Nontunneled Dialysis Catheters Research Articles

Development and Implementation of a Novel Emergency Department Based Procedure Team for Inpatient Hospital Procedures

BackgroundEmergency medicine (EM) demands proficiency in a broad set of procedural skills for emergency physicians (EPs). However, there is a literature gap on integrating EM expertise into procedure teams, especially in inpatient settings ObjectivesThis study aims to outline the development and implementation of a novel ED-based procedure team for inpatient care MethodsThis retrospective study conducted between June 6, 2022 and December 31, 2023, describes the development and implementation of an ED-based procedure team. Key procedures included central lines, arterial lines, and non-tunneled dialysis catheters, with specific guidelines to ensure safety and consistency ResultsDuring the study, the procedure team conducted 525 procedures. Midline insertions and paracentesis were the most common. The team performed an average of 27.3 procedures per month. Additional provider hours needed to complete the procedures averaged 4.8 per month and showed a trend toward stabilization over time. Financially, the team secured reimbursements for 516 cases at $98 per case, observing a positive trend in gross payments ConclusionsThe ED Procedure team has played a pivotal role in delivering essential bedside procedures for the patient, demonstrating improvements in provider proficiency, resident training, and favorable revenue outcomes. The interdepartmental collaborative and well-coordinated efforts have ensured the timely completion of necessary procedures.

Infectious Recidivism in Tunneled Dialysis Catheters Removed for Bloodstream Infection in the Intensive Care Unit

PurposeTo determine the rate of recurrent infection of ICU patients who underwent tunneled dialysis catheter (TDC) exchange or removal for bloodstream infection. Materials and MethodsForty seven patients, with a total of 61 TDCs removed for bloodstream infection while admitted in an ICU from 2017–2020, were identified. TDCs were exchanged over a wire or removed and replaced. Thirteen patients (21%) were managed with non-tunneled dialysis catheters (NTDCs) until delayed TDC replacement at ICU departure. Forty seven TDCs were removed for bacteremia (77%), 13 for fungemia (21%), and 1 for both (2%). Thirty TDCs (49%) were exchanged over-the-wire (ICU-exchanged TDCs), and 31 (51%) were removed. Of the patients who underwent TDC removal, 9 had a new TDC placed while still admitted in the ICU (ICU-replaced TDCs), and 7 underwent delayed TDC replacement at ICU departure. Data regarding infection, removal technique, catheter replacement, and patient outcomes were analyzed. ResultsThere were 10 instances of recurrent bloodstream infection (infectious recidivism), occurring in 7 ICU-exchanged TDCs (7/30, 23%) and 3 ICU-replaced TDCs (3/9, 33%). Bloodstream infection complicated 22% of NTDCs used in patients undergoing delayed TDC replacement. No cases of TDC infectious recidivism were observed in patients who underwent delayed TDC replacement (0/7, 0%) after ICU departure. ConclusionsHigh rates of infectious recidivism exist in the ICU, meriting further investigation into how to optimally manage these patients. In those in whom TDCs are removed, withholding TDC replacement until ICU departure may help to minimize the rate of recurrent infection.

Bedside Tunneled Hemodialysis Catheter Placement in Patients with COVID-19

BackgroundCOVID-19, the syndrome caused by the novel SARS-CoV2, is associated with high rates of acute kidney injury requiring renal replacement therapy (RRT). It is well known that despite the ease of bedside insertion, the use of nontunneled dialysis catheters (NTDCs) is associated with increased complications compared to tunneled dialysis catheters (TDCs). Our objective was to develop a strategy for TDC placement at the bedside to provide effective dialysis access, conserve resources and decrease personnel exposure at our medical center in an epicenter of the COVID-19 pandemic.MethodsA technique for bedside TDC insertion with ultrasound and plain radiographs in the intensive care unit was developed. Test or clinically COVID-19-positive patients requiring RRT were evaluated for bedside emergent NTDC or nonemergent TDC placement. Patients who underwent NTDC placement were monitored for ongoing RRT needs and were converted to TDC at the bedside after 3–5 days. We prospectively collected patient data focusing on complications and mortality.ResultsOf the 36 consultations for dialysis access in COVID-positive patients from March 19 through June 5, 2020, a total of 24 bedside TDCs were placed. Only one patient developed a complication, which was pneumothorax and cardiac tamponade during line placement. In-hospital mortality in the cohort was 63.9%.ConclusionsBedside TDC placement has served to conserve resources, prevent complications with transport to and from the operating room, and decrease personnel exposure during the COVID-19 pandemic. This strategy warrants further consideration and could be used in critically ill patients regardless of COVID status.

