HemoDoc, From Doctor to Patient

Is Daily Dialysis Dangerous?

By Peter Laird, MD

Kidney International recently published a study on daily dialysis alleging worse outcomes for patients on daily in-center dialysis as compared to conventional in-center thrice weekly dialysis. The authors noted that this was a different outcome than prior observational dialysis studies on more frequent and longer duration strategies.

A multinational cohort study of in-center daily hemodialysis and patient survival

Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

The researchers conclude that their study is the most conclusive and best evidence on mortality of daily dialysis in-center. However, simply reviewing their methods and results brings into question several areas of concern with this latest publication.

First, the most obvious data needed to compare the patients in this cohort is the clinical indication for why they were on daily dialysis in the first place. While daily dialysis at home is a utilized in the United States and more widely in Europe and Australia, even in those nations, daily dialysis in-center is not ordinarily utilized without specific clinical reasons. In America, many patients who are failing on conventional thrice week therapy often advance to four times a week treatments or more as a rescue strategy. Incredibly, this study failed to gather any data on why patients were on daily dialysis in-center and they indicated informally that rescue may have been an operative indication:

A multinational cohort study of in-center daily hemodialysis and patient survival

Most importantly, we do not have any information as to why daily hemodialysis was prescribed to individual patients in this study. If daily hemodialysis was prescribed as a ‘rescue’ option, patients selected for this therapy may have been sicker than those maintained on conventional dialysis. Some French patients may have been selected in this way (personal communication, CC and RG).

In addition, the short daily group had twice as many grafts compared to the conventional group and 30% of the short daily patients had no access data at all. Given the significant risk of death from AV grafts compared to fistulas, this could lead to significant confounding bias. Other data lacking in this study included no documentation of residual renal function, severity of co-morbid disease or socioeconomic factors, all of which are known predictors of survival. 

In addition, a secondary analysis of the FHN short daily and nocturnal studies by the same lead author focused on access issues speaks negatively of daily dialysis in yet another study:

Risk of Vascular Access Complications with Frequent Hemodialysis

In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

Many are already discouraged from recent studies and negative commentaries on daily dialysis. Others that know and understand the benefits of daily dialysis and will simply ignore this latest study:

Despite the risks of more frequent dialysis, I will continue, thank you

Studies like this, in my humble opinion, do more harm than good. Some doctors would potentially be put off by this risk of access problems and not recommend more frequent dialysis for their patients. The benefits of the modality are mentioned only in passing and the entire focus of the paper is access problems. This may be all right when you look at it purely from a statistical perspective. But I am really worried that the paper might have just taken daily dialysis off the menu for some people about to get onto dialysis.

That is sad, indeed.

I agree with Kamal Shaw except in one regard. I don't believe that this author in two separate studies has truly proven that more frequent hemodialysis has higher complications and higher mortality. Yes, indeed, that is the conclusions of her two articles, yet can we discount all of the positive articles that have come before? A noted deficiency of the FHN articles is that they did not report whether they used constant site cannulation, better known as buttonhole cannulation which has a lower risk of stenosis and aneurysm, but may increase infections in an in-center setting.

Blood flow rates were not noted in either of these studies as well. Unfortunately, a common practice of many dialysis nurses with short daily dialysis is to significantly increase the blood flow rate to the maximum allowable levels. This is a known cause of access complications that is entirely preventable, but many nurses and patients increase the blood flow rate to improve solute clearances and reduce the time of dialysis. Unfortunately, this data is lacking as well.

I have now completed six full years of hemodialysis and by God's grace and mercy, I have yet to have any access complications. I am now completing nearly 4 years on continuous home hemodialysis with 5-6 cannulations each week. More than once, dialysis professionals have commented that my fistula is the "prettiest" fistula that they have seen.

It is clear when you evaluate the causes of access failure and complications that technique is paramount to assuring reduced adverse events. Taking care of an access requires time that most dialysis technicians simply do not have. It takes me about 20 minutes to remove my scabs, control any bleeding and place betadine, let it dry and remove the excess with alcohol pads prior to inserting my own needles. Most techs simply apply the disinfectant, wipe off any excess and stick a needle into the fistula in less than a minute for both, perhaps two minutes in some cases.

