekly. A catheter exit site flow sheet was developed to facilitate objective documentation of the exit site condition. The use of this tool has bee~ de-. scribed previously (Prowant et al., 1987). The catheter exit site was evaluated each time the patient was seen
Table 1 Patient Characteristics According to Exit Site Care Procedure and for All Study Patients Sex Mean Age :_·; .Type of PD nme on PD ... Catheter Group · (M/F) . (yrs.),. ·.; (C/1) . · ·. ':::(mos.) -~·-·. _:_~::··_-( •
•c I
•
• ·. ·*:"
••
.
••
.,,
= continuous technique, that is, CAPO or CCPD
= intermittent regimen
Table 2 Incidence of Catheter Exit Site Infection According to Exit Site Care Procedure
in the outpatient clinic or hospital, and the assessment was recorded on the study flow sheet.
Results 1\venty-three patients entered the study from November 1984 through April 1986. Characteristics of the patients are shown in Thble 1. Subjects assigned to Method 1 had been on CAPD longer and had their peritoneal catheters in place longer than the other groups; however, this group included four patients with catheters less than 1 month after insertion. Four patients assigned to Method 2 also had catheters less than 1 month old and five patients with new catheters were assigned to Method 3. Subjects assigned to Method 2 were somewhat younger than those in the other two groups and there were more men in the group using Method 3. Three patients who were initially assigned to Method 3 experienced skin irritation and deterioration of the catheter exit site. These patients discontinued use of this procedure and were reassigned to either Method 1 or Method 2. The amount of experience with the study procedure and incidence of exit site infections for patients using each of the three procedures is shown in 'Dlble 2. The subjects using Method
1 had a markedly lower incidence of exit site infections. None of these patients discontinued the study due to deterioration of the exit site or procedure-related complications and no catheters were removed due to exit site infection. One subject discontinued Method 2 due to skin excoriation and two patients on Method 2 required catheter removal due to chronic exit site infections. Three patients discontinued Method 3 due to sensitivity to tape, sensitivity to povidone iodine, and deterioration of the exit site and one patient .on Method 3 required catheter removal because of a recurrent exit site infection.
Discussion . Patients using Method 1, the soap and water procedure, for routine exit site care had an infection rate less than ~ that of the patients using Methods 2 or 3. This procedure was also superior in that no patients required catheter removal for recurrent infection, none experienced procedure-related complications, and none chose to discontinue using this procedure. This infection rate is much lower than that cited by the CAPD Registry (Lindblad et al., 1987). In contrast, the rates experienced by patients using Methods 2 and 3 are similar to registry results.
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We do not believe that the lower infection rate experienced by patients using Method 1 was influenced by the longer time on PD or longer catheter life as seen in Thble 1. A single patient who had been on CAPD for 76 months with a single catheter skewed these data. This young woman actually participated in the exit site care protocol only 1 month before she received a cadaver kidney transplant. If her numbers are eliminated, the mean time on peritoneal dialysis, 10.9 months, and mean catheter life, 10.3 months for patients on Method 1, are similar to the values for the other two methods. Patient compliance with the procedures is obviously a variable that may have had an effect on the outcome. Patients agreed to randomization and then to perform the procedure as taught. A single patient who never followed the Method 2 protocol procedure was not included in the data analysis. Other patients were dropped from the study at the time their exit site care procedure was changed either by staff recommendation or by patient noncompliance. Recent studies indicate that both povidone iodine and hydrogen peroxide are cytotoxic (Lineaweaver, et al., 198S; Nathan, Silverstein, Brukner, & Cohn, 1979; Zamora, 1986); however, this research has evaluated the effect of disinfectants on open wounds or cell cultures. It does not seem unreasonable to hypothesize that the deterioration of exit sites and higher infection rates seen in patients using Methods 2 and 3 could be due to the toxic effects of chronic exposure to disinfectants, although the effects of continued exposure of intact skin to povidone iodine and hydrogen peroxide have not been studied. Parametric statistics were not used to compare data among groups because there has been some controversy as to whether or not statistical tests can be appropriately applied to this type of data (D'Apice & Atkins, 1981; Pierratos, et al, 1982), and our numbers are not large enough to perform life table analyses. Although dally cleansing with soap and water yielded the lowest incidence of exit site infection, it must be emphasized that the routine cleansing procedure is effective only if used in conjunction with other principles of
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Rgure 1 Sample page from Flip Chart and Patient Pamphlet Used for Patient Education (Bartelt, et al., 1986)
~
w
Tension and Tugging
Scratching
Dirt
Submersion In water
Crust
Powder
Nonprescrlbed ointments
Alcohol
peritoneal catheter care. These include: (a) hand washing prior to handling the catheter, (b) securing the catheter to . prevent tension and trauma, and (c) avoiding pressure at the catheter exit site. Because we studied a small number of patients in a single institution, these fmdings cannot be genemlized to other CAPD populations. Nor can these data be generalized to inflamed or infected exit sites or the period immediately after catheter implantation. Further studies are required to confirm these results, to delineate optimal postoperative care, and effective procedures for inflamed or infected catheter exit sites.
Conclusions These data demonstrate that dally cleansing of the well-healed, noninflamed peritoneal catheter exit site with soap and water results in a markedly lower rate of exit site infection than procedures that use a povidone iodine paint or hydrogen peroxide and povidone iodine ointment. This procedure is safe, simple, and cost-effective. 0 References Bartelt, C., Burrows, L., Prowant, B., Ryan, L., Satalowich, R., & Schmidt, L. (1986). Management ofthe per/to-
Irritation from clothing
neal catheter exit site. Columbia, MO: University of Missouri. Clayton, S., Fmer, C., Quinton, C., Jabaz, 0., Clark, S., Kelman, B., & Oleopoulos, D.O. (1980). 'Il'aining patients for continuous ambulatory peritoneal dialysis at the 1bronto Western Hospital. In M. l..cgrain (Ed.}, Continuous ambulatory peritoneal dilllysis (pp. 162-166). Amsterdam: Ex-
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(Ed.), Peritoneal dialysis (pp. 441524). Boston: Martinus Nijhoff Pub-
lishers. Lindblad, A.S., Novak, J.W., Stablein, D.M., Cutler, S.J., & Nolph, K.D. (1987). Report of the National CAPD
Registry of the Nationa~ Institutes of Health: Characteristics of participants and selected outcome measures for the period January 1. 1981 through August 31. 1986. Bethesda, MD: NIH. · Lineaweaver, W., Howard, R., Soucy, D., McMorris, S., Freeman, J., Crain, C., Robertson, J., & Rumley, T. (1985). 1bpical antimicrobial toxicity. Archives of Surgery. 120. 267-270. Moncrief, J.W., & Popovich, R.P. (1985). Continuous ambulatory peritoneal dialysis. In K.D. Nolph (Ed.), Peritoneal dialysis (pp. 209-246). Boston, MA: Martinus Nijhoff Publishers. Nathan, C.F., Silverstein, S.C., Brukner, L.H., & Cohn, Z.A. (1979). Extracellular cytolysis by activated macrophages and granulocytes: II Hydrogen peroxide as a mediator of cyto-
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