Outcomes of tunneled and nontunneled internal jugular catheters for hemodialysis at Zenith Medical and Kidney centre, Nigeria

Objectives: Tunneled and nontunneled jugular access routes are the most widely used routes for hemodialysis (HD) in developing countries. This study was a retrospective review of the utility, safety, and outcomes of both tunneled and nontunneled curved internal jugular catheter use in patients with end-stage renal disease (ESRD) in Zenith Medical and Kidney Centre, Abuja, Nigeria. Materials and Methods: This is a retrospective study of 100 ESRD patients on maintenance HD at the center between June 2019 and December 2019. All patients on maintenance dialysis with tunneled and nontunneled curved internal jugular catheter were observed for immediate and short-term complications associated with the catheter. Results: Among the patients, 90 (90.0%) had tunneled dialysis catheters placement and dialyzed with it, while 10 (10%) patients had nontunneled dialysis catheters use. While 90 (90%) of the patients with the dialysis catheters developed no complications, ten (10%) patients had catheter-related complications either during catheter insertion or while it was being used for dialysis. The most common in this study was reactionary hemorrhage which occurred in 5% of the patients evaluated. Ten (10%) of the patients with catheter placement required ultrasonic guidance. No death was recorded during catheter placement. Conclusion: Internal jugular tunneled and Non tunneled dialysis catheters (NTDCs) are safe with good outcomes among our ESRD patients.

Efficacy of Using Non-tunneled Dialysis Catheters During Arteriovenous Fistula till its Maturation: A Retrospective Study.

Due to high prevalence of diabetes mellitus and subsequent nephropathy, the need for access to start and continue dialysis has been increased. In this study, we aim to study the efficacy and complications of non-tunneled catheters (NTC) till fistula maturation because of being easy and cheap implementation as well as similar complications compared to tunneled catheters (TC). In this retrospective observational study, 247 patients with first-time AVF creation referred to Vascular Surgery Centre of Mashhad University of Medical Sciences, Iran, were recruited since March 2016 to December 2017. Only 153 patients who have completed the study, and were monitored every two weeks in case of un-maturation along with the status of temporary catheters. Mean age of patients was 49.9 ± 7.74 years, and 75 (49%) were females, which was comparable with literature. Preference of NTC implementation was at right jugular because of the easy access to central vein and less chance of complications. Catheter location was at right internal jugular in 61.4% of the patients. Out of 24 femoral cases, 18 was done at femoral. AVF location was done at left/right cubital in most cases (52.3%). The rate of infection was 15.0%, which was less than NTC's infections reported in the literature. Use of non-tunneled catheter in the form of outpatient in the period of AVF maturation time is recommendeddue to similar complication rate.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting.

Introduction:Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population.Methods:In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done.Results:The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock.Conclusions:The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

Catheter related blood Stream Infection (CRBSI) Associated with Hemodialysis non-Tunneled Dialysis catheters in Tertiary care Hospital—A Preliminary Study

Catheter related blood Stream Infection (CRBSI) Associated with Hemodialysis non-Tunneled Dialysis catheters in Tertiary care Hospital—A Preliminary Study

Non-tunneled versus tunneled dialysis catheters for acute kidney injury requiring renal replacement therapy: a prospective cohort study

BackgroundAcute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high morbidity, mortality and resource utilization. The type of vascular access placed for AKI-RRT is an important decision, for which there is a lack of evidence-based guidelines.MethodsWe conducted a prospective cohort study over a 16-month period with 154 patients initiated on AKI-RRT via either a non-tunneled dialysis catheter (NTDC) or a tunneled dialysis catheter (TDC) at an academic hospital. We compared differences in renal replacement delivery and mechanical and infectious outcomes between NTDCs and TDCs.ResultsPatients who received TDCs had significantly better RRT delivery, both with continuous venovenous hemofiltration (CVVH) and intermittent hemodialysis (IHD), compared to patients who received NTDCs; these findings were confirmed after multivariable adjustment for AKI-specific disease severity score, history of chronic kidney disease, renal consult team, and AKI cause. In CVVH and IHD, the median venous and arterial blood flow pressures were significantly higher with TDCs compared to NTDCs (p < 0.001). Additionally for CVVH, the median number of interruptions per catheter was higher with NTDCs compared to TDCs (Rate Ratio (RR) 2.7; p < 0.001), and for IHD, a higher median blood flow was seen with TDCs (p < 0.001). There were a significantly higher number of mechanical complications with NTDCs (RR 13.6 p = 0.001). No significant difference was observed between TDCs and NTDCs for positive blood cultures per catheter.ConclusionsCompared to NTDCs, TDCs for patients with AKI-RRT had improved RRT delivery and fewer mechanical complications. Initial TDC placement for AKI-RRT should be considered when not clinically contraindicated given the potential for improved RRT delivery and outcomes.

