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MANITOBA RENAL PROGRAM SUBJECT  Collection of Blood Culture Specimen From a Hemodialysis Access SECTION 30.30.Vascula...

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MANITOBA RENAL PROGRAM SUBJECT  Collection of Blood Culture Specimen From a Hemodialysis Access

SECTION

30.30.Vascular Access

CODE

30.30.15

AUTHORIZATION  Professional Advisory Committee, Manitoba Renal Program  Nursing Practice Council, St. Boniface Hospital

EFFECTIVE DATE

June 2013

REVISION DATE

PURPOSE: 1. To collect a blood culture specimen from an adult hemodialysis patient.

POLICY: 1. Registered Nurses (RN)/Licensed Practical Nurses (LPN) in the Manitoba Renal Program who have received instruction and who have demonstrated competency may collect a blood culture specimen, from an adult hemodialysis patient. 2. A CBC and blood cultures are drawn on hemodialysis patients with a temperature of 38 degrees Celsius or higher, or if the patient has rigors and chills. The physician is notified when the blood cultures are drawn. 3. Clinical Microbiology Lab must be consulted prior to collection of blood culture for fungemia (fungal infection— excludes yeast); Legionella or Bartonella; or AFB (mycobacteria). Specific collection bottles are required for these blood cultures. 4. For persons 28 kg or greater, minimally 30 ml of blood are collected from two sites. When the patient has a central line, one aerobic and one anaerobic sample can be collected from one port of the line. The second aerobic and a second anaerobic sample should be from a peripheral site for best results. If unable to draw a peripheral sample, the second aerobic culture should be drawn from the second port of the line. 5. For persons 28 kg or greater, minimally 30 ml of blood are collected from two sites for AVF/AVGs. If a bacteremia is suspected, one aerobic and one anaerobic sample can be collected from both of the fistula needles. If an AVF/AVG infection is suspected, one set should be collected from the AVF/AVG and a second set from a peripheral site (e.g. a different vessel than the fistula). 6. For persons 9-28 kg, 3 paediatric blood culture bottles are collected for central lines; one from each port of the central line and one from a peripheral site. (4 ml per bottle). 7. Adult blood culture bottles require 10ml of blood. Underfilling or overfilling will give a false result. When filling the bottles, avoid getting air into the anaerobic bottle as this can lead to a false negative result. Never use paediatric bottles for adult patients weighing more than 28 kg, as they are not designed for the volume of blood obtained from adults. 8. The top of the blood culture bottle should be decontaminated with alcohol and allowed to dry prior to inoculation.

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9. If available, the Vascular Access Team or a Phlebotomist from the facility may be utilized to obtain peripheral samples. All cultures must be submitted to the lab together. 10. If other bloodwork is being collected at the same time, inoculate the blood culture bottles first before the other sample tubes.

EQUIPMENT:

KEY POINTS:

 



A third aerobic and second anaerobic bottle may be required if ordered.

 

For peripheral samples Appropriate gauge for patient’s vein

      

Blood culture requisition Blood culture bottles (2 aerobic-blue; 1 anaerobicpurple) Alcohol swabs Chlorhexidine/alcohol swab sticks or pads Gloves Face masks Single use tourniquet Safety engineered needle (syringe type) 20 or 30 ml syringe

PROCEDURE:

KEY POINTS:

A. Patients with a Central Venous Catheter (CVC): 1. Perform hand hygiene 2. Gather supplies 3. Complete requisition 

Two patient identifiers

7. Remove caps from blood culture bottles and scrub each with an alcohol swab. Allow to dry



Sterilizing the stopper of the blood culture bottle reduces the risk of a contaminate giving a false positive result

8. Access one port of central line as per 30.30.02, Accessing and Locking a Dialysis Central Venous Catheter (Anticoagulant/Thrombolytic/Antibiotic Locking).Ensure that a minimum volume of 5 mls is removed from the CVC port used.



5ml ensures removal of the instillation so that the blood sample is not diluted.

