This document discusses the insertion and management of tunneled dialysis catheters. It begins with an overview of venous anatomy and various sites for catheter insertion. Details are provided on equipment, catheter length selection, and the procedure for right internal jugular insertion. Potential acute complications during insertion like arterial puncture, pneumothorax, and air embolism are reviewed along with preventative measures. Subacute issues such as malposition, clotting, and fibrin sheath formation that can cause reduced flow are described. Management of tunnel tract infections is also covered. The document emphasizes safety throughout catheter procedures.
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Vascular access in Haemodialysis (2).pptxMithunAhmed5
national institute of kidney disease and urology (nikdu)
Dialysis access refers to the creation of an entrance way into the bloodstream so that the blood can be cleansed by the dialysis procedure. It is well established that dialysis cannot be provided without access.
The attainment and maintenance of a single reliable, long-lasting dialysis access with minimal complications continue to be challenging.
Achievement of such an access is associated with optimal patient clinical outcomes, superior quality of life, and minimal costs.
Buttonhole Cannulation Technique Power PointKelley Stanley
My BSN Capstone project done on buttonhole technique cannulation for arteriovenous fistulas. Study of the facts, the evidence, an intervention plan, evaluation plan, and a disemmination plan for buttonhole technique implementation to an outpatient hemodialysis unit.
Vascular access in Haemodialysis (2).pptxMithunAhmed5
national institute of kidney disease and urology (nikdu)
Dialysis access refers to the creation of an entrance way into the bloodstream so that the blood can be cleansed by the dialysis procedure. It is well established that dialysis cannot be provided without access.
The attainment and maintenance of a single reliable, long-lasting dialysis access with minimal complications continue to be challenging.
Achievement of such an access is associated with optimal patient clinical outcomes, superior quality of life, and minimal costs.
Buttonhole Cannulation Technique Power PointKelley Stanley
My BSN Capstone project done on buttonhole technique cannulation for arteriovenous fistulas. Study of the facts, the evidence, an intervention plan, evaluation plan, and a disemmination plan for buttonhole technique implementation to an outpatient hemodialysis unit.
In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein)
Central Venous Access Devices Made Incredibly Easy!Cathy Lewis
Target audience: RNs during New Hire Orientation and nurses needing additional training on identifying, assessing, and maintaining central lines.
Developed in conjunction with subject matter experts (SMEs) from IV Team. Principles based on practice at this particular institution.
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
9. Sites of CVC insertion:
B
A
C
D
E F
A - Central IJV approach
B - Subclavicular subclavian
vein approach
C – Posterior IJV vein approach
D - Supraclavicular subclavian
vein approach
E – Low IJV approach
F – Innominate vein approach
Insertion of Tunneled Dialysis Catheter
11. In general, in patients with a body
surface area of 1.5 to 2.0 m2
-A 12-15 cm catheter should be
selected for the jugular vein in the low
right position and
-A 15-19 cm catheter for the left
jugular vein.
-A 14 to 17 cm catheter should be
used for the right subclavian vein and
A17 to 22 cm catheter for the left
subclavian vein.
12. Length of Cuffed Catheters:
Length:
• Rt IJC: 24, 28 cm
• Lt IJC: 28, 32 cm
• Rt femoral/iliac CATH 36, 42 or 55 cm
• Lt femoral/iliac CATH 55 cm
There are many variations according to patient size and CATH availability
13. Introduction:
• Insertion of a central venous catheter for hemodialysis is an interventional procedure in
which many principles of endovascular techniques are applied.
• It involves obtaining vascular access under real time ultrasound guidance, wire
manipulations and sheath placements.
Insertion of Tunneled Dialysis Catheter
14. Right Sided IJ Tunneled Catheter Insertion
Insertion of Tunneled Dialysis Catheter
Catheter insertion will be provided
during the practical part of the
workshop
16. • Regardless of how “minor” or “simple” the procedure, never underestimate the
complications that may arise during the procedure.
• Obeying the “rules” and developing good habits during training can go a long way to
decrease procedure related complications.
Acute Complications of Tunneled Dialysis Catheter Insertion
The following are some of the complications that one may encounter during dialysis
catheter placement, and the precautions and steps to treat them if they occur:
17. Prevention:
1. Always access the vein under real time ultrasound guidance and pay attention to the
depth and ultrasound plane.
2. Always use the micro puncture set to access the vein initially as cannulation created
using the micro puncture needle is small and bleeding can be stopped readily by
compression.
3. Always verify the position of the micro puncture wire by fluoroscopy.
A. Arterial Puncture:
Treatment :
It depends on which stage of the procedure the complication is discovered:
1. If the complication is discovered before dilatation of the venotomy tract, the wires
and micro-puncture sheath can be safely removed and direct compression applied to
arrest the bleeding.
2. If the complication is discovered after dilatation of the venotomy tract, leave the
dilator in-situ to tamponade the vessel and call for help. The arterial puncture can be
closed either by open surgical repair or using an arterial closure device.