Cardiac Assist Devices and Hemodialysis Catheter Procedures - What Do the Nephrologists Need to Know?

The use of ventricular assist devices (VAD) and total artificial heart (TAH) is increasing rapidly, and a large proportion of these device recipients already have or will develop severe renal dysfunction at the time of device implantation. As a consequence, nephrologists are becoming more and more involved in the care of this challenging population. As nephrologists take upon themselves many aspects of dialysis vascular access care, they need to be familiar with the special circumstances of performing hemodialysis catheter procedures in these patients. This review describes the important characteristics of these devices that have serious implications for the technique of placing or replacing dialysis catheters. These implications apply for both tunneled and nontunneled dialysis catheters and so concern all nephrologists, not only the interventionalists. We describe the important anatomical factors, anticoagulation management, device management, vascular access management and technical considerations of placing or replacing tunneled and nontunneled hemodialysis catheters from the perspective of a nephrologist establishing and maintaining lifesaving dialysis vascular access. Without a good understanding of these devices, serious consequences such as VAD rotor damage or blockage, or artificial heart valve blockage or damage can occur. These artificial devices are lifesaving, and any such complication is unacceptable. This review describes steps to minimize the risks.

Ethanol Locks Do Not Prevent Infection in Temporary Dialysis Catheters

Patients in the intensive care unit (ICU) frequently require hemodialysis through temporary, nontunneled dialysis catheters (DCs), which present a high risk for infection. Studies have suggested that filling the catheter lumen with antimicrobials when the catheter is not in use (i.e., an antimicrobial lock) reduces infection risk; however, when repeated several times, this practice may promote colonization with resistant microorganisms. Ethanol, …

Abstract No. 323 - Evaluation of catheter infection rates in patient after conversion of temporary to tunneled dialysis catheters versus de novo placement

Purpose Prior studies have reported infection rates of converting non tunneled dialysis catheters (NTDC) to tunneled dialysis catheters (TDC) vs. de novo placement of TDCs while using povidone-iodine as the sterilization agent. Chlorhexidine, as per the CDC guidelines, has been exclusively used as our sterilizing agent since 2005. Therefore, our study aims to determine whether there is a difference in infection rates between conversion and de novo placement when utilizing chlorhexidine. Materials and Methods A retrospective analysis of adult patients was performed evaluating a cohort of patients who underwent placement of a NTDC which was subsequently converted to a TDC and a second cohort who underwent de novo TDC placement from 1/1/2009 to 8/10/2012. To assess the rate of infection, the following data points were collected: date of procedure(s), indication, outcomes, site of catheter insertion, lab values pre and post procedure, imaging, complications, infection rates within the life of the initially placed catheter, length of catheter use before exchange (catheter days) and survival. Catheter-related infections were defined as any patient with an indwelling catheter that had positive blood cultures, positive tip cultures, or documented pus at the insertion site of the catheter. Results The conversion cohort was composed of 205 patients, 141 of which were lost to follow-up, leaving 64 patients within this group. (A majority of our patients receive dialysis at outside facilities, which accounts for the high number of patients lost to follow-up.) The de novo cohort included 60 randomly selected patients. Of the 64 patients who underwent conversion, 24 developed a catheter related infection, with a calculated infection rate of .27 events per 100 catheter days. Of the 60 de novo catheter events, 19 developed infection with a calculated infection rate of .26 events per 100 catheters days. Conclusion In this series, there is no difference in infection rates between conversion of NTDCs to TDCs vs. de novo TDC placement when utilizing chlorhexidine as the sterilzation agent. However, these infection rates are superior to those reported when using povidone-iodine.

Catheter Outcomes in the Short‐term Inpatient Setting: A Controlled Quality Improvement Study Comparing Citrate and Heparin Lock

Heparin and citrate are used as catheter lock solutions to reduce risk of catheter dysfunction and infection in hemodialysis. There is a paucity of data comparing these two locks in the short-term, inpatient setting. We compared the efficacy of 2.2% acid citrate dextrose (ACD) versus 5000 U/ml heparin as catheter lock in the inpatient setting. The study was conducted at two sites within our system, with ACD locks used at site 1 and heparin locks at site 2. We assessed catheters for catheter dysfunction and infection. Both nontunneled dialysis catheters (NTDC) and tunneled dialysis catheters (TDC) were evaluated. We studied 250 catheters and 139 met inclusion criteria: 90 catheters in the ACD group and 49 in the heparin group. ACD had superior outcomes for NTDC; event rate was 0.052 for NTDC/ACD and 0.125 for NTDC/heparin (p = 0.032). There was no difference for TDC. Univariate (odds ratio [OR]: 1.88, confidence interval [CI]: 0.931, 3.82) and multivariate (OR: 1.35, CI: 0.64, 2.87) analyses demonstrated a trend toward increased odds of event with heparin. Catheter lock with 2.2% ACD has lower risk of catheter dysfunction as compared with that of 5000 U/ml heparin in the short-term inpatient setting in NTDC and similar risk in TDC.