10. Immediately attach the safety engineered needle and fill the blood culture tubes. (Inoculate the anaerobic bottle first)



Ensure that no air enters the anaerobic bottle as this will give a false negative result Ensure 10 ml of blood to each vial

11. Cleanse the peripheral blood culture site with a chlorhexidine/alcohol swab stick with at least 30 seconds of friction rub. Allow to dry completely.



4. Verify patient identification 5. Perform hand hygiene 6. Don gloves.

9. With a 20 ml or 30 ml syringe, withdraw 20 ml of blood from the CVC port

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Improper cleansing of the peripheral sample site will give a false positive result. If palpation of the vessel is required after cleansing, don sterile gloves.

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PROCEDURE:

KEY POINTS:

12. Perform venipuncture and obtain 20ml of blood from the vessel



If necessary, the second anaerobic sample may be omitted and 10 ml collected.

13. Inoculate the blood culture tubes, anaerobic first (if using)



Ensure that no air enters the anaerobic bottle as this will give a false negative result

14. Using a gauze, apply pressure to the venipuncture site until bleeding stops



Patient can hold if able



Sterilizing the stopper of the blood culture bottle reduces the risk of a contaminate giving a false positive result



Ensure that no air enters the anaerobic bottle as this will give a false negative result Ensure 10 ml of blood to each vial

15. Cover with bandaid. 16. Remove gloves and perform hand hygiene B. Patients with an AVF/AVG 1. perform hand hygiene 2. Gather supplies 3. Complete requisition 4. Verify patient identification 5. Don gloves 6. Remove caps from blood culture bottles and scrub each with an alcohol swab. Allow to dry

7. Access AVF/AVG per 30.30.01 Venipuncture of Arteriovenous Fistula/Graft for first needle. 8. With a 20 ml or 30 ml syringe, withdraw 20 ml of blood from the AVF/AVG needle. 9. Immediately attach the safety engineered needle and fill the blood culture tubes. (Inoculate the anaerobic bottle first)

10. If blood culture collection is to confirm bacteremia:

 

For suspected bacteremia, the collections may be obtained from the same vessel



A peripheral sample will help to determine if the suspected AVF/AVG infection is localized or systemic.

a) Access AVF/AVG per 30.30.01 Venipuncture of Arteriovenous Fistula/Graft for second needle b) With a 10 or 20 ml syringe, withdraw 10 ml of blood from the AVF/AVG needle c) Immediately attaché the safety engineered needle and fill a second aerobic blood culture tube 11. If blood culture collection is to confirm suspected infected AVF/AVG, a peripheral site must be used for the second aerobic blood culture specimen: Follow steps 10-15 in Section A

DOCUMENTATION: 

In patient health record: date, time, site of blood culture collection. Include patient symptoms (temperature, rigors, other pertinent information).

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REFERENCES: Diagnostic Services of Manitoba Inc.—Microbiology. 2011. Sample Collection Procedure Manual. P. 11-12. Retrieved July 25, 2012 from http://www.dsmanitoba.ca/professionals/files/Policy_120-10-05.pdf Lagace-Wiens, P., Manickam, K., Hoban, S. and Alfa, M. 2009. Blood cultures matter! in DSM MicroNotes, Clinical Microbiology Discipline Publication, diagnostic Services of Manitoba retrieved July 25, 2012 from http://www.dsmanitoba.ca/professionals/microbiology/Micronewsletter_06-08-09.pdf St. Boniface Hospital (2007). Blood Culture (61 lbs or more). Diagnostic Services of Manitoba Inc. Laboratory Information Manual. Retrieved July 25, 2012 from http://apps.sbgh.mb.ca/labmanualviewer/viewTest.action?url=http://sbghapps/labmanual/test/3666 National Kidney Foundation. (2006). K/DOQI Clinical practice guidelines for vascular access. American Journal of Kidney Disease, 37(Suppl. 1), 137-181. Diagnostic Services of Manitoba Inc. Document # 100-10-20 Phelbotomy Collection Manual. Pp. 6, 8, 11-13, 2123. Retrieved July 25, 2012 from http://www.dsmanitoba.ca/professionals/files/100-10-20.pdf

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