Exit-Site Drainage and Chills in a Catheter Patient
Mr. D, 59, dialyzes through a tunneled right internal jugular catheter placed three weeks ago. He arrives for his Tuesday treatment with a temperature of 37.9°C and says he had chills overnight. On inspection you see erythema around the exit site and a small amount of purulent drainage on the dressing. He is otherwise stable, BP 138/84, no shortness of breath. The catheter is on the schedule to be used today. His bay also holds a patient with a healing AV fistula and a patient waiting for a chair. The unit has no isolation room free, and the shift is running 30 minutes behind.
1. What do you do before the catheter is used, and who needs to know?
Read the worked answer
Recognize the picture. Purulent exit-site drainage plus chills plus a temperature of 37.9°C in a three-week-old tunneled catheter is a suspected catheter-related infection, possibly bloodstream infection, until proven otherwise. This is not a dressing problem.
Before the catheter is used.
- Notify the RN and the nephrologist immediately - before cannulation, not after treatment.
- Do not manipulate or express drainage into the tunnel; that pushes organisms along the catheter track.
- Blood cultures are typically drawn from the catheter and a peripheral site before antibiotics - the RN/physician's call, but the technician should be ready to support it and should not begin treatment while the question is open.
- Continue to monitor temperature and vital signs; watch for hypotension or rigors during the session (rigors on starting dialysis suggest a biofilm/line infection).
- The treatment may still proceed through this catheter if no other access exists - that is a team decision, not a technician decision. The technician's job is to surface the finding and get the right person to the chair.
Delaying the report until the end of the run exposes him to a bloodstream infection that may already be seeded.
2. Describe the access-care technique for this patient's treatment and explain why each element matters.
Read the worked answer
Exit site.
- Cleanse with chlorhexidine-based antiseptic and allow it to dry; apply a new sterile dressing. Do not scrub drainage into the site.
- Inspect and document the site before dressing it - size, color, drainage, tenderness along the tunnel.
Hubs and connection.
- Scrub the hub with chlorhexidine/alcohol using friction for at least 15 seconds and let it dry completely before connecting. The drying step is where most lapses occur.
- Mask the patient and yourself; use sterile gloves for the connection; new gloves after site care.
Why it matters. Catheter hubs are the dominant entry point for organisms, and drying time is what makes the antiseptic work. A hub that is scrubbed and immediately accessed is barely better than one that is not scrubbed.
During treatment. Watch for fever, chills, or rigors; a rigors episode shortly after the pump starts is a classic sign of a colonized catheter. Stop, notify, and treat it as urgent.
3. What are the infection-control implications for the bay and the other patients, and what do you teach Mr. D?
Read the worked answer
For the bay and other patients.
- Standard precautions and hand hygiene are the core measure; drainage is contained under a dressing, so this is not a respiratory or contact-spread scenario requiring airborne isolation.
- Clean and disinfect the station and any shared equipment after the treatment, and do not share supplies between stations.
- Keep his supplies dedicated and his dressing covered; place him so that his access is not adjacent to another patient's access if space allows.
- The real transmission risk in the unit is bloodborne - reinforce that every patient's access is treated as potentially infectious, every time.
Teaching Mr. D.
- Report fever, chills, drainage, redness, or pain at the site before the next treatment, not at the next treatment.
- Keep the dressing dry and intact; no swimming or soaking; follow the unit's shower instructions.
- Do not let anyone else open or manipulate the catheter.
- Explain that a catheter infection can spread to the blood and that early reporting protects both the catheter and his life.
Document the teaching and the patient's understanding.