Abstract No. 97: [Cope] The Case for Primary Tunneled Dialysis Catheter Placement over Nontunneled Dialysis Catheters in Acute Renal Failure

NTDC are widely used as initial hemodialysis access in new onset renal failure. The K/DOQI recommendations for hemodialysis access in acute renal failure (ARF) are that NTDC should be used for dialysis duration of less than 1 week, because of the increased risk of infection compared to TDC with longer use. However, estimation of when a patient will recover renal function is very difficult. We sought to determine whether primary placement of tunneled dialysis catheters (TDCs) in this setting is more appropriate. In our practice, by mutual consent of the dialysis access team, all patients referred to IR in whom no contraindications to TDC exist (i.e. uncorrectable coagulopathy, bacteremia) receive a TDC. Using a QA database, 74 patients who received primary TDCs for ARF and who eventually recovered renal function were retrospectively reviewed. Cause for renal failure, various renal function parameters, and demographics were collected, as were TDC dwell times, in an effort to determine predictors of recovery and/or extended duration of use. IRB approval was obtained. Mean TDC dwell time in patients who eventually recovered from ARF was 35 days; only 15/74 (20%) recovered within 1 week. At the time of TDC placement, the mean serum creatinine was 6.1 mg/dL, 24-hour urine volume was 788 ml, and duration of oliguria was 0.8 days. Mean platelet count was 200K and mean INR was 1.3. Subsets of patients who recovered in less than 1 week vs greater than 1 week were similar: the mean Cr was 6.0 vs 6.2 mg/dL, 24-hour urine volume was 751 vs 800 ml, and duration of oliguria was 1.3 vs 0.7 days, respectively. Mean platelet count was 219K vs 194K, and mean INR was 1.3 for both groups. Mean TDC dwell time for in patients recovering renal function is 4 weeks more than the K/DOQI maximum recommended NTDC dwell time of 1 week; 80% of patients did not recover by 1 week. This therefore argues for primary placement of TDC in patients with ARF who require hemodialysis and in whom no contraindications exist, as we were unable to identify any predictors of renal function recovery in less than 1 week.

Clinical consequences of infected arteriovenous grafts in hemodialysis patients

Arteriovenous (AV) graft infection is a serious adverse event in hemodialysis patients; however, there is little published literature describing its consequences. We identified prospectively all AV graft infections occurring at our institution during a 4.5-year period. We analyzed immediate complications, as well as long-term consequences, including the need for subsequent vascular-access procedures and duration of catheter-dependent dialysis therapy. Ninety graft infections were identified in 78 patients, yielding a rate of 8.2 infections/100 graft-years. Patients with graft infection were much more likely to have a low serum albumin level (<3.5 g/dL) in the month preceding the infection compared with noninfected controls (73% versus 18%; P < 0.001). Infections occurred within 1 month of graft placement in 15%, at 1 to 12 months in 44%, and longer than 1 year from surgery in 41%. The pathogen was a gram-positive coccus in 97% of cases, particularly Staphylococcus aureus (60%) and Staphylococcus epidermidis (22%). The initial graft infection entailed hospitalization for a mean of 7.5 days. Eleven patients (12%) developed a total of 17 major complications, including death (5 patients), clinical sepsis requiring vasopressors (4 patients), septic arthritis (3 patients), epidural abscess (1 patient), endocarditis (1 patient), osteomyelitis (1 patient), myocardial infarction (1 patient), and cerebrovascular accident (1 patient). After removal of an infected graft, patients were catheter dependent for a median of 3.8 months. The duration of catheter dependence was less than 3 months in 36%, 3 to 6 months in 38%, 6 to 12 months in 14%, and greater than 1 year in 12%. During the period of catheter dependence, patients required a mean of 9.7 access procedures, including graft removal (1.0 procedure), nontunneled dialysis catheters (4.4 procedures), tunneled dialysis catheters (3.0 procedures), and new permanent accesses (1.4 procedures). In addition, patients averaged 0.85 episodes of bacteremia while they were catheter dependent. In conclusion, graft infection results in substantial morbidity, prolonged dependence on dialysis catheters, and multiple vascular-access procedures. © 2001 by the National Kidney Foundation, Inc.