Buttonhole cannulation does not lend itself to that type of rapid access cannulation. What puzzles me the most is the number of nephrologists who actively seek to prove daily dialysis inferior. Is it not time that we enter the rest of the realm of medical practice where we seek to avoid complications, improve procedures and improve outcomes? Sadly, in my opinion, much more effort is generated to discouraging patients from seeking home daily hemodialysis than promoting this wonderful modality.

In my opinion, having God's blessing of no complications from my dialysis to date, frequent daily hemodialysis is easy and safe to administer. I have no doubt that the technical difficulties that in-center patients suffer causing many of these complications are easily correctable but they must have time to do so. It never ceases to amaze me how little the so called dialysis professionals in-center understand about home hemodialysis and commonly used home dialysis techniques.

The better question to answer and promote is why is it that some patients can secure their access without any significant complications for decades, yet some in-center patients suffer frequent episodes of these "common" complications. It is with great regret that I have come to understand that a large majority of "common" dialysis complications are in reality iatrogenic in nature. Access complications appear to be no different.

I would hope that the story of dialysis will one day include a marvelous period of reawakening of how to do things better. The intensive care central line infection rates ravaged patients throughout America until a wise doctor in Johns Hopkins realized that we could improve the technique of inserting and caring for central lines. (here and here) Today, using a simple protocol for all of these procedures, infetions of a central line is now consider a "never" event since it should never occur. This is a prime example of improving the technique of a procedure to eliminate "common" infections which in the end analysis were iatrogenic in nature.

The dialysis industry has yet to embark on the same quest of excellence that our colleagues in other specialities have embraced decades ago. I understand that my risk of infection and complications is quite low even with daily dialysis due to adherence to strict techniques to eliminate potential complications. I am not alone in that many home hemodialysis patients have never had any major complications for years either. Is it not time to start looking at how to prevent complications instead of spending so much time and energy trying to denigrate optimal dialysis?

Perhaps I am simply asking too much but I don't believe so. With my understanding of the benefits of daily dialysis, I wonder when will the American nephrology community learn how to best apply simple techniques to routine dialysis practice that in the end is not costly at all and will save patients suffering, death and pain while reducing secondary treatment costs substantially.

Yes, daily dialysis in the hands of current technicians may indeed be dangerous. Daily dialysis in my hands is easy, safe and effective by strict protocols much in the same fashion as the central line bundle. I wish I could be there for every single patient to apply my own tried and true hygiene and cannulation techniques I have learned from many wise people such as Stuart Mott, but alas, I can't nor can Stuart. Why is it that select individuals can perform these procedures with minimal complications, yet the industry in general cannot? I believe I know the answers to that question, but the industry is not even asking that question. Perhaps that is the biggest problem of all.

The Genius of Stuart Mott: Solving Buttonhole Infections

By Peter Laird, MD

Buttonhole cannulation is an underutilized resource in the hemodialysis setting that recently has come into further question due to studies showing higher rates of infection than standard cannulation techniques. I have long believed that proper hygiene and disinfection can circumvent this higher infection risk leading me to conclude that it simply may be a failure of infection control techniques rather than a failure with buttonhole methodology itself.  Recently, Stuart Mott addressed these issues and developed a new approach and technique that may prove to be the solution to this problem of higher infection rates with the constant site techniques.

