Temporary Vascular Access for HemodialysisYousaf khanLecturer Renal DialysisIPMS-KMU

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.

Indication for 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

Indications for vascular catheter:

• 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

Types of catheters

• Cuffed / non Cuffed.

• Luminal design.

• Material.

• Antiseptic impregnated.

Temporary non Cuffed Catheters

• 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

Cuffed Tunneled Catheters

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

Advantage of 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

Catheters Disadvantages

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

Catheter Location

Contents of double lumen catheter

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.

Seldinger technique1. Setup of Equipment and Sterile Preparation2. Landmarking the Access Site3. Anesthesia4. Location of the Vein with a Seeker Needle [Optional]5. Placing the Introducer Needle in the Vein6. Assessment for Venous or Arterial Placement7. Insertion of the Guide Wire8. Removal of the Introducer Needle9. Skin Incision10. Insertion of the Dilator11. Placement of the Catheter12. Removal of the Guide Wire13. Flushing and Capping of the Lumens14. Secure the Catheter

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.

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

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.

Early and immediate complications

• 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

Late Complications

Thrombosis Fibrin sheath formation Infection Vascular thrombosis and stricture AV fistula

Injury to adjacent structures Brachial plexus Trachea Recurrent laryngeal nerve

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

Fibrin Sheath

• Outer side.• Cover the pores.

Compose of Thrombus with fibrin, Endothelial cells, Smooth muscle cells, endothelial cells and collagen.

Treatment:• Thrombolysis.• Wires and balloons.

Hemodialysis Catheter-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.

Types of 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.

Investigations for 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.

Thank you