Hemodialysis Catheter Placement Research Articles

Thiamine as a Renal Protective Agent in Septic Shock. A Secondary Analysis of a Randomized, Double-Blind, Placebo-controlled Trial

Acute kidney injury (AKI) is common in patients with sepsis and has been associated with high mortality rates. The provision of thiamine to patients with sepsis may reduce the incidence and severity of sepsis-related AKI and thereby prevent renal failure requiring renal replacement therapy (RRT). To test the hypothesis that thiamine supplementation mitigates kidney injury in septic shock. This was a secondary analysis of a single-center, randomized, double-blind trial comparing thiamine to placebo in patients with septic shock. Renal function, need for RRT, timing of hemodialysis catheter placement, and timing of RRT initiation were abstracted. The baseline creatinine and worst creatinine values between 3 and 24 hours, 24 and 48 hours, and 48 and 72 hours were likewise abstracted. There were 70 patients eligible for analysis after excluding 10 patients in whom hemodialysis was initiated before study drug administration. Baseline serum creatinine in the thiamine group was 1.2 mg/dl (interquartile range, 0.8-2.5) as compared with 1.8 mg/dl (interquartile range, 1.3-2.7) in the placebo group (P = 0.3). After initiation of the study drug, more patients in the placebo group than in the thiamine group were started on RRT (eight [21%] vs. one [3%]; P = 0.04). In the repeated measures analysis adjusting for the baseline creatinine level, the worst creatinine levels were higher in the placebo group than in the thiamine group (P = 0.05). In this post hoc analysis of a randomized controlled trial, patients with septic shock randomized to receive thiamine had lower serum creatinine levels and a lower rate of progression to RRT than patients randomized to placebo. These findings should be considered hypothesis generating and can be used as a foundation for further, prospective investigation in this area.

Association Between Allergies and Psychiatric Disorders in Patients Undergoing Invasive Procedures

Associations between allergies and psychiatric disorders have been reported in the context of depression and suicide; psychiatric disorders may affect pain perception. To investigate the relationship of allergies with psychiatric disorders and pain perception in the context of invasive procedures, specifically during tunneled hemodialysis catheter placement. We identified 89 patients (51 men, 38 women), mean age 66 years (range: 23-96), who underwent tunneled hemodialysis catheter placement (1/2014-2/2015), recording numeric rating scale pain scores, medications, psychiatric history, allergies, and smoking status. Of 89 patients, 47 patients had no allergies, and 42 had ≥1 allergy. Patients with allergies were more likely to have a pre-existing psychiatric disorder compared to those without allergies, odds ratio 2.6 (95% CI: 1.0-6.8). Having allergies did not affect procedural sedation or postprocedural pain scores. Multiple logistic regression with age, sex, smoking, presence of allergies, psychiatric history, inpatient/outpatient status, procedure time, and procedural sedation administration as inputs and postprocedural pain as the outcome showed that the only independent predictor was receiving procedural sedation (P = 0.005). Findings corroborate anecdotal reports of allergies as a marker for psychiatric history. However, having allergies was not associated with increased pain or need for more sedation. Further studies could prospectively assess whether allergies and psychiatric disorders affect patient/doctor perceptions beyond pain during invasive procedures.

Revival of the Forgotten Rout: Tunnel Hemodialysis Catheter Placement using the Supraclavicular Approach to Overcome Stenosis of the Internal Jugular vein at its Origin

A case of ESRD on HD who is referred for placement of tunnel hemodialysis catheter insertion because his arterial-venous fistula is still immature to be used for HD. He had had 3 TDC placed in the right IJ on previous occasions. His angiogram revealed stenosis of the internal jugular vein at its junction with subclavian vein. After 3 failed attempts at right internal jugular vein cannulation the Supraclavicular approach of the SCV cannulation was achieved with ease overcoming the stenosis in the right internal jugular vein.