Milestone has been reached in buttonhole infections

1. At the end of June 2012 a milestone was reached with 4 000, cannulation of buttonholes. This projected was started in June of 2009 with just two patients and a lot of doters noted at the time. In January of 2010 two more patients where add as a resulted of the first two. No infections and buttonhole integrity remained in tactated.The use of shower scrubbers were initially used but in the summer of 2010 while getting more shower scrubbers at the local Wal-Mart I notice the exfoliating facial buffs. When first trying them out I notice a result that was far better than the shower scrubbers. Faster cleaning and better cleaning of the buttonhole site. The removal of dead skin as well as the oil around the site leads me to believe that his technique was the way to go. Immedelty after using the exfoliating facial buffers the scab remove became the key to the elimination of the infections problem. All the scab material was removed from the buttonhole site and only in rare occasions was there any scab left. What is left is the buttonhole plug. This is removed by using the pickers that come with the needles. 
2. The use of the technique is as followed.  Non-sterile, clean gloves. Cut the pad in half for longer use. You will notice after 30 to 40 uses the pad becomes compacted, it time to use the other half
3. Place the exfoliating facial pad under hot water for 30 to 45 seconds to warm and moisten the pad prior to applying to skin.
4. Apply one to two drops of antibacterial soap to the pad.  Using your fingers spread the soap around on the pad to provide even distribution of the soap.
5. Using a circular motion, the staff or patient scrubs the buttonhole site/scab in a circular motion using moderate pressure approximately 10-12 times.
6.  using a clean paper towel dry the site and throw the paper towel away , don’t use water to rise the site off.
7. Examine site to determine if all scab material around buttonhole site is removed.
8. If scab material remains in the buttonhole track, remove using a sterile needle that is provided in the needle kit.
9. Betadine will be utilized to cleanse buttonhole site immediately prior to cannulation with fistula needles.

Air dry exfoliating pad during treatment by placing pad on top of the dialysis machine.

The lecturer on this infection of buttonholes is limited with in formation. But with this in mind the lowest reported was 0.16 per thousand cannulation(Doss, Schiller, & Moran, 2008; Marticorena et al., 2006, 2009; van Loon, Goovaerts, Kessels, van der Sande, & Tordoir, 2009; Verhallen, Kooistra, & Van Jaarsveld, 2007).  The Mott method for cleaning buttonholes  use somewhat different approach in that it cleans the whole area and not just the area around the buttonhole.

Since February a multiply content approach using this technique is in play, Australia, Canada and Europe are in different phase of getting this approved. The outcomes will be written about in the next year.

Stuart and his team has achieved an incridible 4000 buttonhole cannulations withour a single infection using this novel technique. Stuart is now engaged in an international, multi-center study to validate his initial observations in a study now commencing. Should the initial results Stuart obtained in his home unit be duplicated with a significant reduction in infections, one of the biggest considerations against using buttonhole cannulation will evaporate.

Buttonhole cannulation in my opinion should be the standard of care using Touch Cannulation to eliminate the variance between multiple cannulators. With these preliminary results, Stuart may single handedly be on course to solve the remaining issues that prevent universal acceptance of constant site cannulation which is known to reduce aneurysm development. The results of this ongoing study will hopefully confirm and promote a standard process for scab removal. With over 4000 infection free scab removals and cannulations, it is certainly a process that demands further study.

Touch Cannulation: The Genius of Stuart Mott

By Peter Laird, MD

Many aspects of dialysis care that is beneficial for patients came about by serendipitous application of chance observations. The buttonhole technique came into practice when Dr. Twardowski had little option on some patients with only short areas on fistulas for cannulation. He began using a single site cannulation that developed scar tissue and a track. In the days before highly available access to disposable needles was the rule, multiple reuse of needles created dull points. After successfully establishing buttonhole or constant site cannulation, the observation that new sharp needles caused more difficulties than the old dull needles when accessing established buttonholes.

The battle between the use of sharp and dull needles became part of the usual difficulties associated with buttonhole cannulation. I have now utilized this proven technique for nearly five years. In that time, I have been able to establish reliable tracks that worked well for weeks or months, but inevitably, I would have to every once in a while use a sharp needle even on the best buttonholes. Over the last six months, my arterial site needed more frequent cannulation with sharps.

I had heard of "Touch Cannnulation" in the last two years, but had done well learning how to place my dull buttonhole needles following the same exact angle each time. Initially, I had no reason to try to refine my technique any further, it  had worked well the overwhelming percentage of attempts. The last few months changed my attitude and I reconsidered the Touch Cannulation method when I needed to use sharp needles more and more frequently. I was skeptical it would work but decided to try it out of frustration of frequent sharps cannulations. (Please review the detailed directions by Stuart Mott on how to perform Touch Cannulation in the link above.)

