Dialysis Catheter Management
D. Thor Johnson
Thomas M. Vesely
According to the 2006 National Kidney Foundation Guidelines for Vascular Access (Kidney Disease Outcomes Quality Initiative [NKF-KDOQI]), an arteriovenous fistula should be created 6 months prior to requirement for renal replacement therapy (1). Arteriovenous fistulas have lower costs, longer durability, and fewer complications when compared to prosthetic grafts and central venous catheters. Despite these national recommendations, nearly 80% of patients will initiate hemodialysis treatment through a central venous catheter and 25% of patients continue hemodialysis via central venous catheter (2).
Hemodialysis catheters can be categorized by duration of use (acute or chronic catheters) and method of insertion (tunneled or nontunneled catheters); tunneled catheters are appropriate for most clinical situations. Nontunneled, temporary catheters are used primarily for hospitalized patients without an existing functional access.
Central venous catheters do have several advantages when compared to arteriovenous fistulae and prosthetic grafts. These include simplicity of insertion, immediate utility, access without needle cannulation, and ease of replacement and removal. For these reasons, tunneled and less-often nontunneled hemodialysis catheters continue to play an important role in renal replacement therapy.
Indications
1. A patient with urgent need of renal replacement therapy who does not have a functional hemodialysis fistula or graft
2. Patients with stage 5 chronic kidney disease (CKD5) who require acute hemodialysis treatment but do not have usable hemodialysis access
a. Long-term (tunneled) catheters should be used in conjunction with a plan for permanent vascular access or peritoneal dialysis catheter placement, while awaiting placement or maturation of an arteriovenous fistula or prosthetic graft.
b. There are few indications for use of a tunneled central venous catheter as a permanent vascular access including patients with cardiac failure who cannot tolerate a left-to-right shunt, upper extremity vascular anomalies or
disease precluding placement of a graft or fistula, and patients with diffuse dermatologic conditions that would complicate surgical placement or recurrent needle cannulation of fistula.
disease precluding placement of a graft or fistula, and patients with diffuse dermatologic conditions that would complicate surgical placement or recurrent needle cannulation of fistula.
c. A tunneled hemodialysis catheter may also be the most appropriate access for patients with a limited lifespan (i.e., malignancy).
3. Patients with a failed arteriovenous fistula or prosthetic graft who are awaiting surgical revision or creation of a new vascular access
4. Patients who have exhausted all surgical options for an arteriovenous fistula or graft placement
5. Patients with a dysfunctional or infected peritoneal dialysis catheter
6. Patients without renal failure who have metabolic disturbances, uncorrectable without hemodialysis, undergoing plasmapheresis, or stem cell harvest
Contraindications
Absolute
1. Sepsis is an absolute contraindication to placement of a tunneled hemodialysis catheter. A nontunneled catheter can be placed temporarily in patients who require hemodialysis.
2. Uncorrectable coagulopathy. A nontunneled catheter placed with ultrasound guidance to minimize punctures and prevent complications may be indicated.
Relative
1. Coagulopathy. Patients with abnormal coagulation parameters or low platelet counts should be appropriately corrected prior to access placement. Uremia also causes platelet dysfunction that can result in bleeding, which may require therapy such as desmopressin acetate (DDAVP) administration.
2. Electrolyte abnormalities. Uremic patients may have hyperkalemia and cardiac irritability, so measurement of serum potassium is recommended for patients with clinical signs or symptoms of acute renal failure. Elevated potassium can induce arrhythmias manifested by peaked T-waves, flattened P-waves, prolonged QRS, and cardiac irritability that render patients susceptible to arrhythmias. All patients with hyperkalemia, particularly acute hyperkalemia should be assessed by electrocardiogram (ECG), and measures should be taken to decrease serum potassium. Interventions include oral Kayexalate (sodium polystyrene sulfonate), intravenous (IV) insulin and glucose, and inhaled albuterol.
3. Orthopnea. Patients with congestive heart failure, pulmonary edema, or sleep apnea may not be able to maintain a supine position during an interventional procedure. Optimization of oxygenation and judicious administration of sedation is required. A lower extremity temporary or tunneled catheter can be considered because patients are not required to be entirely supine in femoral or saphenous vein placement.
