Home Dialysis
With regard to exit site care, what is the role of hypertonic compresses and your experience with them?

Submitted by PDU Administration - 06/09/2005

Not much good literature on this but we use as adjunct for exit site infections and I also use it to treat equivocal exit site infections if I am reluctant to give antibiotics.

We rarely use hypertonic compresses any more.

I agree with Beth on compresses.

I am not having great luck in getting perfect fully epithelialized exit sites in the majority of my patients. For me this is the most disappointing part of my care for my PD patients. Any new pearls of wisdom?

Submitted by Talha Imam - 10/26/2004

Are you treating primarily patients with diabetes or who are on steroids? If not, I would try another surgeon.

For exit sites, stabilize, no sutures, keep dry for 4-6 weeks post op. No new silver bullets that I know.

Obtaining a healthy exit-site begins with proper location and construction. The site must be located where it will not be subject to irritation and trauma, therefore, should avoid the belt line, skin creases, or the crest of a mobile pannus. The tunneling device should not exceed the diameter of the catheter and passed in the direction from the insertion incision toward the exit-site. This leaves the skin tight around the catheter and avoids pushing bacteria from the exit wound up into the tunnel tract. The superficial cuff should be positioned no closer than 2 cm of the exit wound. The catheter should be immobilized on the skin with tincture of benzoin and sterile adhesive strips (not sutures) during the postimplantation healing period. Thereafter, the catheter should always be immobilized with the dressing or tape to prevent tugging or mobility of the catheter at the exit-site. Taping the catheter with excessive traction should also be avoided. Confirm that the patient is not getting alcohol, peroxide, or other tissue injuring agents into the exit sinus during daily care.

Since using mupirocin routinely for catheter exit-site infection prophylaxis, we have seen two patients' catheters begin to deteriorate. Our surgeons use Cruz catheters, but I don't know the composition of the material they are made from. I have seen one 1998 article implicating polyurethane catheters as being susceptible to this problem. What is the latest word on this issue? And should Cruz catheters be avoided for this reason?

Submitted by Michael Jacobson - 8-2-04

Catheters are made of polyurethane and no antibiotic ointment should be placed around these catheters. This has been shown in two different studies (one published only in abstract form to my knowledge and presented at a meeting but had impressive pictures of catheter malformation--it was not only mupirocin used but also other antibiotic ointments). This has not been shown for silicone catheters. We use only silicone catheters and have seen no damage from either cream or ointment over more than 10 years.

To my knowledge the Cruz catheter is the only one commercially available that is polyurethane. I am also unaware of data on cream antibiotics as opposed to ointment.

I agree with Beth. Under no circumstances did we advocate ointment. We specified cream and our handouts (Ad Hoc Committee report) stated cream.

I agree with Beth's note. The Cruz catheter deteriorates when exposed to alcohol, which is in the mupirocin ointments. In addition, we had several late leaks with the Cruz catheters. That is, after a couple of years. At the time of catheter removal, the inner cuff had disconnected from the catheter. This was also reported in an abstract at one of the ADC. Therefore, we stopped using them several years ago.

How does one go about trimming an external PD catheter cuff that has extruded out from the exit site? How long after treatment of ESI should we wait before trimming, and should the patient receive prophylactic antibiotics at the time of trimming?

Submitted anonymously - 8-27-04

I have not trimmed these cuffs, but have had the patient apply gentamicin drops to the cuff 2 times per day. This has permitted patients to keep the catheter for up to 3 years beyond the extrusion without infection.

With regard to superficial cuff extrusion - the management would depend upon whether there is associated exit site infection or not. If there is no associated exit site infection, there is no need to do any intervention. We have had several patients in the last few years who have had their catheters placed in Mexico, came to us with the superficial cuff extruded and remained problem-free for years. If there is associated infection, the infection would not resolve without removing the cuff - either shaving the cuff or removing the catheter. So, the cuff shaving would need to be done under cover of antibiotics and should be continued after the cuff has been shaved. One has to be careful in shaving the cuff such that the catheter is not nicked.

If the cuff is within 1-0.5cm from the exit site, the options are to bluntly dissect the cuff out (hemostat/pickups) under local anesthesia or to use hydrogen peroxide at the CES for 1 wk (1-2 times q day ) since this will loosen fibroblast anchoring and the cuff may be marsupialized quicker than if you just followed the cuff on standard CES care. The injection of local anesthetic should be directed away from the catheter to avoid inadvertently piercing the catheter.

The main reason to remove a near extruded or an extruded cuff is to avoid a tunnel infection behind the infected cuff or a re-infection especially if it is staph aureus. I even try to relocate the external cuff if the patient has a recurrent catheter exit site (CES) infection since there is a high likelihood that the external cuff is infected. After the cuff is extruded it can be bluntly removed by a pickup or hemostat. Once the majority of the cuff has been removed some glue may remain and very fine sandpaper can be utilized to smooth the area. In some patients I may elect to leave the glue behind and over time it decreases in size.

I would not use any sharp instrument for fear of cutting the catheter. I would treat a patient that has a partially extruded cuff that I was dissecting out with antibiotics, if I merely was removing the cuff I use local care with exsept and bactroban. If there is an infection at the CES the sooner the cuff is externalized the lower the risk for recurrent infection or persistent infection.