Permanent Tunneled Catheter Research Articles

A Modified Switching Procedure from Temporary to Tunneled Central Venous Dialysis Catheters.

Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous catheter is often placed for immediate dialysis. The most critical step in the catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.

Pattern of vascular access-related infection in hemodialysis patients

Background Vascular access-related infections (VARI) represent a substantial burden for patients undergoing hemodialysis (HD) that is unfortunately inevitable. The spectrum of causative organisms varies between different regions and centers, so it is necessary for each dialysis unit to have its database. This prospective descriptive multicenter study was conducted over a 6-month duration to delineate the pattern of VARI among patients undergoing HD units of Alexandria University Hospitals, and to determine the possible relationship between VARI, type of vascular access, pattern of causative organisms, and various risk factors. Materials and methods The study enrolled all patients with documented clinical and bacteriological evidence of VARI. Infection incidence-rate event/1000 dialysis session (ds) was calculated. Results During the study period, 877 HD patients were approached. A total of 66 VARI episodes were identified in 62 patients, with 58 bloodstream infection (BSI) episodes and 8 local-access infections, with an overall incidence rate of 4.64/1000 ds. About 64% of isolated organisms were Gram-negative bacilli, 33.3% Gram-positive cocci, and 2.8% fungi. The most frequent isolated pathogens were Klebsiella pneumonia, Escherichia coli, and methicillin-resistant Staphylococcus aureus (MRSA). Conclusion VARI rate was higher in HD patients with temporary central venous catheter compared with permanent tunneled catheters. Gram-negative microorganisms and MRSA were the most frequent identified organisms. Creation of arteriovenous fistula should not be delayed to avoid the use of temporary catheters, which carry high risk of VARI.

MO883: Cardiorenal Syndrome in Dialysis: Outcomes and Prognosis in Comparison With a Control Population

Abstract BACKGROUND AND AIMS The interactions of both organs in Cardiorenal Syndrome (CRS) exacerbate the damage and determine a worse prognosis in these patients [1]. The aim of our study is to compare the development and prognosis of CRS patients compared with control patients. METHOD: In a retrospective fashion, we assigned 60 patients with CRS who underwent dialysis, and we compared them with a control population of 60 patients without CRS in dialysis. We analyzed baseline characteristics of the patients and the dialysis parameters. Survival rates at 1 and 5 years were determined. RESULTS The baseline characteristics were similar between groups. The mean age was 72 ± 9 years in CRS and 68 ± 12 years in the control group. Men were more prevalent in both groups CRS (55%) and control (53%). Charlson's Score was 8 ± 2 points in the CRS group and 7 ± 3 points in the control group. Diabetic nephropathy was the most frequent etiology of end-stage renal disease in CRS patients (37%), followed by nephroangiosclerosis (20%). In the control group, the most common etiologies were nephroangiosclerosis (32%), diabetic (22%) and interstitial nephropathy (11%). CRS patients had more diabetes mellitus (55% versus 35%; P < 0.05), dyslipidemia (63% versus 38%; P < 0.05), ischemic cardiopathy (50% versus 31%; P < 0.05), atrial fibrillation (66% versus 21%; P < 0.05) and valvular heart disease (27% versus 6%; P < 0.05). There were no differences in hypertension (80% versus 76%; P = 0.58), ictus (31% versus 23%; P = 0.30) and peripheral arterial disease (40% versus 33%; P = 0.44) between groups. CRS patients had more hospitalizations due to heart failure before starting dialysis than the control group (52% versus 1.7%; P < 0.05) Haemodialysis was the most common technique in both groups CRS (98%) and control (95%). The use of permanent tunneled catheters as definite vascular access was more common in CRS patients (60% versus 26%; P < 0.05). There were no differences in the duration of haemodialysis sessions (252 ± 18 versus 257 ± 23 min), neither in interdialytic weight gain (2.3 ± 0.7 versus 2.4 ± 0.9 Kg). CRS patients had worse ultrafiltration tolerance with a hypotension rate of 48% in CRS versus 10% in the control group (P < 0.05). The median time in dialysis was inferior in the CRS group [24 (8–42) versus 61 (26–106) months; P < 0.05] compared with controls and the survival rates at 1 and 5 years were worse in the CRS group (71% versus 93%; P < 0.05) and (15% versus 50%; P < 0.05), respectively. The main cause of death was the cardiovascular events in both groups (35% versus 20%; P = 0.06). However, tumor as a cause of death was superior in the control group (18% versus 0%; P < 0.05). CONCLUSION CRS patients have more cardiovascular risk factors and cardiovascular disease as expected, as well as more hospitalizations caused by heart failure before starting dialysis. They have more frequent use of a permanent tunneled catheter. It could be explained because of worse tolerance to the use of arteriovenous fistula in these patients. - The survival rates at 1 and 5 years are significantly inferior in the CRS group, which highlights the poor prognosis of these patients [2,3]. - The tumor as a cause of death was superior in the control group due to greater time in dialysis of these patients compared with CRS patients