To my greatest surprise, not only did holding the tubing behind the "wings" of the dialysis needle work but it worked well.  I have now been using Stuart Motts' Touch Cannulation for over three weeks and the method has worked each and every time. All it takes is to place your thumb and index finger behind the wings on the tubing and line up the right angles and then let the needle find its own path. For those of us who are parents, there may be an object lesson for us to learn as well about guiding but letting them when at the right age seek their own ways in life.

My skepticism has now come full circle to enthusiastic support of this little known method. Stuart Mott continues to be the most sought after expert on cannulation and with good reason. I wish to personally thank Stuart for helping me overcome one of my own difficulties that added to the stress and discomfort of dialysis. My wife also appreciates the ease of cannulation and being able to avoid sharp needles once you have an established buttonhole track.

This may also prove to be one of the solutions to the difficult problems of utilizing buttonhole cannulation in an in-center dialysis unit where multiple techs over time will cannulate the patient. Many units disparage the buttonhole method becuase it is operator dependent. I suspect that if the Touch Cannulation method were applied widely, the disparity between different cannulators may disappear if everyone involved learns how to let the needle find its own way. Witht  the Touch Cannulation method, that is exactly what the needle does each and every time. The only complaint I have is that I did not try it sooner.

Buttonhole Cannulation: Avoiding Fistula Infections

By Peter Laird, MD

Buttonhole cannulation is a beneficial procedure in prolonging the health of  dialysis fistulas in the home hemodialysis population. Known also as constant site cannulation, it is useful especially in patients who have limited sites for rotation on a fistula. Recent concerns from the FHN revealed an increased risk of vascular access procedures and infections.  Part of the difficulty with the FHN data is a lack of documentation on how many of these complications occured in patients self cannulating or in those that had nurses cannulating with the buttonhole technique. In many ways, buttonhole cannulation is only an option when a patient or one dedicated care giver acceses the site. Even minor changes in the angle of entry will render the buttonhole unusable. An old video from Dr. Stanley Shaldon is a reminder of how far we have come since the early days of self cannulation. (Not for the faint of heart)

 

I have been fortunate to utilize buttonhole cannulation for nearly five years without any complications to date other than a very small thrombosis which required me to move to another buttonhole location.  By God's grace, I have yet to have a single infection in my dialysis access. I believe that there are several factors that contribute to this fortunate outcome, not the least of which is my my medical training on how to perform minor surgical procedures and the importance of proper skin preparation techniques.

I start my dialysis session by setting up my home hemodialysis machine and then let it "cook" while doing other pre-dialysis chores. I always shower prior to dialysis and place clean clothes. I have an upper arm fistula also called a brachiocephalic fistual for the  brachial artery and cephalic vein used to create this access. My first step when beginning my buttonhole cannulation is "pick" the scabs.  I use a bit of an unorthodox technique for scab removal with a 21 ga needle that many experts on cannulation don't recommend, but it works for me by being diligent and very gentle with the needle and essentially peeling the scab away without digging or creating a larger wound. Other techniques for softening the scab work well for many patients, but didn't seem to soften my scabs enough to work in my situation. The key in any of these techniques is to avoid excess trauma to the buttonhole site with scab removal which opens the door to infection through tissue damage.

I always start first prior to scab removal by cleaning the entire area with an alcohol pad. One issue that many do not consider is that the arterial and venous sites are essentially two separate wounds and you should avoid cross contamination. I use one needle for the arterial and a new needle for the venous site. In addition, many use metal, reusable tweezers to assist in picking the scabs once they start to peel. This can be a source of serious infections with drug resistant bacteria that are difficult to completely clean from metal objects. I use a plastic, disposable but sterile tweezers for each buttonhole and never use one on both buttonholes.  Lastly, once I have peeled my scabs off, I keep the area free of all clothing by taping the shirt sleeve to my shoulder prior to removing the scabs.

