Form Of Vascular Access Research Articles

Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children.

Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The 'Fistula First' initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a 'Catheter First' to 'Catheter Last' approach. In this review, recent evidence is summarized in order to promote change in current practices.

2102. Peripherally Inserted Central Catheter (PICC) Placement: Indications and Financial Impact

BackgroundAlthough PICCs are important for venous access, they pose risk of infection, venous thrombosis, and are costlier relative to other forms of vascular access. We conducted a preliminary quality improvement study to assess the indications for PICC placement at our institution and also to evaluate the associated healthcare cost.MethodsWe obtained data on all PICCs placed by the vascular access team over a representative 2-month period (November and December 2017) at Allegheny General Hospital. Indications entered during order entry for PICC placement were collected. Additionally, charts of all central line-associated blood stream infections (CLABSI) in 2017 were reviewed to determine the number of events where PICC may have been implicated. We calculated the cost incurred for PICC placement and that for treating infection in PICC-associated CLABSI. The cost of each PICC insertion is about $4,700 and that of each CLABSI approximates $25,000.ResultsA total of 451 PICCs were inserted over the 2-month period. Documented indications for PICC insertion included: “poor venous access” (128, 28.3%), “receiving high-risk drugs” (91, 20%), “requires multiple simultaneous IV infusions” (84, 18.6%), “needed upon discharge for long-term use” (63, 13.9%), and “receiving vasopressors, total parental nutrition or chemotherapy” (61, 13.6%). There was no indication described for 23 PICC orders (5.2%). Twenty-five CLABSI were encountered in 2017; 10 of them were PICC associated. Of those, PICC was not absolutely indicated in two patients based on chart review (with cost burden of about $65,000 in these two instances).ConclusionPoor venous access and multiple IV infusions are not absolute indications for PICC insertion in most circumstances. In our study, this amounted to nearly half (212/451) of the indications for PICC placement. Our hospital could have potentially saved a million dollars in the 2-month study period if PICCs were not placed for these indications. Given the costs and risks associated with PICC use, alternative venous access devices should be strongly considered. By rigorously reevaluating indications for PICC use we may improve both patient outcomes and reduce healthcare costs.Disclosures All authors: No reported disclosures.

How to use… Imaging for umbilical venous catheter placement

It is 03:00 and you are staring at the X-ray of an umbilical venous catheter (UVC) you inserted earlier in the shift. The nursing team want to know if they can start to use the line. Is it safe? Does it need adjustment? Can you start total parenteral nutrition (TPN)? What about inotropes? This article aims to equip you with the ability to answer these questions using an understanding of the relevant anatomy and which UVC positions on X-ray are most likely to cause harm. UVCs are commonly used to administer: drugs, fluid and blood products, TPN, hypertonic fluid (concentrations of glucose solution above 12.5% in hypoglycaemic infants needing fluid restriction, for instance) or for exchange transfusion in the early neonatal period. There are various formulae that are employed to determine how far UVCs should be inserted.1 2 The distance from the base of the umbilical stump to the xiphisternum, adding the length of the umbilical stump, works as an acceptable approximation for emergency insertion. UVCs can sometimes be inserted some days after birth when deemed essential, but as the umbilical stump dries the procedure becomes increasingly difficult. As for any form of indwelling central vascular access, UVCs are subject to complications such as infection and thrombus formation. Butler-O’Hara et al ’s prospective study in infants with birth weights below 1251 g found that the overall rate of UVC-related infection was 17% and thrombus formation was 11%.3 Again, in common with other forms of vascular access, the risk of line-related infection may be limited by strict adherence to insertion protocols and minimising the length of time that the UVC is left in place.3 4 Specific problems relating to different catheter tip positions are listed in table 1. Of particular note, if UVCs with tips in the liver …

Assessment of left ventricular mass changes after arteriovenous fistula surgical banding in end-stage renal disease.