Preprocedure Preparation
Basic Considerations
1. A focused assessment of the patient’s current and recent medical history should be performed including:
a. Primary diagnosis and relevant medical history
b. Knowledge of prior central venous access procedures and complications
c. Drug allergies including contrast agents
2. Informed consent should be obtained and documented.
3. Light or moderate sedation is often administered for catheter insertion procedures, and qualified personnel and physiologic monitoring equipment are required. The patient should be fasting (nil per os [NPO]) as per hospital policy for
sedation. Typically, solid food should be restricted for 6 hours and clear liquids for 2 hours prior to the procedure.
sedation. Typically, solid food should be restricted for 6 hours and clear liquids for 2 hours prior to the procedure.
4. Preprocedural laboratory studies include an international normalized ratio (INR) for all patients, an activated partial thromboplastin time (APTT) for patients receiving heparin, and a platelet count only in patients with specific risk factors. Patient’s coagulation profile should be corrected to an INR <1.5 and a platelet count >50,000 per µL. Clopidogrel should be withheld for 5 days before the procedure. An 81-mg aspirin antiplatelet therapy does not require discontinuation.
Exchange or removal of a tunneled hemodialysis catheter is considered low risk for bleeding, and preprocedural coagulation testing should be limited to patients with known bleeding disorders, significant liver disease, and anticoagulated patients (3).
5. Preprocedural administration of systemic antibiotics has not been shown to decrease the incidence of postprocedural catheter-related infections (4).
Selection of Catheter Insertion Site
1. The preferred site for insertion of a tunneled or nontunneled hemodialysis catheter is the right internal jugular vein. If the right internal jugular vein is not usable, then the left internal jugular vein or right external jugular vein should be used.
2. A tunneled catheter should not be inserted on the same side as a maturing hemodialysis fistula or graft. Use the contralateral jugular vein for catheter insertion.
3. Avoid use of the subclavian (sole venous outflow of ipsilateral upper extremity) vein due to risk of central venous stenosis and thrombosis. The subclavian vein should only be used when surgical options in the ipsilateral upper extremity have been exhausted.
4. Femoral vein catheters
a. Catheters inserted into the femoral vein have a higher incidence of infection and shorter patency times (5).
b. Placement of a nontunneled hemodialysis catheter into the femoral vein limits mobility and should only be used for bed-bound patients.
c. Due to the risk of iliac vein stenosis, the femoral vein should only be used after thoughtful discussion with transplant surgery.
Evaluation of Catheter Insertion Site
1. The neck, chest wall, and shoulder region should be examined for:
a. Skin conditions or scars that may interfere with catheter insertion or creation of a subcutaneous tunnel
b. Presence of superficial collateral veins indicative of central venous obstruction
c. Presence of an implanted transvenous pacemaker or cardioverter-defibrillator devices
2. The location and patency of the access vein should be evaluated with ultrasound prior to draping the patient. Images should be recorded to satisfy compliance requirements.
Selection of a Hemodialysis Catheter
1. Criteria for selecting a hemodialysis catheter
a. Duration of use: Nontunneled hemodialysis catheters are for short-term use (<1 week). They rarely may be appropriate in patients not stable enough to undergo sedation or any prolonged medical procedure. A tunneled (cuffed) hemodialysis catheter should be used when the anticipated duration of hemodialysis treatment is >1 week.
b. Catheter performance: Numerous publications have reported the performance characteristics of various designs and features of hemodialysis catheters, but the majority of catheters provide equivalent rates of blood flow.
There is currently no proven advantage of one catheter design over another. Catheter choice should be based on local experience, goals for use, and cost.
There is currently no proven advantage of one catheter design over another. Catheter choice should be based on local experience, goals for use, and cost.
The NKF-KDOQI guidelines recommend the use of tunneled catheters that can sustain a blood flow rate of >350 mL per minute. Longer catheters (i.e., femoral) have increased resistance to blood flow but a rate of 300 mL per minute should be achievable, although not all patients require these flow rates for adequate hemodialysis treatment (6).
c. Catheter length: The distal tip of a hemodialysis catheter should not be cut or trimmed. Hemodialysis catheters are available in several standard lengths, and correct catheter length is determined by patient size and the site of insertion. Depending on the manufacturer, the length of the catheter may be measured from tip to cuff or from tip to hub. Rigid nontunneled catheters should have the distal tip positioned at the junction of the superior vena cava and right atrium. Soft tunneled catheters can be positioned with the catheter tip in the right atrium. Femoral catheters should be positioned with the catheter tip in the inferior vena cava (IVC), cephalad to the confluence of the common iliac veins.
