This document provides information on inserting tunneled dialysis catheters. It discusses the preferred insertion sites being the right internal jugular vein. Potential acute complications during insertion include arterial puncture, pneumothorax, hemothorax, and air embolism. Subacute complications after insertion include suboptimal flow due to malposition, kinking, clots or fibrin sheath formation. Tunnel tract infection is also discussed as a complication requiring antibiotic treatment and catheter removal. The document provides guidance on preventing and managing these potential complications.
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"
Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall.
It is convenient for the patient, quick, time saving, and cost effective
Interventional radiologists
placement and
management
research and development of hemodialysis catheters
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"
Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall.
It is convenient for the patient, quick, time saving, and cost effective
Interventional radiologists
placement and
management
research and development of hemodialysis catheters
This procedure is knowledge required for the dialysis, in this PPT include introduction, definition, indication, Advantages, Disadvantages, Nursing care and complication of Arteriovenous graft.
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
This procedure is knowledge required for the dialysis, in this PPT include introduction, definition, indication, Advantages, Disadvantages, Nursing care and complication of Arteriovenous graft.
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
Precautions for Central Venous Catheters in NeonatesKing_maged
Includes: different methods of venous access, CDC guidelines for prevention of catheter-related infections as well as precautions for umbilical catheters use .. Prepared by Dr. Maged Zakaria, NICU Resident, Ain-Shams University Maternity Hospital
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)
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Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
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2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
2024.06.01 Introducing a competency framework for languag learning materials ...
Tunneled catheter insertion
1. Tunneled HD
Catheters
Dr.Zaghloul Gouda
Nephrology Department,
Damanhour Medical National
Institute
ww.hd-cath.com www.telekidney.co
Dr.Mohamed Abd El Gawad
Nephrology Specialist at New Mansoura
General Hospital
6. 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
ww.hd-cath.com www.telekidney.co
7. Sites of Insertion:
The preferred site of insertion is the right
internal jugular (IJ) vein as it is the shortest
and most direct route to the right atrium.
The alternative insertion sites, in
descending order of preference:
• Left IJ,
• Right external jugular (EJ),
• Left EJ,
• Right femoral and left femoral vein.
• Subclavian veins should not be used for
catheter placement as they are
associated with an unacceptably high
incidence of stenosis, which would
compromise future upper limb AV
access placement. The
Insertion of Tunneled Dialysis Catheter
ww.hd-cath.com www.telekidney.co
8. 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
ww.hd-cath.com www.telekidney.co
9. Equipment
Will be provided during the workshop
Insertion of Tunneled Dialysis Catheter
ww.hd-cath.com www.telekidney.co
10. Length/French 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
• Rt IJV CATH (24 cm), French 14 or more
• Other approaches at least 15 French
French:
ww.hd-cath.com www.telekidney.co
11. Right Sided IJ Tunneled Catheter Insertion
Insertion of Tunneled Dialysis Catheter
Catheter insertion will be provided
during the practical part of the
workshopww.hd-cath.com www.telekidney.co
13. • 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:
ww.hd-cath.com www.telekidney.co
14. 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.
ww.hd-cath.com www.telekidney.co
15. 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
ww.hd-cath.com www.telekidney.co
16. 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:
ww.hd-cath.com www.telekidney.co
17. 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:
ww.hd-cath.com www.telekidney.co
18. 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.
ww.hd-cath.com www.telekidney.co
19. Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow
Fibrin
Sheath
Clots
Mal-
Position
ww.hd-cath.com www.telekidney.co
20. 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:
ww.hd-cath.com www.telekidney.co
21. ( 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
ww.hd-cath.com www.telekidney.co
22. 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:
ww.hd-cath.com www.telekidney.co
23. 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:
ww.hd-cath.com www.telekidney.co
24. 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
ww.hd-cath.com www.telekidney.co
25. 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
ww.hd-cath.com www.telekidney.co