Left ventricular hypertrophy (LVH) is a multifactorial complication frequently seen in patients with advanced chronic kidney disease. An arteriovenous fistula (AVF) is the preferred method for hemodialysis access. Once functional, AVFs demonstrate better patency rates and fewer complications when compared to other forms of vascular access. AVFs have been implicated in cardiac remodeling, but it is controversial whether those changes can be reversed by surgical ligation or blood flow reduction. In this study, we describe a cohort of asymptomatic patients with LVH who underwent AVF banding with a two-dimensional-echocardiogram done before and after the intervention to evaluate the association between AVF surgical banding and left ventricular mass (LVM) changes. Our results show that AVF surgical banding did not alter the left ventricular mass index (LVMI) with a mean prebanding LVMI of 70.3 ± 57.5 g/m2 and mean postbanding LVMI of 81.9 ± 55.9 g/m2, (P = 0.4). Our study shows that AVF flow reduction by surgical banding did not alter LVMI, and therefore LVH, in end-stage renal disease patients who have not yet shown clinical manifestations of cardiac disease.

Preoperative vascular access evaluation for haemodialysis patients.

Haemodialysis treatment requires reliable vascular access. Optimal access is provided via functional arteriovenous fistula (fistula), which compared with other forms of vascular access, provides superior long-term patency, requires few interventions, has low thrombosis and infection rates and cost. However, it has been estimated that between 20% and 60% of fistulas never mature sufficiently to enable haemodialysis treatment. Mapping blood vessels using imaging technologies before surgery may identify vessels that are most suitable for fistula creation. We compared the effect of conducting routine radiological imaging evaluation for vascular access creation preoperatively with standard care without routine preoperative vessel imaging on fistula creation and use. We searched Cochrane Kidney and Transplant's Specialised Register to 14 April 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We included randomised controlled trials (RCTs) that enrolled adult participants (aged ≥ 18 years) with chronic or end-stage kidney disease (ESKD) who needed fistulas (both before dialysis and after dialysis initiation) that compared fistula maturation rates relating to use of imaging technologies to map blood vessels before fistula surgery with standard care (no imaging). Two authors assessed study quality and extracted data. Dichotomous outcomes, including fistula creation, maturation and need for catheters at dialysis initiation, were expressed as risk ratios (RR) with 95% confidence intervals (CI). Continuous outcomes, such as numbers of interventions required to maintain patency, were expressed as mean differences (MD). We used the random-effects model to measure mean effects. Four studies enrolling 450 participants met our inclusion criteria. Overall risk of bias was judged to be low in one study, unclear in two, and high in one.There was no significant differences in the number of fistulas that were successfully created (4 studies, 433 patients: RR 1.06, 95% CI 0.95 to 1.28; I² = 76%); the number of fistulas that matured at six months (3 studies, 356 participants: RR 1.11, 95% CI 0.98 to 1.25; I² = 0%); number of fistulas that were used successfully for dialysis (2 studies, 286 participants: RR 1.12, 95% CI 0.99 to 1.28; I² = 0%); the number of patients initiating dialysis with a catheter (1 study, 214 patients: RR 0.66, 95% CI 0.42 to 1.04); and in the rate of interventions required to maintain patency (1 study, 70 patients: MD 14.70 interventions/1000 patient-days, 95% CI -7.51 to 36.91) between the use of preoperative imaging technologies compared with standard care (no imaging). Based on four small studies, preoperative vessel imaging did not improve fistula outcomes compared with standard care. Adequately powered prospective studies are required to fully answer this question.

"You know your own fistula, it becomes a part of you"--Patient perspectives on vascular access: A semistructured interview study.