Assessing Pain Level, Patient Satisfaction, and Frequency of Injury to Adjacent Anatomical Structures During Central Venous Catheter Placement Under Local Anesthesia

Background: Central venous catheters (CVCs) are increasingly used for central vein pressure measurement, fluid replacement, blood-product transfusion, hemodialysis, and chemotherapy. Considering the urgent nature of placing CVCs in many patients, local anesthesia is used in order to facilitate recovery and prevent the side effects of general anesthesia. The successful placement of CVCs can reduce injury to adjacent structures. Objectives: This study aimed to assess the patients’ pain level, satisfaction, and injury to adjacent structures. Patients and Methods: This case series evaluated 213 patients with end-stage renal disease (ESRD) who had been referred for duallumen hemodialysis catheter (large-bore) placement during the year 2011 at Hasheminejad kidney center (Tehran, Iran). Catheters were placed by a single surgeon, and 5 ml of subcutaneous lidocaine 2% was used at the site of catheterization. At the end of the procedure, pain was measured using a visual analog scale, and the patients’ satisfaction was verbally determined with regard to whether they would accept local anesthesia if they required catheter placement again in the future. Results: Fifteen patients reported that they would prefer general anesthesia for a similar procedure in the future. Five of these patients experienced mild pain with the present procedure, and the remainder had severe pain. The mean pain scores were 1.93 ± 0.799 in patients who preferred general anesthesia and 1.26 ± 0.450 in the remainder. The difference between the two groups was significant. One hundred ninety-eight patients experiencedmild pain during catheter placement, of which 187 (94.4%) would accept local anesthesia for this procedure in the future. Twenty-two (10.3%) patients underwent arterial puncture, 163 had single-attempt venous puncture, and 50 had two or more puncture attempts. In nine patients, the puncture was unsuccessful and the vein could not be found despite three attempts to insert the needle; for these patients, the anatomical area approached for access was changed. Conclusions: Local anesthesia facilitates quick recovery, is time-saving, and can reduce hospital expenses. It seems to be a suitable method for reducing complications and increasing patient satisfaction.

PC134. Incidence of Central Venous Stenosis and Other Adverse Outcomes Related to Placement of Tunneled Hemodialysis Catheters During Maturation of Autogenous Arteriovenous Fistulas

PC134. Incidence of Central Venous Stenosis and Other Adverse Outcomes Related to Placement of Tunneled Hemodialysis Catheters During Maturation of Autogenous Arteriovenous Fistulas

Renal Ultrasound, Dialysis Catheter Placement, and Kidney Biopsy Experience of US Nephrology Fellows.

Procedures are a key component to the practice of nephrology. The Accreditation Council for Graduate Medical Education (ACGME) requires nephrology fellows to acquire skills and demonstrate competency in the performance of several procedures during fellowship training, including temporary hemodialysis catheter placement, biopsy of native and transplanted kidneys, and various dialytic therapies. It is also required that fellows acquire competency in the interpretation of renal imaging, including renal ultrasound, during their training. To gain a more recent perspective of nephrology fellows' experiences regarding renal ultrasonography, dialysis catheter placement, and kidney biopsies, we carried out a national survey of nephrology fellows in May 2014. A majority of the programs did not offer formal clinical training in renal ultrasonography. In addition, a significant percentage of fellows in adult nephrology may not be acquiring the required procedural skills and competency during fellowship training. In this perspective, we explore some of the reasons for this occurrence and propose some measures that the nephrology training community can take to enhance procedural skills and competency of fellows.

Complications of Permanent Hemodialysis Catheter Placement; Need for Better Pre-Implantation Algorithm?