In addition, I avoid excess dust in the dialysis area by closing the heating and cooling vents on our central air system in the dialysis room. My wife is a great help in this area since she was a supervisor in housekeeping at the hospital where we met. After twenty years in this relationship, I have had to adapt to her hygiene expectations of picking up my clothes and making the bed in the morning since I am usually the last one up. I truly hate the smell of bleach, but it is a regular ingredient in all of our bathrooms, I just ask that she let me leave the house first. My wife has always hated clutter and it makes for a perfect home dialysis setting.

After I have finished the final preparation of the machine and am ready to cannulate, I start once again by cleaning the entire area with alcohol pads being careful to avoid touching the cleansed skin with my hands in any manner. Many dialysis units now send us very small and skimpy alcohol pads and I must simply use two at a time to avoid contaminating the skin while trying to clean it. At this point I have surgical mask and non-latex gloves as does my wife. Once the alcohol has dried, I use betadine pads that I apply in a circular manner to a large area around both buttonholes. My dialysis nurses and my wife believe that my excessive application of betadine paint to such a large area is over kill, but with nearly five years of infection free daily cannulation, who can argue with success.

The key here is to use the standard surgical prep technique of starting from the center and work to the outside of the area cleansed in larger and larger circular motion where you NEVER go from the outside back to the center. I utilize betadine due to an allergic skin reaction to other more effective agents. When using betadine, there are two more precautions to keep in mind with this topical cleanser. First, you must let it dry completely before cannulation and lastly, betadine is irritating to open wounds so I also remove it carfully with several alcohol pads until the skin directly surround the buttonholes has only a faint trace of yellow. The chemical irritation of betadine in a catheter or needle tract can lead to inflammation that increases the risk of infections.

At this point, I use a very careful technique to avoid contaminating the cleansed buttonhole and gently insert the needle along the established track while at the same time pulling the skin taught with my fourth and fifth fingers of the same hand. I hold the needle between my thumb and index finger in a modified touch cannulation. I would point out that I cannot cannulate using this techique in a few seconds as I see many nurses in dialysis centers attempt with a quick swab of alcohol and jam the needle away. It is a bit time consuming to say the least. However, despite some studies suggesting increased complications with buttonholes, I suspect that they are in part due to lack of diligent technique especially when used in a dialysis center with a high patient turnover every day. Buttonhole cannulation is a safe and effective manner of preserving the fistula from aneurysm formation and it is easy to learn how to develop your own sites should you need to abandon an established site once you are home using sharp needles temporally.

Last of all, I place a clean bandaide over the buttonhole before I pull the needles out and then a pressure bandage on top. One issue I have done since starting dialysis is to avoid placing any tape directly over the insertion site.  Anyone that has medical tape on their arm for any length of time understands that the adhesive to the tape stays even after washing and scrubbing with alcohol. Preventing tape on the open hole keeps that adhesive from gathering dirt and bacteria. After I have the pressure bandage on for two hours after dialysis, I take it off, clean off the remaining betadine with alcohol and replace the soiled bandaids with clean bandaides that I keep on for another 8 hours while the protective scab is reforming.

I believe that this is the final culmination of all the previous steps I take to avoid infections. Blood is a great food source for bacteria as noted in the popular blood agar used in microbiology labs for bacterial cultures.  I must confess to being quite paranoid about these issues since I have spent a great deal of my professional life caring for serious access related infections in septic dialysis patients. You can become critically ill in a matter of only a few hours for simply neglecting to be diligent at all times. 

I cherish the independence that buttonhole cannulation offers. It can be challenging at times and as with any procedure, there are specific complications that can occur no matter how careful you are. But for myself, with nearly five years and only a very small aneurysm on my venous site that is clinically unimportant, not a single infection and not a single vascular intervention, I recommend that all patients who are capable of self cannulation should consider this as an optimal access method.  My wife hates my methodical approach to cannulation and rolls her eyes from time to time, but at this point, it is too late to teach an old dog any new tricks. I believe that slow and methodical is the only approach when you continually use a constant site to cannulate. I am continually amazed by the lack of any infection in two continuously open wounds in my arm that defies all of my medical training, but it simply works and works well when done well.