The success of hemodialysis depends on functional vascular access but such an invasive, semipermanent intervention can be confronting for patients. Vascular access complications are potentially life threatening and reduce treatment satisfaction and quality of life. This study aims to describe patient perspectives on vascular access. Face-to-face, semistructured interviews were conducted with 26 adult patients receiving hemodialysis with any form of vascular access at two dialysis units in Australia. The transcripts were analyzed using thematic analysis. We identified five major themes describing patient perspectives on vascular access: developing mental fortitude for access (accepting necessity for survival, self-advocacy, experiential confidence and competency, dependency on others, gaining vascular knowledge), device intrusiveness on the body (restricting normal function, finding compensatory solutions, bodily invasion, confronting appearance), inhibiting pain (aversion to surgery, persisting needle anxieties), exposure to dire health consequences (resigning to inevitable failure, anticipating serious complications, technological skepticism, wary of medical incompetence), and imposing burdens (generating additional expenses, encumbering family members). Patients with a vascular access rely on a precarious lifeline, which is confronting, intrusive, and burdensome. Some develop mental resilience to cope with the pain and invasiveness of vascular access. The results suggest that more attention to address needle anxieties, self-advocacy, lifestyle disruption, fear of complications, and concern for caregiver burden may improve treatment satisfaction and outcomes for patients on hemodialysis.

Intraosseous Samples Can Be Used for Creatinine Measurements - An Experimental Study in the Anaesthetised Pig

Intraosseous (IO) access is a valuable tool in prehospital locations and in emergency departments when other forms of vascular access are unavailable. Creatinine is often used for dose adjustment of drugs that may be administered through intraosseous cannulae. We aimed to study the possibility of analysing creatinine in intraosseous samples and study the accuracy and precision of such measurements. Eight pigs with endotoxin induced septic shock were sampled hourly for six hours and analysed for plasma creatinine. Samples were collected from arterial, venous, and IO cannulae. There was an increase in creatinine values during the later part of the experiment. The coefficients of variation between the three sampling sites were less than 10% at all sampling times. Based on our findings intraosseous samples can be used for creatinine determination in emergency settings.

Chronic hemodialysis in children weighing less than 10 kg

Hemodialysis (HD) in infants is usually used when peritoneal dialysis (PD) has failed. We describe our experience with HD, outlining the morbidity, complications, and outcomes for infants weighing less than 10kg managed with HD for more than 6months over a 10-year period. A retrospective review of the clinical notes was conducted to collect demographic information, anthropometric data, dietary history, site and form of vascular access, details of HD prescription, complications, and outcomes. Nine patients weighing less than 10kg were hemodialyzed for more than 6months. Median age at commencement was 9months. Median weight and height standard deviation score (SDS) at commencement of HD were -2.14 and -0.61, respectively, and at the end they were -1.56 and -1.61. Median energy intake was 96.6kcal/kg/day and protein intake was 1.66g/kg/day. Median number of line revisions was 0.32 line changes/patient year. Median central venous catheter (CVC) longevity was 13months. Mean rate of line infection was 0.14/patient year. Median time on HD was 27months. Median age at transplantation was 3.4years. This case series shows that chronic HD is a viable management option in children <10kg. Access issues can be minimized with good line care to maximize line longevity and minimize line infection rates.

Intraosseous samples can be used for opioid measurements – An experimental study in the anaesthetized pig

Aim. The intraosseous route provides access to the systemic circulation in an emergency situation when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. The intraosseous access has also been used for collecting samples for laboratory testing. A question that may arise in an unconscious or severely exhausted patient is whether this condition is caused by an unknown drug. We aimed to evaluate whether intraosseous samples could be used to measure opioids and to study the accuracy and precision of such measurements. Methods. Five healthy, anaesthetized pigs were treated with a continuous morphine infusion as part of the anaesthesia procedure. Samples for morphine testing were collected hourly for 6 h from two tibial intraosseous cannulae and a central venous catheter. Results. The differences in morphine concentrations between the two tibial intraosseous cannulae were less than 10% in 32/33 times. The values were also relatively stable over time. Conclusion. Our findings suggest that intraosseous samples can be used for the analysis of opioids if an IV route is not available.