Evaluation of the approach to hemodialysis vascular access during the pandemic period

Objective: During the pandemic, some surgeries were postponed due to the large number of patients admitted by hospitals. It was tried to shorten the hospitalization period of some patients. Hemodialysis patients who had to come to the hospital frequently were also affected by this situation. Physicians working during the pandemic period prefer to use less invasive techniques. In this study, it was aimed to investigate whether there is a change in the choice of vascular access used for hemodialysis in this period. Material and Method: In this study, 552 patients who were treated for hemodialysis vascular access in the cardiovascular surgery clinic of Kastamonu Training and Research Hospital between March 2019 and 2021 were retrospectively analyzed. The patients were divided into two groups as pre-pandemic (Group 1) and pandemic (Group 2). Patients in Group 1 and Group 2 needed high-flow vascular access to perform hemodialysis. For this purpose, 2 techniques are frequently used, the first being arteriovenous fistula(AVF) and the other permanent hemodialysis catheter insertion. The distribution of these techniques used in patients was examined. Results: In our study, we found that before the pandemic between March 2019-2020, 109 patients had AVF and 193 patients had a permanent tunneled catheter. Between March 2020- 2021, which started with the pandemic process, we found that AVF was opened in 74 patients and a permanent tunnel catheter was placed in 176 patients. Conclusion: Uremic patients who need hemodialysis should not be affected by the pandemic problem and the most permanent procedures should be applied for these patients. Like all vascular patients, dialysis patients should not become secondary afflictions of Covid-19

Hemodialysis Catheter-related Infections: Incidence, Microbiology and Outcome 5 years of Dubai Hospital Experience

Background: The central venous catheters (CVC) has recently become a worldwide commonest technique for vascular access, however; prone to infection and associated with other complications more than other vascular access techniques, such as fistula or graft.
 Objective: To investigate the incidence, the types of micro-organism, the most sensitive and suitable antibiotics, the outcomes associated with CVC infection in chronic hemodialysis patients treated through tunneled CVC.in a single-center population.
 Methods: The records of hemodialysis patients from January 2012 to December 2016 were reviewed. Patients above 14 years of age, on hemodialysis via a permanent tunneled catheter at any time of the mentioned period, were included. The rate of CRBSI (Catheter-Related Blood Stream Infections) was calculated as density of incidence and reported per 1000 catheter days. Patient mortality was recorded.
 Results: In 5 years, a total of 73 episodes of CRBSI in 49 hemodialysis patients were recorded. 59.2% were male with a mean age of 53.57 years. 40.8% had end-stage kidney disease secondary to diabetic nephropathy. In all, 67.3% episodes grew Gram-positive isolates, among those staphylococci epidermidis (26.4%, n=19) and staphylococci aureus (25%, n=18) were the most common organism, whereas Klebsiella pneumonia (8.3%, n=6), Enterobacter cloacae (8.3%, n=6), pseudomonas aeruginosa (5.5%, n=4) and E.coli (5.5%, n=4) were the most common Gram-negative isolates. A total of 6 isolates were multidrug-resistant, which includes Klebsiella pneumonia, Citrobacter, and E. coli. Only 1 out of 18 staphylococci aureus cases were methicillin-resistant and 21% (n=6) of Gram-negative isolates were Extended-spectrum beta-lactamase (ESBL) producing organisms. The average hospital stay was 9 days (2-30 days). The hemodialysis catheter was removed for 19 (38.77%) patients and 4 (8.1%) patients expired due to septic shock despite catheter removal and being on appropriate antibiotics.
 Conclusion: The mainstay to reduce CRBSI would be ideal to avoid catheters or decrease the duration of catheters. This can be achieved through more aggressive counseling and fast-track protocols for AV Fistulae creation at the pre-dialysis stage.

