Đề ôn thi thử môn hóa (63)

422

Fig. 24.5 (continued)

A. M. Onder and M. J. G. Somers


24  Infectious Complications of Hemodialysis in Children

Fig. 24.5 (continued)

423


424

Fig. 24.5 (continued)

A. M. Onder and M. J. G. Somers


24  Infectious Complications of Hemodialysis in Children

425

Fig. 24.5 (continued)

to assess during such infection-­centered rounds,
with separate auditing tools for items that should
be surveyed frequently compared to those requiring only intermittent or special consideration.

Conclusion
This risk of infection for the child on hemodialysis is most influenced by the child’s dialysis
access. Although children with permanent vascular access in the form of AVF or AVG are much
less likely to have dialysis-related infections than
children who receive HD via catheter, many children on HD rely on catheters. The ongoing development and adoption of practices specific to HD
catheter use and care should help minimize infection risk, with special focus on improving rates of
CRBSI (Fig. 24.8).
Key Take-Home Messages for This Chapter
Include
Reports from both single pediatric centers and a
multicenter collaborative of pediatric dialysis
units show that implementation of guidelines that
stress meticulous hand hygiene, chronic care of
the catheter exit site, and aseptic connections to
the HD catheter hubs decreases CRBSI in
children.
Antisepsis of skin near the exit site and of the
HD catheter hubs should use agents with demonstrated efficacy in the dialysis setting, notably
>0.5% chlorhexidine with alcohol, 70% alcohol,
or 10% povidone-iodine.

Triple antibiotic ointment or a chlorhexidine
patch should be placed at the exit site and then
covered with a transparent dressing or gauze; the
exit site should be visualized with each dialysis
treatment, and exit site care and a new dressing
placed at least weekly.
Antibiotic locks are an effective prophylactic
strategy and have also been shown to augment
cure rates when used with systemic antibiotics

for treatment of CRBSI.
With suspected CRBSI, blood cultures should
be obtained from the catheter hubs/HD circuit
prior to antibiotic treatment; broad-spectrum
antibiotics such as vancomycin and ceftazidime
are commonly used empirically while awaiting
culture results.
CRBSI with microorganisms that are difficult
to clear from vascular catheters such as
Pseudomonas, Staphylococcus aureus, or fungus
generally mandates catheter removal.
Persistently positive blood cultures or recurrent symptoms during antibiotic treatment also
require HD catheter removal; wire-guided
exchange can be safely utilized for most patients.
Antibiotics should be provided with CRBSI
for at least 2–3  weeks after negative blood cultures are first obtained; complicated infections
may require longer therapy.
Exit site and tunnel infections generally
respond rapidly to initiation of antibiotics and
usually are not associated with CRBSI.
AVF and AVG infections are rare; AVG infections are more likely to be complicated or require
surgical intervention.


426

Fig. 24.6  Infection prevention intermittent frequency
rounding tool. Various factors relating to the environment
of care that play a more limited role in infection risk, but
nonetheless should be assessed at intervals. This rounding

tool covers environmental parameters that should be

A. M. Onder and M. J. G. Somers

assessed with intermittent frequency. (Rounding tool
shared with permission: Standardizing Care to Improve
Outcomes in Pediatric End Stage Renal Disease (SCOPE)
Collaborative, Children’s Hospital Association)


24  Infectious Complications of Hemodialysis in Children

Fig. 24.6 (continued)

427