There is a correlation between central venous cannulation and the development of central venous stenosis. Minor retrosternal vein lesions can be easily missed. Computerized tomographic (CT) venography is the diagnostic procedure of choice. The aim of this study was to examine the complications after catheter implantation in patients with prior permanent catheter placement and to evaluate present diagnostic procedures performed prior to choosing permanent access site in order to reduce possible complications after catheter placement. Complications of permanent CVC insertion in our department were analyzed between October 2011 and February 2015. We have implanted the Tesio twin catheter system and the Hickman Bard dual lumen catheter. All patients with prior permanent dialysis catheter were evaluated with color doppler, while patients with suspected central venous stenosis (CVS) or thrombosis were evaluated with phlebography or CT venography prior to catheter placement. One hundred and ninety-eight permanent dialysis catheters were placed (173 Tesio [87.4%] and 25 Hickman [12.6%]) in 163 patients. There were 125 patients (76.7%) with prior temporary catheter and 61 (48.8%) of them had more than one prior permanent catheter (1.92 catheter per person).There were 4/61 (6.5%) patients with catheter-related complications without prior phlebography and CT venography. Phlebography and CT venography were performed in 30 (24.0%) patients with suspected CVS/thrombosis and with dialysis vintage of 76.23 months (52.78-98.28). Phlebography and CT venography were more sensitive than color doppler in the detection of CVS/thrombosis in patients with prior permanent catheter placements (P < 0.001). Since this diagnostic algorithm was introduced prior to catheter placement there were no catheter insertion-related complications or dysfunctions (P < 0.001). All our procedures on patients with prior permanent catheters followed preliminary color doppler diagnostics. Nevertheless, in four cases, the vessel obstruction and abnormality led to catheter insertion-related complications. When phlebography and CT venography was performed before the procedure in patients with prior permanent catheters and one or more CVS or thrombosis, early and late catheter-related complications were avoided by careful selection of the least injured vein and planning of procedure. When planning a permanent dialysis catheter placement in patients with prior multiple CVC, phlebography and CT venography may be diagnostic procedures of choice for avoidance of early catheter dysfunction and CVC placement complications.

Use of an ECG-based confirmatory technique for bedside placement of reverse-tunneled cuffed dialysis catheters in three morbidly obese patients

We are currently in the midst of a worldwide obesity epidemic, including in patients with end-stage kidney disease. Placing hemodialysis catheters is a particular challenge in patients with extreme obesity. Here we describe the merging of two technologies to place catheters in patients who are too heavy (over 225 kg) to be placed safely on a procedure table for fluoroscopic guidance. The first technology is ECG-guided placement of catheters, well established for guidance of peripherally inserted central catheters (PICCs) and tunneled and nontunneled central venous catheters. The second is reverse-tunneling dialysis catheters, which allow precise placement of the tip of the catheter before creating the tunnel. We successfully placed catheters in three morbidly obese patients with acute kidney injury and followed them until their kidneys recovered and the catheters were removed. The catheters were placed in the patient's bed in a procedure room with subsequent confirmatory chest radiographs. Catheter performance based on blood flow rates was excellent and there were no complications. We suggest placement of ECG-guided tunneled hemodialysis catheters using a reversed-tunneling technique in those patients with extreme obesity who are too heavy to place on a fluoroscopy procedure table.

Successful Obturator vein Vascular Access for Hemodialysis Catheter Placement in Patients with End-stage Renal Disease

Successful Obturator vein Vascular Access for Hemodialysis Catheter Placement in Patients with End-stage Renal Disease

Catheter tip malposition after percutaneous placement of tunneled hemodialysis catheters.

The percutaneous catheterization of central veins is increasingly used in nephrological practice as a temporary or permanent vascular access. The aim of our study was to present and to analyze episodes of catheter tip malposition during percutaneous tunneled hemodialysis catheter insertion in the large, unselected group of patients. All patients who underwent the procedure of catheter insertion in our department during year 2012 were analyzed retrospectively. One hundred four tunneled hemodialysis catheters were inserted in 101 patients. In 58 patients, the catheter was inserted at the initiation of hemodialysis therapy as the first access and in 46 the catheter was placed because of the failure of the existing one. In 68 patients, the catheter was inserted into the right internal jugular vein and in 20 patients into the left internal jugular vein (LIJV). Subclavian veins were used in five cases and femoral veins in 11 cases. Malposition of the catheter tips occurred in six patients. In all cases, the LIJV was cannulated. In two cases, the catheter tip malposition was in the right innominate vein and in four cases in the azygos vein. Our data demonstrate that with the blind insertion of tunneled hemodialysis catheters, the risk of catheter tip malposition is significantly higher with the left side insertion. As catheter insertion through the LIJV holds very high (30%) risk of the tip malposition, it should always be performed under the fluoroscopic control.

Unusual sites for hemodialysis vascular access construction and catheter placement: A review.

As more end-stage renal disease patients require hemodialysis and live longer, many will fail to develop or maintain a functioning upper extremity vascular access. When a patient exhausts vascular access sites in the upper extremities, new fistulas and grafts can be constructed in the lower extremities, thorax, and abdomen as long as a pair of proximate artery and vein provide adequate blood inflow and outflow, respectively. When only a moderate size vein with adequate blood flow provides a conduit to either a patent superior or inferior vena cava, inserting a double-lumen venous hemodialysis catheter can provide temporary or permanent access. We review the literature and report the unusual sites for hemodialysis vascular access and catheter placement.