Çocuk Hastalarda Tünelli Santral Venöz Kateterlerin Perkütan ve Cerrahi Yerleştirilmesindeki Komplikasyonlar

Objective: Percutaneous insertion of permanent tunneled catheters, accompanied by ultrasonography (USG) guidance, has established itself as practical, safe, and widely used procedure. The purpose of our study; To examine and compare the complications associated with permanent tunneled catheters placed by percutaneous or open surgical method in pediatric hemato-oncology patients. Methods: Medical records of 101 pediatric patients from the ASA 3-4 group who were placed in a Hickman-type tunneled central venous catheter for bone marrow transplantation between 2013 and 2015 in our clinic were retrospectively reviewed. Demographic data of the patients, catheter insertion location, size, complications encountered during and after the intervention, and reasons for catheter removal were recorded. Results: One hundred and one tunneled central venous catheters were placed percutaneously under USG guidance in 54 patients, and using open technique in 47 patients. Patients in both groups were similar in terms of age, height, weight, size of the inserted catheter, duration of catheterization, and reasons for removal. No difference was found between percutaneous and surgical groups in terms of intraoperative and postoperative to technique, and infective complications related to catheter. Conclusion: In pediatric hemato-oncology patients, there is no difference in terms of intraoperative, and postoperative complications between percutaneous technique and open technique for permanent tunneled central catheter insertion. Both techniques can be used with low complication rates, and the percutaneous technique may be preferred because it is less invasive.

Bacillus Cereus Catheter-Related Bacteremia in a Patient Diagnosed with Neuroblastoma

Bacillus species can be found in air, water, soil, feces, and particularly in the normal flora of patients with a prolonged length of hospitalization. Therefore, isolation of these microorganisms from clinical samples is a common condition and usually regarded as contaminants. Previously, Bacillus cereus has been rarely associated with infections, but in the last few years, it has been reported with increasing frequency as the bacterial pathogen in patients with intravenous drug abuse, trauma, immunodeficiency syndrome, immunosuppressed patients with a history of underlying malignancy and granulocytopenia. In this study, we present a 3-months-old baby girl who was presented to a private health center with a complaint of not sucking well enough. After clinical examination she was diagnosed with neuroblastoma stage 4 S, metastasis was detected in the liver and bone marrow and surrenalectomy and 14 cures of chemotherapy were applied to the patient. Patient was discharged from the hospital with a permanent tunneled catheter, but she returned to the pediatric emergency department with high fever. After laboratory tests she was diagnosed with febrile neutropenia and ceftazidime and amikacin treatment was started. Ceftazidime treatment was stopped after the isolation of B. cereus from peripheral and catheter blood cultures of the patient and teicoplanin treatment was started. Permanent tunneled catheter was removed under anesthesia, and this suggested the case as a catheter-originated bacteremia after reducing fever of the patient. As a result, we suggest that B. cereus isolation in blood cultures could not everytime mean contamination, and B. cereus may cause catheter-related infections in immunosuppressed patients. (JAREM 2015; 5: 75-7)

Catheter-related atrial thrombus: tip of the iceberg?

Although guidelines recommend catheters as a last resort for establishing a vascular access in patients undergoing dialysis, they continue to be used widely for this purpose. Catheter-related atrial thrombus (CRAT) is rarely reported in this group of patients, and it can lead to serious complications. The aim of this study was to determine the incidence of CRAT in patients undergoing hemodialysis with permanent-tunneled catheters. A total of 50 patients undergoing hemodialysis with permanent catheters were included in this study. The diagnosis of CRAT was based on transthoracic echocardiography findings. Thrombus was present in nine patients (18%) and related to the tip of the catheter in all cases. Except for one patient with two foci of thrombus, all patients had a single focus. There were no significant associations between the development of thrombus and the duration of catheter use or the location of the catheter. Furthermore, catheter-related atrial thrombus did not appear to have a significant effect on mortality. The asymptomatic character of CRAT can be responsible for the low reporting rates, and its exact role in increased mortality and morbidity related with catheter use remains unknown. While planning management strategies, information on different options for vascular access routes and possible catheter-related complications should be provided to all patients who will undergo dialysis, together with a discussion involving other replacement alternatives for end-stage renal disease.

