Catheter access final
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This document provides an overview of catheter access options for hemodialysis and their risks and management. The preferred options are an arteriovenous fistula, followed by a graft or tunneled catheter. Complications of catheters include pneumothorax, malposition, arrhythmias, infection, and thrombosis. Infection risks can be reduced through strict sterile technique, antibiotic locks, and catheter removal when unnecessary. Overall, the document discusses vascular access types, placement techniques, complications, and infection prevention for hemodialysis catheters.
Catheter access final
- 1. الرحيم الرحمن هللا بسم
- 2. Catheter Access for Hemodialysis A brief review Dr. Ramadan Arafa; FRCPI Physician and Nephrologist Fujairah hospital, UAE
- 3. Vascular accesses for Hemodialysis are: AV fistula, an AV graft, and a venous catheter
- 4. Recommendations Renal Association 2011 guidelines • Preferred type of vascular access We recommend that any individual who commences haemodialysis should do so with an AVF as first choice, an AV graft as second choice, a tunneled venous catheter as third choice and a non tunneled catheter as an option of necessity. (1B)
- 5. Types of hemodialysis catheter
- 6. Catheter Kit
- 11. Indications for Central Venous Catheterization and the preferred insertion sites Indications Site 1 Site 2 TPN SC IJ Acute HDF /plasmapharesis F IJ Emergency transveous pacemaker RIJ LIJ or SC General purpose for drug or irritant medications RIJ or SC LIJ CVP monitoring RIJ or SC LIJ Long term hemodialysis RIJ F
- 12. • What to do if the patient has IJV, Subclavian and femoral vein thrombosis ???
- 14. • 23 patients required a single transhepatic access procedure. • Technical success was achieved in 22 procedures. • Functionality success was achieved in 20 patients. Functionality failure occurred in 3 patients. • The trans-hepatic catheters stayed in place between 90 and 300 days. Complications occurred in 14 patients (3 major + 11 minor).
- 15. Prosthetic axillary- axillary AVG • Prosthetic axillary-axillary arm loop AVG for hemodialysis (Hossam El Wakeel et al; 2013): – The primary patency rate at 1 year was 63.4% and at 2 years was 21.8%. The secondary patency rate at 1 year was 75.6% and at 2 years was 43.5%. • AVG with outflow in the proximal axillary vein (Teruya et al 2009): – Patency rates were 78%, with mean follow-up of 16 months.
- 16. Translumbar inferior vena cava catheter • Initially used for post bone marrow transplantation • Later was used as a vascular access in ESRD patients for hemodialysis with difficult access • A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins Alain Guy Assounga et al; SAMJ 2008 Goupta et al; J Am Soc Nephrol. 1995 Rajan et al; Radiographics 1998
- 17. Transthoracic SVC catheterization • Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available. Wellons et al; Journal of Vascular Surgery 2005
- 18. General rules
- 19. • If the patient has a coagulopathy, the femoral or external jugular veins are the preferred first site, and the internal jugulars are the 2nd choice. • Relative contraindications for subclavian insertion include bilateral pulmonary pathology, high-pressure mechanical ventilation, and altered local anatomy.
- 20. • If one attempt at subclavian insertion has been unsuccessful, an attempt on the opposite subclavian is relatively contraindicated because of the risk of bilateral pneumothorax • If a unilateral pulmonary disease is present, SC and IJ insertion should be done on the same side as the affected lung.
- 21. •Avoid putting lines close to contaminated areas (eg burns, infected tracheostomy site) • Inexperienced operators are only allowed 2 passes for the vein at a particular site before requesting help •Only insert lines with the number of lumens that are required e.g patients requiring long-term venous access for antibiotics only require a single lumen
- 22. • K/DOQI Guidelines state that subclavian vein (SCV) catheterization should be avoided in patients with ESRD because of the risk for central venous stenosis, with subsequent loss of the entire ipsilateral arm for vascular access.
- 23. • Both the National Institute of Clinical Excellence in the UK and the USA KDOQI recommend ultrasound guidance as the preferred method for insertion of central venous catheters into the internal jugular vein
- 24. Documentation The following must be legibly documented in patient notes: • Date, time • Operator(s) and his / her assistants. • Form of anaesthesia or use of analgesia • Line type and indication for use • Insertion site • Complications recognized during insertion, including arterial puncture • CXR result
- 26. EJV approach for perm. Cath insertion Ali Akbar et al; Adv Biomedical Research J 2014
- 28. Complications decreased over the time from 18% to 6% after 6 months
- 29. 1. Bleeding: Check the clotting screen on the day of insertion. CVC insertion should be postponed (or done by experienced clinicians) if the platelet count is < 50,000 or the INR is > 1.5. 2. Arterial puncture Stop procedure and compress the site for 10 minutes by the clock (better to use US-guided insertion) 3. Air embolism Patient should be lying head down -15 to -20° during SC or IJ insertion. Keep the needle hub and catheter lumens as close to patient skin as possible.