Buttonhole Cannulation: RCT Finds Higher Complications

By Peter Laird, MD

Buttonhole cannulation, also known as constant site cannulation , is a technique for accessing dialysis fistulas utilizing dull needles in an established tract. However, there are very few studies available on how well it compares to standard techniques such as the "rope ladder" technique that moves up and down the fistula. A recent study on 70 patients randomized to either rope ladder or buttonhole technique revealed higher complication rates in the buttonhole cohort:

A randomized controlled trial of Buttonhole cannulation for prevention of fistula access complications

Method:  70 subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles.  Once the tunnel was developed, blunt needles were used.  The control group continued with usual practice (rope ladder rotation technique).   

Results:  Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p= 0.11).  Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p< 0.05). 

Conclusions: This study showed that buttonhole cannulation resulted more infections, haematoma formation, and site pain during dialysis than with the rope ladder rotation group.  A further larger scale longitudinal study is recommended.

It is unclear at this time what the advantages of Buttonhole cannulation serves in the incenter population where nurses may not have the necessary time to adequately prepare the buttonhole before cannulation. Removing the scab prior to cannulation takes me several minutes, something that most dialysis technicians and nurses don't have in abundance. The finding of increased pain in this study is also interesting and I wonder if that was in relation to the process of scab removal by the nurses or the actual needle insertion. I greatly appreciate my own gentle hand when it comes to removing my scabs , but in the beginning before I acquired that task, the nurses removing the scab often hurt me more than the actual cannulation.

I would also like to see the same study in self care dialysis patients at home to see how well the incenter results compare to home patients. The issue of increased infections is a serious issue that in my opinion is related to individual preparation techniques more so than the buttonhole constant site technique itself since I have utilized buttonhole cannulation for four years without a single infection to date. Likewise, I know Bill Peckham has also avoided access infections while utilizing constant site cannulation for several years.

In addition to proper preparation and scab removal, I take great care with my fistula after dialysis, changing my band aids soaked with blood when I remove the pressure dressing in two hours, first cleaning around the site with alcohol pads.  I only use a sterile needle for each site to pick the scabs as well as sterile disposable plastic tweezers to help clean the scab, never using the same needle or tweezer for both. For my own care, the pain of inserting needles in an established buttonhole is greatly diminished. Adding to that, I have never had a hematoma formation. Buttonhole cannulation in the hands of a self care patient is still a consideration in my opinion based on my own experiences. I believe it simply takes dedication to the fundamental principles of infection control before, during and after dialysis as well as a willing patient to learn self cannulation.

I would hope that this study does not diminish the utilization of the only proven method of decreasing aneurysm formation that thousands of patients worldwide utilize on a daily basis. Further studies are warranted but I would suggest comparing self care buttonhole cannulation at home to that of in-center care where the technicians and nurses perform the cannulation. For myself, I am grateful for this useful technique and that I further have not had any of these complications listed in this study. Longitudinal studies employing self cannulation hopefully will improve upon the results in this study as some smaller studies already show:

Cannulating in haemodialysis: rope-ladder or buttonhole technique?

According to the nurses, in 26 cases (79%) the use of the buttonhole method was considered a success, especially because of easier cannulation with less pain. The cosmetic effects of the buttonhole method, compared with the rope-ladder method, were considered favourable in 12 patients: less haematomas and less scar tissue were present compared with the rope-ladder technique; none of the patients suffered from negative cosmetic effects (Table 2).

The paradoxical findings between the prior observational studies conducted over several months and years and this randomized and controlled trial needs further explanation before application in the clinical setting.  Certainly we do know that adherence to proper buttonhole technique including complete scab removal and infection control is the key to success for many dialysis patients who continue to note the benefits of buttonhole cannulation.  Regardless of the disappointing results of this RCT on buttonhole cannulation, it remains in my opinion a useful technique especially in the home hemodialysis population. 