Experience with Chest Wall Arteriovenous Grafts in Hemodialysis Patients

Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest. We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft. Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%). CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

Permanent catheters for hemodialysis is not ideal but sometimes considered a necessity: a prospective study

BackgroundIt is not always easy to achieve an adequate arterio venous fistula in long-term dialysis patients; hence, permanent cuffed tunneled central venous catheters represent necessity in some ESRD patients like those with advanced age and/ or comorbid conditions.PurposeTo report the technique and the results of the permanent tunneled catheters as a vascular access .Patients and methodsThis report describe the technique and the results of the permanent tunneled catheters as a vascular access for hemodialysis at Mansoura University Hospitals. Catheter was inserted by seldinger percutaneous technique with the use of radioscopic guidance by an experienced vascular surgeon.ResultsThe study included 33 patients for whom 38 catheters were inserted (17 males,16 females), nine of whom were hypotensive, with a mean age of 48,9 years.The cumulative primary patency rate at 1 year was 52.6% and at 2 years, 21.05%. Complications developed including ,tunnel haematoma, thrombosis, and infection.ConclusionPermanent cuffed, tunneled catheters play a larger role, particularly among those in whom finding a vascular access can be challenging.

Catéter transhepático: última opción de acceso vascular en mujer de 26 años

El acceso vascular (AV) es la base fundamental de todo tratamiento extracorpóreo de diálisis, su funcionamiento adecuado infl uye directamente en la calidad de vida del paciente y en su morbi-mortalidad. El AV vascular ideal debe permitir el abordaje seguro y continuado del sistema vascular, proporcionar fl ujos sufi cientes para alcanzar una dosis de diálisis adecuada y carecer de complicaciones. Según las guías SEN la primera opción de AV es la fístula arteriovenosa (FAV): nativa preferentemente, protésica, etc. Sin embargo, cuando estas posibilidades se agotan, se recurre a catéteres permanentes tunelizados.

Drenaje permanente tunelizado de la ascitis maligna: experiencia inicial con el catéter PleurX ®

Objective The most common treatment in recurrent malignant ascites is generally temporary peritoneal drainage. We present our experience in placing permanent tunneled catheters in a series of patients and analyze the safety and efficacy of the treatment. Material and methods We used total aseptic measures in the interventional ultrasonography suite to place permanent tunneled catheters in 10 patients under ultrasonographic guidance and local anesthesia. Results The catheters remained patent for a median of 52 days in the nine patients who died. In one of these, the catheter was withdrawn while still patent due to generalized sepsis. At the end of the study, one patient still had a permeable catheter 124 days after placement. Conclusion Although the low number of patients in our series precludes generalizations, tunneled peritoneal catheters seem to be a safe and effective minimally invasive treatment for malignant ascites in terminal oncologic patients. This approach facilitates the draining of the ascites at home, obviating the need for repeated hospital visits and punctures and the risks involved therein. Nevertheless, further experience and prospective randomized trials are necessary.

Permanent tunneled drainage for malignant ascites: Initial experience with the PleurX® catheter

ObjectiveThe most common treatment in recurrent malignant ascites is generally temporary peritoneal drainage. We present our experience in placing permanent tunneled catheters in a series of patients and analyze the safety and efficacy of the treatment. Material and methodsWe used total aseptic measures in the interventional ultrasonography suite to place permanent tunneled catheters in 10 patients under ultrasonographic guidance and local anesthesia. ResultsThe catheters remained patent for a median of 52 days in the nine patients who died. In one of these, the catheter was withdrawn while still patent due to generalized sepsis. At the end of the study, one patient still had a permeable catheter 124 days after placement. ConclusionAlthough the low number of patients in our series precludes generalizations, tunneled peritoneal catheters seem to be a safe and effective minimally invasive treatment for malignant ascites in terminal oncologic patients. This approach facilitates the draining of the ascites at home, obviating the need for repeated hospital visits and punctures and the risks involved therein. Nevertheless, further experience and prospective randomized trials are necessary.

