Disinfection of the Transfer Set during a Change

The transfer set reduces mechanical malfunction due to normal wear and tear from stress or manipulation to the chronic PD catheter. The transfer set is changed every 6-9 months to reduce infection rate. When the transfer set is separated from the chronic PD catheter, the catheter with or without the adaptor is soaked in disinfectant to reduce infection complications.

Disinfectants that are popularly used are povidone-iodine or sodium hypochlorite and will be compared for efficacy and side effects. Other disinfectants containing polyethylene glycol or alcohol will not be discussed. Cracks were observed in polyurethane catheters after exposure to polyethylene glycol or alcohol [22]. No side effects from disinfectants are associated with silicon catheters.

The use of Amuchina 50% solution versus povidone-iodine 10% solution for transfer set change in PD patients was first described by Cabralda et al. [23]. No episode of peritonitis occurred related to transfer set change using povidone-iodine or Amuchina 50%. The soaking time with Amuchina 50% was 2 min and the nursing time was 5 min compared to 10 min soaking time and 20 min nursing time for povidone-iodine. Transfer set change used 20-30 ml of Amuchina solution compared to 120 ml povidone-iodine. The procedures for using sodium hypochlorite or povidone-iodine as disinfectants during transfer set replacement are included in table 1.

Sodium hypochlorite was compared to povidone-iodine as the disinfectant used during transfer set changes to determine the impact on infection rate and peritonitis rate [24]. Two inner city PD clinics with similar patient demographics participated in this study. Clinic A used Alcavis 50 (sodium hypochlorite 50%) exclusively for transfer set change (160 procedures during 984.9 patient-months) and trained their patients to use Alcavis 50 for accidental touch

Table 1. Protocol to change the PD transfer set

Recommendations

1. Use strict aseptic technique throughout this procedure

2. Perform a solution exchange following the completion of this procedure Gathering the supplies

1. PD Transfer Set Change Kit (10 sterile gauze, catheter or beta clamp, 30 ml soaking tray, 2 face masks with ear loop, 3 pairs of sterile gloves, 2 poly-lined towels for drape, wrap for sterile field, sterile tray)

2. Transfer set

3. Ancillary disconnect cap

4. Sodium hypochlorite 50% or povidone-iodine 10% Getting ready

1. Wash hands with an anti-microbial scrub

2. Open the kit pouch with the label facing up to ensure the kit contents remain upright

3. Don the mask, then have the patient don his or her mask

4. Place drape under transfer set tubing making sure the catheter connection adapter is over the drape

5. Wash hands again with an anti-microbial scrub Preparing the sterile field

1. Don one sterile glove

2. Open the wrap using the non-gloved hand

3. With the gloved hand, organize the supplies on the sterile field created by the wrap

4. With the non-gloved hand, pour approximately 30 ml sodium hypochlorite 50% into the tray or 30 ml povidone-iodine into the soaking tub and approximately 100 ml povidone-iodine into the tray

5. Don the remaining sterile glove

Scrubbing the catheter adapter connection and tubing

1. Pick up one sterile gauze by the four corners. Dip the center portion of the gauze into the sodium hypochlorite or povidone-iodine solution in the tray. Repeat with a second sterile gauze

2. Place the catheter adapter connection and tubing between the two sodium hypochlorite 50% or povidone-iodine soaked sterile gauze and scrub the catheter adapter connection and tubing for 5 min

3. Pick up a dry sterile gauze and place around the adapter connection to prevent it from touching the drape

4. Discard the gauze used for the scrub

Soaking the catheter adapter connection in the soaking tub: (forpovidone-iodine only)

1. Submerge the adapter connection into the tub with povidone-iodine

2. Apply a downward and sideways pressure with the thumbs, pushing the tubing into the crimped slots of the tub

3. The adapter connection of the catheter should rest on the bottom of the tub to allow maximum coverage and soaking

4. Close the lid on the tub. Note: Lid closure is not leak-proof

5. Soak the catheter adapter connection for 5 min

6. Open the lid on the tub

7. Remove the soaked catheter adapter connection from the tub by lifting up

8. Place a dry sterile gauze around the adapter connection to prevent contact with the drape

9. Place the tub off to the side

10. Remove soiled gloves and discard

Table 1. (continued)

Soaking the open end of the catheter

1. Don the second pair of sterile gloves

2. Clamp the catheter clamp on the catheter

3. Place the second drape under catheter

4. With a sterile gauze in each hand, firmly hold each end of the transfer set junction and disconnect the transfer set from the patient catheter. Make sure the open end of the catheter does not touch the drape

5. Hold the tray with sodium hypochlorite 50% or povidone-iodine close to the open end of the catheter

6. Submerge the open end of the catheter in the container. Soak for 2 min with sodium hypochlorite or 5 min with povidone-iodine

7. Remove the soaked catheter end and place in a sterile gauze, making sure the catheter end does not touch the drape

8. Remove soiled gloves and discard

Connecting the open end catheter to the sterile transfer set

1. Open the packaging of the sterile transfer set and keep within easy reach while maintaining sterility of the set

2. Don the last pair of sterile gloves

3. Pick up the sterile transfer set, close the roller/twist clamp, and remove the tip protector

4. Lift up the open end of the catheter adapter from the gauze

5. Connect the set to the catheter adapter

6. Luer-lock firmly in place to ensure a tight connection. The double-seal locking connector does not need to be secured by taping or protective dressings

7. Open the ancillary disconnect cap packaging. Remove the tip protector on the transfer set and Luer-lock the disconnect cap into place

8. Remove the catheter clamp and the drapes. Immobilize the catheter tubing and secure the transfer set

9. The transfer set exchange procedure is completed

10. Allow 5-10 ml to drain out of the patient

11. Place a new sterile minicap contamination at home. Clinic B used povidone-iodine for transfer set change (174 procedures during 868.6 months) and trained their patients to use povi-done-iodine impregnated caps for accidental touch contamination. The protocols using Alcavis 50 and povidone-iodine for transfer set change were similar in that standard clinic procedures were used. Transfer set tip was soaked in 50 ml of Alcavis 50 solution for 1 min to treat accidental touch contamination. Whereas, subjects using povidone-iodine attached a povidone-iodine minicap to the transfer set tip for 10 min and repeated the procedure with a new cap for another 10 min, a total or 20 min. Both systems then required a flush of the system before the next fill. Total infection rate (peritonitis and exit site) was 1.7 episodes/1,000 days in clinic A compared to 2.9 episodes/1,000 days in clinic B (x2, p = 0.019). The peritonitis rate in clinic A was 0.7 episodes/1,000 days compared to 2.2 episodes/1,000 days in clinic B (x2, p < 0.001). Exit-site infection rates were 1.0 and 0.8 episodes/1,000 days for clinics A and B, respectively (x2, p = 0.092). No adverse symptoms or reactions were reported in either group. This study showed that Alcavis 50 resulted in significantly fewer infections than the povidone-iodine group when used as a disinfectant for transfer set change and accidental touch contamination.

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