 

STOP! Wash Your Hands

By Peter Laird, MD

Inadequate infection control practices remains the single largest preventable source of dialysis related complications by many reports. Sadly, the culture of overlooking basic hand washing, changing gloves and proper cleaning of the dialysis machine is prevalent in every dialysis unit I have dialyzed (9 in 7 different states).  The lessons learned in the ICU preventing blood borne infections with central line catheters by a simple check list where health care associated infections (HAI) have been essentially eliminated should become the model of care in dialysis units.

The World Health Organization (WHO) is now sponsoring the Clean Care is Safer Care initiative which promotes the annual wash your hands day events now ongoing in Canada, but apparently it has yet to catch on here in the United States.

STOP! Clean Your Hands Day

The Canadian Patient Safety Institute (CPSI) launched a national hand hygiene campaign in 2007 under the theme “STOP! Clean your hands”. CPSI is working on this initiative with the Community and Hospital Infection Control Association–Canada, the Canadian Council on Health Services Accreditation and the Public Health Agency of Canada.

A simply mental checklist is also available to remind health care workers when they must wash their hands to prevent HAI's from the WHO.  Simply applying these simple concepts could help prevent thousands of dialysis center acquired infections every year. It is time to put this life saving knowledge to work and change our cultures of death in our American dialysis centers.

My 5 Moments for Hand Hygiene

The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.

This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings.

This approach recommends health-care workers to clean their hands

• before touching a patient,
  
• before clean/aseptic procedures,
• after body fluid exposure/risk,
• after touching a patient, and
• after touching patient surroundings.

 

 

 

 

 

Overcoming the Fear of Needles

By Peter Laird, MD

The fear of needles, large dialysis needles, is a very commonly cited reason for seeking alternative treatments to hemodialysis with peritoneal dialysis and renal transplantation. I have always  hated needles despite my use of needles on a near daily basis in my internal medicine practice, the difference being I was giving not receiving the use of the needles. Despite my calm assurances to my patients with the needles I used on them, I would run away from my annual TB test which has a tiny little needle injected in the very surface layers of the skin.  While in the Army, I was able to avoid the whole panel of injections needed to be deployed on an emergency basis should they have called. I quite simply hate needles and always have, yet today, not only do I use needles to stay alive, I use very LARGE needles that have an internal lumen large enough to look inside of them.

While all patients starting dialysis express a dislike of needles, there are a small percentage that have an actual physical reaction to needle insertion with heart racing, cold, clammy skin and some people actually pass out.  Scientists have identified up to 10% of the population that have either an acquired reaction to needles and/or a genetic predisposition to the fear of needles.  For patients that must utilize needles for dialysis, this becomes a significant problem not only for the patient, but for the staff treating them.

A common reaction by patients with severe needle phobias is to keep their catheters and avoid fistula or graft placement, yet this exposes them to higher risks of infection and death. Behavioral therapy techniques are effective in overcoming these fears often through forms of desensitization. Home Dialysis Central has an excellent review on the fear of needles and techniques that work at the bedside for patients that all should review if this reaction is preventing you from obtaining the treatment options such as a fistula which is known to improve survival on dialysis: Dialysis Needle Fear: Easing the Sting.

Fortunately, for most patients, it is simply the fear of the pain of the needles themselves that is the issue. Many patients ask for local pain shots before cannulation, but this can cause build up of scar tissue and is best avoided if possible.  A popular form of local anesthesia is topical creams such as EMLA ( Eutetic Mixture of Local Anesthetic) which contains two topical anesthetics, Lidocaine and Prilocaine. Many patients use this product effectively and are able to learn to self cannulate once the pain is controlled. Many patients simply become tolerant to the pain which lasts only momentarily and is accepted as simply a minor inconvenience.  

The most important issue is to not let your fear of needles become a reason for accepting less than optimal renal care. If you are unable to overcome the fear of needles, peritoneal dialysis and renal transplant may help prevent some of the complications associated with long standing catheter use. Ask your nephrologist and nursing staff how to overcome this very common complication of hemodialysis treatment, your fear can be turned away in most cases.