Comparison of Complications and Dialysis Adequacy Between Temporary and Permanent Tunnelled Catheter for Haemodialysis

Number of hemodialysis patients each day is increasing. The quality of their lives is largely determined by the quality of hemodialysis treatment. One of the most important factors is the type of applied blood approach. The type of blood approach in the most case is artery venous fistula, permanent, temporary catheters, grafts. Any complications of blood strand approach inevitably leads to lower quality of hemodialysis treatment which is connected with not adequate dialysis and poorer general state of patients. Our research was carried out as a prospective study, for the period of 36 months. In the study were included 31 patients, which are on chronic haemodialysis treatment. During this study, we are followed all complications, which occurred at temporary, and permanent tunneled haemodialysis catheters. Complications have occurred in terms of thrombotic problems, low blood flow, occurrence of infection. All patients are divided in two groups, 16 patients with permanent and 15 patients with temporary catheters. In the course of the study was analyzed blood flow and dialysis adequacy (Kt/Vdp) as well as complications and results was compared with randomly selected 16 patients who haemodialysis treatment performed by artery venous fistula (AVF). Two patients were lost to further follow-up to the end of the study. 26 patients at the end of the study had functional catheters, while in the case of 3 patients the catheter was removed. Infection was found in 10 patients while thrombotic complications were observed in 27 cases regardless of catheter type. Mean blood flow in patients with permanent catheter was significantly higher (296,9+/-28,45 cm3/min) compared to patients with temporary catheter (226,3+/-39,8 cm3/min) (p<0,001). Kt/Vdp delivered was 1,22+/-0,15 on patients with permanent catheter and 1,30+/-0,18 for artery venous fistula (AVF) access respectively. The loss of dialysis efficacy using catheters was estimated at 6%. However, in all cases Kt/Vdp values remained above the recommended values (Kt/Vdp > or = 1,2).

The Cost of Vascular Access Infections: Three Years Experience from a Single Outpatient Dialysis Center.

Vascular access care accounts for a third of ESRD cost and is a leading cause of morbidity in hemodialysis (HD) patients. We designed this study to identify the risk factors for vascular access infection and to determine the cost of related hospitalizations. Methods: All HD patients at DCI Oakland from 1/1/99 to 6/30/02 were prospectively studied for access type, infections (Infx) including bacteremia, exit site, tunnel or cellulitis, and related hospitalizations. Cost data was obtained from the inpatient electronic medical record system. Risk factors for infection were evaluated using Poisson regression analysis, and cost comparison was done using ANOVA. Results: 153 patients were included in the analysis and were grouped by type of access: temporary catheter (TC) n = 84, permanent/tunneled catheter (PC) n = 158, AV graft (AVG) n = 87 and AV fistula (AVF) n = 57. Univariate analysis revealed significant risk factors to be female gender (p = 0.004, RR = 1.85) and type of access. In multivariate analysis, compared to AVF, risk of infection was highest with TC (p < 0.001, RR = 44), followed by PC (p < 0.001, RR = 17) and AVG (p = 0.03, RR = 3). Age, gender, and diabetes were not predictors of infection. The cost per hospitalization in the PC vs. AVG groups was not significantly different. Access type TC PC AVG AVF # Infx/1000 access days 5.0 3.8 0.6 0.1 % Infx requiring hospitalization 12.5 12.2 58.0 60.0 Cost/hosp. admission (mean) $16,896 25,683 9,016 5,650 Conclusions: Catheters are associated with much higher vascular access infection rates when compared to fistulas and grafts. When AVFs or AVGs do become infected, they are more likely to require hospitalization. Infections severe enough to require hospitalization result in similar inpatient cost per admission regardless of access type; however, this may be due to small sample size.

Outbreak of hemodialysis vascular access site infections related to malfunctioning permanent tunneled catheters: making the case for active infection surveillance.

To describe an outbreak of infections with permanent cuffed hemodialysis catheters recognized through ongoing surveillance and related to a specific malfunctioning permanent catheter. The outbreak was suspected from the results of prospective infection surveillance and confirmed by a retrospective cohort study using medical records for patients receiving dialysis between April 1, 1999, and March 31, 2000. Integrated network of six outpatient hemodialysis facilities in southern Idaho and eastern Oregon. Outpatients receiving long-term hemodialysis. During the 18 months prior to the outbreak, the overall infection rate was 4.1 infections per 1,000 dialysis sessions with a catheter rate of 8.9 per 1,000 dialysis sessions. During the 7 months of the outbreak, the overall rate increased to 5.8 per 1,000 dialysis sessions, whereas the catheter rate increased to 18.1 per 1,000 dialysis sessions. Reports of malfunctioning "Brand A" catheters prompted discontinuation of their placement. A manufacturer recall occurred in April 2000. During the 14 months after the outbreak, the overall infection rate decreased to 3.3 per 1,000 dialysis sessions and the catheter rate to 10.8 per 1,000 dialysis sessions. A 12-month retrospective cohort study recognized 96 patients with an identifiable catheter brand and 48 infections. Of these, 27 (56%) occurred in patients with Brand A catheters. The relative risk for infection when compared with other catheter brands was 1.96 (95% confidence interval, 1.32 to 2.92; P < .001). Ongoing infection surveillance in hemodialysis facilities can identify specific device-related outbreaks of infections and promote interventions to reduce infectious complications and promote patient safety. Surveillance for vascular access site infections is recommended as a routine activity in hemodialysis facilities.

