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\nWho this is for: Hospital-based dialysis providers.
\nWhat this is for: Recommendations to help hospital-based dialysis providers safely perform renal replacement therapy (hemodialysis) in patients with Ebola Virus Disease (EVD).
\nHow this relates to other guidance: When necessary for patient care, this information should be used along with Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in U.S. Hospitals
\nThe purpose of this document is to convey information to hospital-based dialysis providers to help them safely perform renal replacement therapy (hemodialysis) in patients with confirmed EVD. Acute renal failure requiring renal replacement therapy can occur in critically ill patients with EVD. The recommendations and information below are specific for hemodialysis and should be implemented with the precautions described in Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in U.S. Hospitals.
\nTreatment decisions should be made by the clinical team caring for the patient. However, infection control considerations may help to inform providers\u2019 decisions and should influence hospitals\u2019 planning processes.
\nInpatient care of patients with EVD should be provided in a hospital with capacity to perform continuous renal replacement therapy (CRRT). Efforts to minimize direct blood exposure to healthcare personnel and blood contamination of the environment are of principal importance due to the high concentration of Ebola virus that can be present in an infected patient\u2019s blood and the large volumes of blood involved in hemodialysis.
\nIn general, CRRT would be preferred over acute peritoneal dialysis (most commonly performed for acute kidney injury in pediatric patients) because of challenges related to performing peritoneal dialysis catheter insertion in the patient\u2019s isolation room and performing exchanges through a peritoneal dialysis catheter that has not completely healed. It should be noted that peritoneal dialysis effluent is likely to be much more infectious than hemodialysis effluent and would need to be handled with extreme care.
\nHemodialysis/CRRT should only be performed in the patient\u2019s isolation room.
\nPatients with EVD may have disseminated intravascular coagulation (DIC), and correction of coagulopathy is not always possible. Read more on Ebola Virus Disease (EVD) Information for Clinicians in U.S. Healthcare Settings.
\nDesignate a highly competent individual, who has also been trained to follow CDC guidelines for proper PPE procedures, to perform catheter insertion.
\nPerform catheter insertion in the isolation room and use local strategies to minimize blood exposure during dialysis catheter placement.
\nThe subclavian site for catheter insertion should be avoided because of the challenges with direct site compression if bleeding occurs. Selection of the internal jugular versus femoral vein for catheter insertion may depend on patient characteristics and operator proficiency. Using a chest X-ray to confirm line placement will require availability of portable X-ray equipment within the isolation room. This and other factors should be considered in the planning stage before it becomes necessary.
\nUltrasound guidance should be used, by an individual fully trained in this technique, to reduce cannulation attempts and mechanical complications, including arterial puncture. If used, the ultrasound machine should be dedicated to the isolation room until it can be terminally cleaned and disinfected. Read more on Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [PDF \u2013 83 pages].
\nAttach closed, needleless connector devices to the catheter hubs to reduce blood exposure during catheter connections and disconnections.
\nIf possible, limit the number and different types of healthcare personnel involved in hemodialysis/CRRT procedures. For example, ICU nurses performing CRRT could eliminate need for dialysis unit nursing staff to also care for the patient.
\nAll staff involved in providing dialysis should follow recommendations for appropriate PPE.
\nStaff should wear a fluid-resistant or impermeable apron if they will be performing any circuit connection/disconnection procedures, handling used dialyzers or tubing, or handling or draining effluent.
\nA hemodialysis/CRRT machine should be dedicated for use on the patient and kept in the isolation room until terminal disinfection procedures are undertaken.
\nAll other dialysis-related supplies, including the dialyzer, should be disposed of after use in accordance with local, state, and federal regulations. Read more on Ebola-Associated Waste Management.
\nUnder no circumstances should a used dialyzer be reprocessed or reused.
\nEbola virus should not be able to cross an intact dialyzer membrane. Because a small dialyzer leak might not be apparent; however, dialysis effluent should always be handled with care, and while wearing appropriate PPE, to avoid contact and splashes.
\nThe effluent should be disposed of in the toilet or other dedicated drain in a manner that prevents splashes and allows safe drainage into the waste water sewer system.
\nUse a dialysis machine that is familiar to the staff who will perform dialysis.
\nCertain CRRT machines have features that make them easier to manage and to decontaminate in the context of caring for a patient with EVD than traditional hemodialysis machines, such as a completely closed system, lack of an internal pathway, and use of disposable dialysate and saline supplies. The possibility of blood contamination of internal machine components through pressure monitors is also much less likely with these machines than with other hemodialysis machines. During CRRT, staff should pay close attention to pressure alarms and failures of pressure monitors and look for and document any failure of the tubing or spillage of fluid outside of the tubing, as these may have implications for more extensive machine disinfection procedures.
\nAdditional considerations:
\nIf use of an intermittent hemodialysis machine is warranted:
\nExternal machine surfaces
\nCleaning and disinfection of external machine surfaces should be performed in accordance with CDC\u2019s Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus and manufacturer\u2019s instructions.
\nGeneral principles include the following:
\nAdditional considerations:
\nCDC has been in contact with some machine manufacturers and may be able to assist in providing more specific guidance for machine terminal disinfection procedures. Call CDC Emergency Operations Center at 770-488-7100.
\nInternal pathways
\nStandard heat or chemical disinfection procedures recommended by machine manufacturers and used routinely by dialysis providers are sufficient to inactivate Ebola virus.
\nInternal machine disinfection of hemodialysis machines should be performed between treatments and conducted in the isolation room.
\nOther internal machine components
\nIf there is concern about the possibility of fluid contamination of internal machine components such as pressure monitors, contact the manufacturer for guidance and notify the appropriate local or state health department and CDC Emergency Operations Center at 770-488-7100.
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