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

7. Tunneled Catheter Kit

8. Venous approach

10. Femoral vein catheter

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 ???

13. Transhepatic vein cannulation

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

25. Risks and Precautions

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

54. Fibrin Sheath Formation

55. Intraluminal Thrombus

56. Exposed Cuff

57. Tunnel Infection
Exit Site Infection
Catheter – related infection