Analysis of intraosseous samples using point of care technology—An experimental study in the anaesthetised pig

BackgroundIntraosseous access is an essential method in emergency medicine when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. A number of publications have discussed the suitability of using intraosseous access for laboratory testing. We aimed to further evaluate this issue and to study the accuracy and precision of intraosseous measurements. MethodsFive healthy, anaesthetised pigs were instrumented with bilateral tibial intraosseous cannulae and an arterial catheter. Samples were collected hourly for 6h and analysed for blood gases, acid base status, haemoglobin and electrolytes using an I-Stat® point of care analyser. ResultsThere was no clinically relevant difference between results from left and right intraosseous sites. The variability of the intraosseous sample values, measured as the coefficient of variance (CV), was maximally 11%, and smaller than for the arterial sample values for all variables except SO2. For most variables, there seems to be some degree of systematic difference between intraosseous and arterial results. However, the direction of this difference seems to be predictable. ConclusionBased on our findings in this animal model, cartridge based point of care instruments appear suitable for the analysis of intraosseous samples. The agreement between intraosseous and arterial analysis seems to be good enough for the method to be clinically useful. The precision, quantified in terms of CV, is at least as good for intraosseous as for arterial analysis. There is no clinically important difference between samples from left and right tibia, indicating a good reproducibility.

Guided Reflection 2nd Edition

This is the 2nd edition of Guided Reflection: A Narrative Approach to Advancing Professional Practice and when one sees the list of three other books on this subject by the editor one wonders how much meat there is left on the bone of reflection. This edition has expanded the themes to include art and performance and the latter is significant as unfortunately the narrative seems to play to the crowds far too much. Reflection or reflective practice as it is usually known can be a useful tool for some to help improve their care through insight into their actions, but books such as this have developed it beyond all recognition and usefulness to a point where it is of debatable benefit. The book itself is not well structured and uninspiring to read with long sections of text and far too much self referencing. There are neither counter-arguments to the techniques described nor description of their suitability in specific situations. I cannot recommend this book as useful and would suggest those looking for a reference book on reflective practice would be better off with something more practical. This edition of the Journal of Renal Nursing focuses on infection control, an area of increasing concern over the past few years. Hospital acquired infections (HAI) are a significant burden to the patient and society as a whole. As many as 10% of people will contract an HAI during their hospital stay, which often leads to an increased risk of complications and higher mortality rates. In addition, evidence from the National Audit Office suggest they cost the NHS in the region of £1 billion. In our specialist renal field, the risk of infection is particularly high due to the necessity for various forms of vascular access. Dialysis catheters are associated with the highest rates of infection and poor outcomes, and should be avoided for longterm treatment where possible. However, while the renal community recommends all patients have dialysis via some sort of native fistula or graft, there is a group of patients for whom this is just not possible or acceptable. It is this group of patients who we need to be particularly careful with to avoid any infections. Books such as these provide the clinical knowledge and evidence we should use in our daily practice. The real benefit of this book is its detail. There are chapters on all major infections and antibiotic treatments. Some chapters are likely to be used more often than others such as that on the recognition and treatment of intravascular catheter (IVC)-related infections. It describes in detail the different types of IVC infections such as exit or tunnel site, phlebitis or catheter colonization and suggests the most appropriate treatment. Recommendations are based on the latest evidence and there are useful statistics on the epidemiology of IVC related HAIs. Other useful chapters describe the potential infection problems associated with transplantation, the use of universal infection control precautions and barrier nursing, and an interesting chapter on hand washing. At first glance hand washing may not appear to be the most interesting subject, but there is much more to it than most would imagine, with a multitude of different organisms that require specific eradication techniques. This excellent book provides everything the renal nurse needs to prevent, diagnose and treat infections, and should be available on all renal wards, dialysis units and outpatient areas. Oxford Handbook of Infectious Diseases and Microbiology

Oxford Handbook of Infectious Diseases and Microbiology

Journal of Renal NursingVol. 3, No. 5 Book ReviewsOxford Handbook of Infectious Diseases and MicrobiologyChris JonesChris JonesSearch for more papers by this authorChris JonesPublished Online:29 Sep 2013https://doi.org/10.12968/jorn.2011.3.5.255AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 1 September 2011Volume 3Issue 5ISSN (print): 2041-1448ISSN (online): 2052-2894 Metrics History Published online 29 September 2013 Published in print 1 September 2011 Information© MA Healthcare LimitedPDF download