Placement of a Permanent Tunneled Peritoneal Drainage Catheter for Palliation of Malignant Ascites: A Simplified Percutaneous Approach

To report a simple, minimally invasive method of palliative drainage of symptomatic malignant ascites, which allows patients to avoid repeated trips to the hospital for paracentesis. Since 1996, 29 patients with symptomatic, large-volume malignant ascites underwent percutaneous placement of a tunneled multiple-side-hole Tenckhoff catheter with use of a modified Seldinger technique employing curved and straight coaxial needles. Unlike previously described methods of tunneled catheter placement, this method does not require an incision. All patients were able to drain their ascites at home and all achieved significant improvement in their symptoms attributable to ascites. Twenty-three of the 29 were outpatients and were able to leave the hospital within several hours of catheter placement. Inpatients remained in the hospital for various reasons unrelated to catheter placement and most left within several days. Only one patient died in the hospital during the same admission. One patient developed cellulitis, one had persistent leakage around the catheter, one catheter had to be replaced, and one catheter was accidentally removed at home. No patient developed clinical symptoms of peritonitis or sepsis. All deaths were attributable to patients' underlying malignancies. Percutaneous placement of a permanent tunneled catheter using a modified Seldinger technique employing curved and straight coaxial needles is a safe, simple, and effective method for palliative drainage of malignant ascites that allows patients to return home quickly.

A prospective study of hemodialysis access-related bacterial infections.

The objective of this study was to describe hemodialysis vascular-access related infections that occurred in hemodialysis patients over an 18-month period. The study is a prospective descriptive analysis of incidence infection rates in a hemodialysis unit in a tertiary-care medical center. Prospective surveillance for hemodialysis vascular access-related infection was performed for all patients undergoing hemodialysis from November 1999 through April 2001 at King Fahd Hospital of King Faisal University, Al-Khobar, Saudi Arabia. The total number of dialysis sessions was calculated. The type of vascular access was noted. Cultures were obtained and all infections were recorded and infection rates were calculated. There were 9627 hemodialysis sessions (5437 via permanent fistulae or grafts, 2409 via temporary central catheters, and 1781 via permanent tunneled catheters) during the 18-month study period. We identified a total of 109 infections, for a rate of 11.32/1000 dialysis sessions (ds). Of the 109, 23 involved permanent fistulae or grafts (4.23/1000 ds); 18 involved permanent-tunneled central catheter infections (10.1/1000 ds); and 68 involved temporary-catheter infections (28.23/1000 ds). There were 38 bloodstream infections (3.95/1000 ds) and 34 episodes of clinical sepsis (3.53/1000 ds). Seventy-one vascular access infections without bacteremia were identified (7.38/1000 ds), including 16 permanent-fistulae or graft infections (2.94/1000 ds), 7 permanent-tunneled central catheter infections (3.93/1000 ds), and 48 temporary-catheter infections (19.92/1000 ds). Staphylococcal organisms were responsible for 77% of the infections, with Staphylococcus epidermidis being the strain most commonly implicated. Gram-negative organisms were responsible for 23% of the infections. In conclusion, infection rates were highest in hemodialysis patients with temporary vascular access, compared with rates in those with permanent arteriovenous fistulae and synthetic grafts. Most of the bacterial organisms isolated from the vascular access sites were gram-positive cocci, with S. epidermidis accounting for 50% of the organisms. The rate of infection with gram-negative bacilli was higher than in other reports. Our greater dependence on central venous catheters, due to local factors, coupled with the immune-compromising comorbid conditions of our patients, may be contributory to the pattern of infection reported. Delays in the creation of vascular grafts for hemodialysis access should be avoided.