18. C. Hemothorax:
In the event of a hemothorax, surgical
intervention is often necessary to stop the
bleeding and evacuate the blood.
B. Pneumothorax:
In the event of a
pneumothorax, chest
tube insertion is often
necessary to evacuate
the air leak
19. Preventive measures:
1. Identify high risk patients. Patients who are dehydrated are at increased risk of air
embolism during line insertion. Their veins may be collapsed or show variation in size
with the respiratory cycle on ultrasound. Give fluid boluses and perform the insertion
with the patient in the Trendelenburg position to minimize the risk of air embolism.
2. Always occlude the hub of the needle and close the hemostatic valve of the peel away
sheath during the procedure. As an added precaution, pinch the peal away sheath
between your fingers after you have removed the inner dilator.
3. Instruct the patient to hold his/her breath during puncture of the IJ vein and insert the
wire though the needle rapidly after successful puncture to avoid this complication.
4. The patient should be instructed to hold his/her breath during exchanges over the
wire.
D. Air Embolism:
20. If there is significant air embolism
1. Immediately place the patient in the left lateral decubitus and Trendelenburg position. If
cardiopulmonary resuscitation is needed, place the patient in a supine and head down
position.
2. Administer 100 % oxygen and do endotracheal intubation if necessary.
3. Attempt removal of air from the circulation by aspirating from the central venous
catheter.
4. Fluid resuscitate the patient and consider hyperbaric oxygen treatment.
D. Air Embolism:
21. E. Cardiac Arrhythmia:
To prevent the wire from triggering
arrhythmias during the procedure,
always pass the guide wire tip into the
IVC during the procedure.
22. Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow
Fibrin
Sheath
Clots
Mal-
Position
23. Mal-position/kink:
If the tunneled catheter has poor flow within a week of placement, it is often due to
suboptimal positioning of the catheter tip, migration of catheter tip or kinking of catheter.
A. Check the position of the catheter tip on a chest x ray, in particular, look for any
kinks in the catheter (Next Fig)
B. Withdraw the catheter if the tip of the catheter is distal to the mid atrium. If the
tip of the catheter is proximal to the mid atrium, advancing the catheter carries
the risk of contaminating the subcutaneous tunnel tract and infection.
In the latter situation, exchanging the catheter over a guide wire is preferred.
Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow:
24. ( a ) Catheter is too short. Arrow shows that the of catheter is in the superior vena Cava.
( b ) Tip of catheter is in an optimal position but the arrow shows that catheter is “kinked”
by the purse string suture at the exit site.
( c ) Arrow shows that the catheter is “kinked” at the venotomy site
ba c
Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow:
Mal-position/kink:
c
25. Clots:
If the catheter tip is in the correct position, a trial of a thrombolytic agent may be
attempted.
A. The procedure should be carried out in a sterile manner. Clean and drape the
patient.
B. Remove the caps of the catheter ports and aspirate 5 ml of blood from each lumen
to remove the locking agent.
C. Instill 2 ml of TPA (1 mg/ml) into each lumen and allow it to dwell for half an hour.
D. Aspirate both catheter ports and discard the initial 5 ml of blood.
E. Test catheter flow with a 20 ml syringe. If the flow remains suboptimal, schedule
for catheter exchange over a guide wire.
Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow:
26. Fibrin Sheath:
If the catheter develops poor flow more than a month after placement, it is probably
secondary to obstruction from fibrin sheath formation around the tip of the catheter.
A trial of tPA may be attempted. If unsuccessful, exchanging the tunneled catheter over a
guide wire with or without disruption of the fibrin sheath is the treatment of choice.
A. Check the position of the catheter tip on chest x ray.
B. Aspirate both catheter ports and discard the initial 5 ml of blood which contains the
locking agent
C. Insert a 0.035 in. angled stiff guide wire through the venous port of the catheter into
the inferior vena cava.
D. Free the preexisting catheter cuff by blunt dissection and withdraw the catheter gently
by approximately 3 cm. Gently inject 10–15 ml of contrast material into the arterial
port to visualize the fibrin sheath.
E. Remove the preexisting catheter and insert the 12–14 mm angioplasty balloon
catheter over the wire via the subcutaneous tunnel tract, and inflate the balloon in the
SVC to disrupt the fibrin sheath.
Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow:
27. F. Exchange a new-tunneled dialysis catheter over the guide wire and place the tip
within the proximal SVC. Inject 10–15 ml of contrast via the arterial port to check for
residual fibrin sheath. If fibrin sheath is still present, repeat the angioplasty. If there is
no residual fibrin sheath, advance the catheter tip to the desired position in the mid
atrium.
Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow:
Stripping of Fibrin Sheath
Will be provided during the workshop
28. Tunnel Tract Infection:
1. Tunnel tract infection is defined as infection of the portion of the subcutaneous tunnel that
extends between the catheter cuff and the venotomy site.
2. Broad spectrum antibiotics are required accompanied by removal of the tunneled dialysis
catheter.
3. Temporary dialysis catheter is often required for dialysis access. A new tunneled catheter is
placed at a new site after the tunnel tract infection is treated