CENTRAL VENOUS ACCESS CARE PRACTICES IN HEMODIALYSIS CENTRES ACROSS INDIA-A CROSS SECTIONAL ANALYSIS

End-stage kidney disease (ESKD) poses a significant and growing health burden in India, where late presentation and limited vascular access planning often necessitate the use of central venous catheters (CVCs) for hemodialysis initiation. Although the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend arteriovenous (AV) fistulas as the preferred vascular access, up to 80% of Indian patients begin dialysis with CVCs, which substantially increases the risk of catheter-related bloodstream infections (CRBSI) and mortality.

This part of the study assessed central venous access care (CVAC) practices across dialysis facilities in India, including the choice of vascular access, adherence to international guidelines and identifying variations in protocols and procedures in accessing central venous catheters and performing CVC exit site care.

A descriptive cross-sectional design was employed in seven dialysis centers (965patients on Maintenance Hemodialysis) representing different regions of India. Data were collected through direct observation of CVC procedures and protocols, facility record reviews, and interviews with nephrologists, nurses, and dialysis technicians. A 12-item checklist based on KDOQI 2019 guidelines was used to evaluate adherence during CVC access and exit-site care.

Findings revealed considerable variability in vascular access practices and infection prevention protocols across facilities. Among the 965 patients undergoing maintenance hemodialysis (HD) across the seven facilities, 573 (59.38%) utilized an arteriovenous fistula (AVF) for vascular access, while 392 (40.62%) were dependent on central venous catheters (CVCs). The proportion of patients with AVF varied widely between centers, ranging from 5.95% to 90%.Among the 392 patients utilizing central venous catheters (CVCs) for vascular access, 215 (54.85%) had a permanent CVC, while 177 (45.15%) were dependent on temporary catheters. The use of temporary catheters varied substantially between facilities, ranging from 0% in two centers to 94.73% in another. In most facilities, HD initiation was routinely performed with a temporary catheter. The two facilities followed a policy of initiating maintenance HD with a permanent CVC when an AV fistula was not available, reserving temporary catheters exclusively for acute or emergency indications. These findings highlight significant deviations from KDOQI recommendations, which advise limiting temporary catheter use to short-term or emergency HD.

Antiseptic use for CVC care differed, with only 2 of 7 facilities using 2% chlorhexidine as recommended; povidone-iodine and spirit were more commonly used. ‘Scrub the hub’ technique was practiced only in 3 facilities. While Heparin was uniformly used as lock solution for catheter lumen, the concentration used varied between facilities from 1000 IU to 10,000 IU. Overall adherence to guidelines averaged 67% (range: 53.8–83.9%).  While compliance to the use of sterile gloves, mask and an occlusive dressing was 100%, poor practice was observed in documentation of CVC site assessments, CRI rates and catheter malfunctions (32.86%). Adherence to the use of Antibacterial ointment at the CVC exit site was only 51.43%. The adherence to protocols related to hand hygiene, aseptic techniques and exposing catheter lumens to air were also found to be unsatisfactory, 74.29%, 67.14% & 54.29% respectively. The mean catheter handling time was 17.7 minutes (range: 12.5–25.5). Exit-site dressing accounted for the largest proportion (mean 8 minutes). All centers, except one used reusable autoclaved stainless-steel sets, though the number and type of items varied. Most dialysis facilities were managed by dialysis technicians, with only three facilities having nurses trained to perform hemodialysis independently and one facility having hemodialysis nurse specialists who do vascular access surveillance.

These findings of the descriptive study underscore the urgent need for standardized operating procedures, competency-based training, and improved resource utilization to optimize CVAC practices.  Strengthening adherence to evidence-based guidelines could significantly reduce infection-related morbidity and mortality among patients receiving haemodialysis in India.