Temporary vascular access for hemodialsi

1. Temporary Vascular
Access for
Hemodialysis
Yousaf khan
Lecturer Renal Dialysis
IPMS-KMU

2. Vascular access for hemodialysis
 Native Arteriovenous fistula (AVF)
 Prosthetic arterio-venous graft (AVG)
 Cathater
• Temporary double lumen cathater
• Permanent Cathater
• Central venous access is defined as placement of a catheter such that the
catheter is inserted into a venous great vessel.
• The venous great vessels include the superior vena cava, inferior vena
cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac
veins, and common femoral veins.

3. Indicationfor Use
• Limited vascular access
• Administration of highly osmotic or caustic fluids or medications
• Frequent administration of blood and blood products
• Frequent blood sampling
• Measurement of CVP
• Hemodialysis
• Hemofiltration
• Apheresis

4. Indicationsfor vascularcatheter:
• Acute renal failure.
• Dialysis for overdose
• ESRD with no access
• ESRD with failure of access
• Peritoneal dialysis with complications
• Transplant patients require HD
• ESRD who lost all possible access
• Hemodialysis/Hemoperfusion for overdose or intoxication

5. Typesof catheters
• Cuffed / non Cuffed.
• Luminal design.
• Material.
• Antiseptic impregnated.

6. Temporarynon CuffedCatheters
• Short
• More ridged
• Easy and fast insertion
• Immediate use
• Higher infection rate
• Preferred IJ or femoral
• Avoid subclavian
• < 3wks for IJ
• <5 days for femoral

7. CuffedTunneledCatheters
• Dacron cuff
• Softer
• Sheath for insertion
• Different holes, length and material
• Requires sedation
• Lower neck insertion site
• More bleeding

8. Advantageof the Catheters
• Universal Application
• Easy to insert
• No maturation time
• No skin puncture
• Short term Hemodynamic consequence
• Lower initial cost
• Provide time for fistula maturation

9. Catheters Disadvantages
• Associated with higher mortality risk than fistula
• Thrombosis
• Infection
• Central venous thrombosis
• Discomfort
• Cosmetic
• Shorter expected using time

10. Catheter Location

11. Contents of doublelumen catheter

12. Sterile Technique
• We will not review sterile technique in
depth here
• For the physician, sterile technique
means wearing a surgical cap, procedure
mask, sterile gown and sterile gloves.
• Sterile setup for the patient should begin
with adequate skin preparation with a
sterilizing solution (proviodine,
chlorhexidine, etc.) in a large area
surrounding your procedure site.
• Place a large sterile sheet on the patient
following this and then isolate the
procedural field with four to six sterile
towels.
• This will minimize infective complications
of the procedure.

13. Seldinger technique
1. Setup of Equipment and Sterile Preparation
2. Landmarking the Access Site
3. Anesthesia
4. Location of the Vein with a Seeker Needle [Optional]
5. Placing the Introducer Needle in the Vein
6. Assessment for Venous or Arterial Placement
7. Insertion of the Guide Wire
8. Removal of the Introducer Needle
9. Skin Incision
10. Insertion of the Dilator
11. Placement of the Catheter
12. Removal of the Guide Wire
13. Flushing and Capping of the Lumens
14. Secure the Catheter

14. Internal jugular vein
• The right internal jugular vein
(IJV) is the most common site
chosen for central venous access
in pediatric cardiac surgery.
• It is large, and runs in close
proximity superficial to the
carotid artery along most of its
length.
• The primary advantage of using
the IJV is that it provides a direct
route to RA.

15. Subclavian Vein
 The subclavian vein is positioned
immediately behind the medial
third of the clavicle.
 Advantages of this route include
the subclavian vein’s relatively
constant position in all ages in
reference to surface landmarks
and the site is comfortable for
awake patient.
 Disadvantages include an
incidence of pneumothorax is
high. Also in 5–20% of patient,
subclavian catheters will enter
the contralateral brachiocephalic
vein or ipsilateral IJV, instead of
the SVC

16. Femoral vein
• The femoral vein has long been
used for central venous
catheterization in pediatric
patients, with no greater
infection or other complication
rate compared to other sites.
• the patient is positioned with a
rolled towel under the hips for
moderate extension.
• The puncture site should be 1–
2 cm inferior to the inguinal
ligament, and 0.5–1 cm medial
to the femoral artery impulse,
with the needle directed at the
umbilicus.

17. Early and immediatecomplications
• Arterial puncture.
• Venous perforation.
• Bleeding & hematoma.
• Pneumothorax.
• Hemothorax & Hemomediastinum.
• Air embolism.
• Arrhythmia and cardiac arrest.
• Cardiac chamber perforation.
• Pericardial Tamponade.
• Injury to adjacent structures: Nerves, Trachea,..etc

18. Late Complications
 Thrombosis
 Fibrin sheath formation
 Infection
 Vascular thrombosis and stricture
 AV fistula
 Injury to adjacent structures
 Brachial plexus
 Trachea
 Recurrent laryngeal nerve

19. HD catheter Thrombosis
within or outside of the lumen.
Prevention with Catheter Lock:
Heparin 1000-10000/ml.
• Affect PT, PTT and cause HIT ( Thrombocytopenia)
• Bleeding
• Allergic reaction

20. FibrinSheath
• Outer side.
• Cover the pores.
Compose of Thrombus with fibrin, Endothelial cells, Smooth muscle cells,
endothelial cells and collagen.
Treatment:
• Thrombolysis.
• Wires and balloons.

21. HemodialysisCatheter-related infection
• Second cause of mortality
• First cause of Morbidity
• Bacterial flora migration
• Exoluminal and Endoluminal growth
• Increased catheter loss, bacteremia, hospitalization
Rate of uncuffed cath. infection:
• 8% by 2wks.
• 25% by 1 month.
• 50% by 2 months.
Catheter related septicemia is 2 -20%.
Vascath:
IJ 2-3wks?
Subclavian 2-3wks?
Femoral. 2-5days?
Cuffed tunneled:
1 year –Indefinite.

22. Typesof HD catheter infection
• Localized exit site infection
• Tunnel infection
• Systemic infection
• Last access cuffed tunneled infected catheter
• Signs and symptoms of Hemodialysis Catheter related infection
• Immunosuppressed patients
• Inflammatory signs:
• redness, hotness, pain, swelling, discharge.
• Fever during Hemodialysis
The catheter is the cause of fever unless proven otherwise.
• Redness over the exit site.
• Discharge from the exit site.

23. Investigationsfor catheter infection
• CBC.
• Blood Culture peripheral and from catheter.
• Catheter tip Cx.
• Exit site discharge.
• Others: Urine, Sputum, Drains..etc.
• Exit site infection:
• Erythema, discharge and tenderness.
• Obtain Cx.
• Could be treated with Local and oral AB.
• Rarely required removing the catheter.

24. Thank you