The D&amp;T Report

The D&amp;T Report

Association of Advanced Glycoxidation End Products and Inflammation Markers with Thrombosis of Arteriovenous Grafts in Hemodialysis Patients

Background/Aims: Intimal hyperplasia at the venous anastomosis of arteriovenous dialysis grafts (AVGs) is a common and costly complication in hemodialysis (HD) patients. Previous studies have shown significant accumulation of advanced glycation end products (AGEs) within the lesions, suggesting a pathogenic role for these compounds in this condition. Methods: We retrospectively analyzed data from 139 HD patients, including 58 subjects with AVGs, to determine any relationship between serum AGEs and other circulating markers, e.g. C-reactive protein (CRP), tumor necrosis factor (TNF-α), vascular cell adhesion molecule-1 (VCAM-1), plasminogen activator inhibitor type 1 and vascular endothelial growth factor, with the presence of graft thrombosis, an index of venous intimal hyperplasia. Results: Patients with previously thrombosed AVGs exhibited significantly higher levels of serum AGEs (42 ± 18 vs. 28± 8 U/ml), CRP (1.4 ± 1.1 vs. 0.6 ± 0.4 mg/dl) and VCAM-1 (3,172 ± 696 vs. 2,447 ± 1,101 ng/ml) than those with uncomplicated AVGs, variances that were mostly attributed to diabetes difference. There was no difference regarding the levels of the parameters studied between patients with AVGs and other forms of vascular access. Conclusions: These results support an association between circulating AGEs, markers of inflammation and endothelial function and intimal hyperplasia at the venous anastomosis of AVGs in HD patients. The implication is that there may be a therapeutic role for anti-AGE interventions in the management of this common clinical condition.

Outcome of Autogenous Fistula Construction in Hemodialyzed Patients Over 75 Years of Age

Background: There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age. Methods: The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 ± 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed. Results: The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 ± 4.3% (± SE) at 1 month; 70 ± 4.7% at 6 months; 59 ± 4.9% at 1 year; 59 ± 4.9% at 2 years; 59± 4.9% at 3 years; 59 ± 4.9% at 4 years, and 58 ± 4.9% at 5 years. The secondary patency rates were: 95 ± 2.0; 92 ± 2.2; 84 ± 3.3; 79 ± 4.0; 72 ± 4.3; 71 ± 4.4, and 69 ± 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques. Conclusions: By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.

Central Venous Catheter Access in Children on HD

Central venous catheters (CVC) remain a frequently used form of vascular access in children receiving chronic hemodialysis (HD). Whereas standard dual‐lumen catheters (DL) are used in many centers, the Tesio catheter has proven to be superior to the DL catheter in terms of catheter survival and infection rates in at least one pediatric study (Sheth RD et al. Am J Kidney Dis. 2001). Recently, the Ash Split catheter became available which, while similar to the Tesio internally, being comprised of 2 separate catheters, may be preferable because of the requirement for only one skin puncture for placement vs. two for the Tesio. However, no pediatric data pertaining to the Ash Split catheter have been published to date. Therefore, we reviewed and compared our experience with a small number of Ash Split (# 16) and Tesio (# 8) catheters used for semipermanent vascular access in our chronic HD population with reference to survival, infectious complications, patency, and dialysis adequacy. The results of this experience are as follows: Tesio Ash Split Survival &gt;3 months 6/8 12/15 Sepsis (epi/catheter mo) 1/30 1/25 Exit‐site infection (epi/catheter mo) 1/8.6 1/19 sp Kt/V urea 1.67 1.88 % sp Kt/V urea &gt;1.2 100 90 Reasons for the removal of Tesio catheters were transplant (4), sepsis (1), deterioration of tubing (1), and accidental (1). Ash Split catheter removal resulted from sepsis (2), fistula placement (4), thrombosis (1), and accidental (2). This preliminary experience reveals similar outcome data for the Tesio and Ash Split catheters when used in pediatric HD patients. Definitive statements regarding the superiority of either catheter awaits additional data collection and analysis.