- 30. Risks and …. continue 4. Arrythmias: • The commonest arrhythmias noticed are premature atrial and ventricular contractions, and supraventricular tachyarrhythmia • The commonest cardiac conduction abnormalities are RBBB, LAHB and very rarely asystole. • CHB is a well-documented complication known to occur during catheterization of one side of the heart when contralateral bundle branch block pre- exists Jain et al; IJCRI April 2011 Unnikrishnan et al; BJA 2003
- 31. Arrhythmias …. continued • RBBB may occur in 5% of cases while CHB may occur in 23% of cases with pre-existing LBBB • In published cases of guide wire – induced CHB, it was transient and most of patients recover without the need for permanent pacing • We have a case report has asystole which alternates with severe bradyarrhythmia and LAHB pattern. He did not respond to immediate measures of atropine, adrenaline or transcutaneous pacing. He was revived only with transvenous pacing. Jain et al; IJCRI April 2011 D. Morris et al; Arch of Int Med 2005
- 32. • The pathophysiology of CHB in patients with pre- existing LBBB is not clear • It may be due to direct impingement of the catheter up on right bundle branch. • Fascicular block may be due to longitudinal dissociation of fibres in the bundle of His. • Careful insertion of guidewire to less than 22 cm decreases the incidence of complications by 70%. So, it is better to consider the safe limit up to 18 cm. Arrhythmias …. continued Jain et al; IJCRI April 2011 Eissa et al; Anaesthesiology 1990 Wani et al; Case reports in Critical Care 2016
- 33. Baseline ECG - LBBB
- 34. Post CPR ECG - LAFB
- 35. Post pacing ECG
- 36. CXR post PPM insertion
- 37. Risks and …. continue 5. Break in sterile technique • Re-gown if required. Replace any contaminated equipment before continuing with the procedure 6. Pneumothorax • If patient is at high risk of pneumothorax because of lung hyper-expansion, the IJ site is preferable. Check CXR post-insertion (SC or IJ)
- 38. Risks and …. continue 7. Malposition • Check CXR post-insertion (SC and IJ only). • Catheter tip should lie in the lower SVC 8. Thoracic duct damage • Avoid the LIJ or LSC site if possible 9. Catheter-induced thrombosis • Limit insertion attempts to 2 for inexperienced clinicians • Tip of SC or IJ CVC should lie in the lower SVC • Any femoral CVC must be removed after 6 days regardless of the clinical situation.
- 39. Risks and …. continue 10. Laryngeal injury 11. Guide wire embolism
- 40. Risks and …. continue 12. Catheter dysfunction: • Kinked Catheter • Catheter Tip in Azygos Vein • Fibrin Sheath Formation • Intraluminal Thrombus • Exposed Cuff • Catheter – related infection
- 41. Catheter – related infection
- 42. What are the interventions for CRI ? 1. Surveillance and data feed back 2. Chlorhexidine for skin antisepsis: during catheter insertion and during dressing changes 3. Hand hygiene audits 4. Catheter care and access care observations 5. Scrub the hub 6. Patient education and engagement 7. Staff education and competency 8. Catheter reduction 9. Antimicrobial ointment or chlorhexidine sponge at catheter exit site
- 43. Treatment of infection • 7.4.1 Catheter exit-site infections, in the absence of a tunnel infection, should be treated with topical and/or oral antibiotics, ensuring proper local exit-site care. In general, it should not be necessary to remove the catheter. • 7.4.2 If a patient with bacteremia is afebrile within 48 hours and is clinically stable, catheter salvage might be considered by using an interdialytic antibiotic lock solution and 3 weeks of parenteral antibiotics in appropriate situations. A follow-up blood culture 1 week after completion of the course of antibiotics should be performed.
- 44. Treatment of infection … cont’d • 7.4.3 Antibiotic lock with antibiotic to which the organism is sensitive is indicated when follow-up cultures indicate reinfection with the same organism in a patient with limited catheter sites. • 7.4.4 Short-term catheters should be removed when infected. There is no conclusive evidence to support a rationale for scheduled replacement except for those in the femoral area. KDIGO guidelines 2006
- 45. Points for discussion 1. Prophylactic vancomycin injection? 2. If yes; before or after the procedure? 3. If No; is it absolutely contraindicated? 4. Thrombolytic therapy for possible infected catheter? 5. Thrombolytic therapy for AVG thrombosis: what is your experience? 6. HIV cases: what is the preferred approach?
- 49. Thank you
- 50. Pneumothorax
- 51. Malposition
- 52. Kinked Catheter
- 53. Catheter Tip in Azygos Vein Catheter tip Catheter tip
- 56. Exposed Cuff
- 57. Tunnel Infection Exit Site Infection Catheter – related infection
Editor's Notes
- #4: Vascular access remains a key component of hemodialysis. The ideal vascular access should provide safe and effective blood flow by enabling the removal and return of blood via an extracorporeal circuit. Vascular access should be easy to use, reliable and have minimal risk to the individual receiving haemodialysis.
- #47: Vascular access implications First of all, catheter use poses a great risk to patients. The bottom line is, catheters kill, and patients with a catheter, depending on the study, have up to double the relative risk of death. So what that means is when you choose, for whatever reason, rightly, wrongly, or because there is no choice, to get a catheter in a patient, in that patient you have increased the risk of dying as part of the contract. We know that fistulas have the lowest complication rates and require the fewest procedures. When you look, this is USRDS data, what you can see is, that although catheter procedures total are lower than grafts, look at the infection, look at the sepsis, and the cost issues. Catheters are a morbidity issue, they are a mortality issue.
- #48: Now, I'm going to show you some data. Rather than go back to the series of studies from the literature I could show you, I chose to show you network data from Florida because it's stuff you haven't seen and it's not as sifted, it's not as manicured. And this looks at hospitalization in the state of Florida, Medicare hospitalization, from claims. So it's claims-based data, and what you can see is, that the folks with catheters in the first 180 days have an admission rate of 1.8 admissions, 2.9 within 365 days, 2007 and 2008. it's not very different now. You could see that the fistula patients are lower, and graft patients are in between. That's just why data is not controlled, but that's what you see, that's what you know from your hospital.
- #49: End-stage renal disease mortality by access type And if you look at mortality, same story. Look at the mortality rate in patients with catheters. First 180 days, first year. Huge mortality relative to these other folks. Now, patients are different, but in studies that Michael Landt has done and numerous other groups have done, every study done shows that catheters, independent of patient characteristics, increase your mortality risk. End of story.