Using Cuffed and Tunnelled Central Venous Catheters as Permanent Vascular Access for Hemodialysis: A Prospective Study

Background. Adequate care of a hemodialysis patient requires constant attention to the need to maintain vascular access (VA) patency. VA complications are the main cause of hospitalization in hemodialysis patients. The native arteriovenous fistula (NAVF), synthetic arteriovenous grafts fistula (GAVF) and silastic cuffed central venous catheters (CVCs) are used for permanent vascular access (PVA). CVCs are primary the method of choice for temporary access. But using this access modality is increasing more and more for PVA in elderly hemodialysis patients and when other PVA is not possible. The primary aim of this study is to investigate survivals and complications of the CVCs used for long-term VA. Methods. We prospectively looked at 92 CVCs (Medcomp Ash Split Cath, 14 FR × 28 cm (Little, M.A.; O'Riordan, A.; Lucey, B.; Farrell, M.; Lee, M.; Conlon, P.J.; Walshe, J.J. A prospective study of complications associated with cuffed, tunnelled hemodialysis catheters. Nephrol. Dial. Transplant. 2001, 16 (11), 2194–2200) with Dacron cuff) inserted in 85 (50 females, 35 males) chronic hemodialysis patients (the mean age: 56.6 ± 14.1 years) from 07 1999 to 01 2002. The overall survival and complications were followed up. Furthermore, the patients were evaluated for demographic and clinical characteristics. Data were analysed by chi-square, Wilcoxon rank and Kaplan–Meier survival tests. Results. The median duration of CVC survival was 289 days (range: 10–720). Eleven (11.9%) CVCs were removed due to complications. In 79 (92.9%) patients, 1, in 5 (5.8%) patients, 2 and in 1 patient, 3 CVCs were inserted. Of the 85 patients, 56 have CVCs functioning. In addition, 27 (31.76%) patients have CVCs functioning for over 12 months, 17 (20%) patients have CVCs functioning for 6 months. The total incidence of CVC related infections was 0.82 episodes/1000 catheter days. Besides, thrombosis was occurred in 10 (10.8%) CVCs. The most frequent indications for CVC removal were patient death (69.4%), thrombosis (16.6%) and CVC-related infections (13.8%). Conclusions. CVCs are primarily used for temporary access. But this study indicates that CVC may be a very useful alternative permanent vascular access for hemodialysis patients when other forms of vascular access are not available.

Transhepatic PermCath for Hemodialysis

The establishment and maintenance of a reliable vascular access continues to be a problem in hemodialysis. We report a patient with end-stage lupus nephritis who had no alternative for vascular access and failed peritoneal dialysis. A vascular access device (PermCath, Quinton Instrument Co, Bothell, WA) was inserted using a transhepatic approach. There were no bleeding or thrombotic complications. The catheter was replaced once through the same track due to poor blood flow and reinserted once after 5 days due to infection. The patient has been doing well and receiving adequate dialytic therapy for over 1 year with this form of vascular access.

Intraosseous infusion — Emergency resuscitation in children

ABSTRACT: Intraosseous infusion provides a relatively safe, simple, rapid and therapeutically successful technique for the provision of fluids, blood, and parenteral medications to critically ill children. The article describes the history, physiology, technique, success and incidence of complications. This form of vascular access has particular application for paediatric resuscitation in rural Australia.

Repeated low–dose streptokinase infusions into occluded permanent, central–venous hemodialysis catheters

Several studies have reported the use of fibrinolytic therapy to re-establish the patency of arterio-venous shunts and fistulas in patients undergoing chronic maintenance hemodialysis [1–7]. In recent years the indwelling Hickman central–venous catheter has been employed as a temporary or permanent access device in patients when more conventional access becomes impossible or when immediate needs for dialysis preclude other alternatives [8]. As with other forms of vascular access, thrombosis and infection remain common problems with these newer devices [9–13].