Concomitant persistent left superior vena cava and horseshoe kidney.

Persistent left superior vena cava (PLSVC) and horseshoe kidney (HSK) are common congenital abnormalities; however presence of both in the same person is extremely rare. A patient with hepatitis C cirrhosis awaiting transplant presented with worsening liver dysfunction, diagnosed with acute renal failure secondary to hepatorenal syndrome, and required X-ray fluoroscopy guided tunneled venous catheter placement for hemodialysis. Review of imaging studies demonstrated coexistence of PLSVC and HSK. PLSVC in adulthood is usually incidental with the most common drainage pattern being without physiologic dysfunction. Isolated horseshoe kidney is still the most common of renal fusion anomalies; however etiology of coexistent PLSVC remains unknown.

Ultrasound-guided cannulation in placement of Hemodialysis Access Catheters in Predialysis Patients

Aim: Ultrasound (USG)-guided hemodialysis catheter placement is known to be superior to and more reliable than catheter insertion guided by anatomical landmarks. USG is used for vascular mapping (VM) before catheter placement, or real time. This study investigated the effect on outcomes of USG techniques used in patients with hemodialysis catheters inserted through the internal jugular vein (IJV) due to emergency hemodialysis indication while being monitored for Predialysis Renal Failure (PRF). Material and Methods: Fifty-nine patients with PRF undergoing USG-guided hemodialysis catheter placement between January 2012 and May 2014 at the Balikesir University Health Practice and Research Hospital were evaluated retrospectively. Results: Twenty-eight patients were male and 31 female. The right IJV was used in 57 patients and the left IJV in two. Success rate at first attempt in real time USG group was 91.3% (21/23), compared to 91.6% (34/36) in the VM group. Average number of puncture was similar (1.08±0.291 vs. 1.16±0.56). No complications occurred in either group. Conclusion: Use of USG in real time and for VM in patients with PRF gives similar results in terms of success and complication rates. We therefore recommend that USG only for vascular mapping be used solely in these patients in order to avoid time loss and increased costs.

A minimally painful, comfortable, and safe technique for hemodialysis catheter placement in children: Superficial cervical plexus block

The superficial cervical plexus block (SCPB) is utilized in pediatric patients to perform certain surgical procedures, but there is no evidence supporting its use in hemodialysis catheter placement. We evaluated the analgesic effectiveness, intraoperative complications, and patient satisfaction associated with SCPB for pediatric patients in renal failure undergoing emergent dialysis catheterization. A total of 52 patients ranging from 1 to 17 years old that required emergent dialysis catheter placement and received SCPB were included in this study. During the catheterization, intraoperative pain scores, requirement for additional analgesia, catheterization access site, and intraoperative complications were recorded. The Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) was used to determine pain ratings during skin puncture with the needle, skin dilatation, and securing the catheter with stitches. The patients had an average age of 8.46 ± 5.3 years. The preferred catheterization entry site was through right internal jugular vein, which was achieved in 80.7% of patients. However, 19.3% of patients required access through the right subclavian vein. The average mCHEOPS score during skin puncture was 1.4 ± 0.5, and the mean mCHEOPS score was 2.3 ± 0.6 for skin dilatation. Finally, the average mCHEOPS score while securing the catheter with stitches was 1.3 ± 0.4. No patient required fentanyl for additional analgesia. No intraoperative complications occurred. The benefits gained from using SCPB performed by an experienced anesthesiologist for hemodialysis catheter placement include providing sufficient analgesia and optimal surgical conditions while avoiding the complications associated with general anesthesia for pediatric patients with renal failure.

Should Nephrology Training Programs Continue to Train Fellows in the Placement of Temporary Hemodialysis Catheters?

Should Nephrology Training Programs Continue to Train Fellows in the Placement of Temporary Hemodialysis Catheters?

Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein.

Background:The number of patients with End-Stage Renal Disease (ESRD) has progressively increased in the population. Kidney transplantation is the specific treatment for such patients; however a majority of patients will require hemodialysis before kidney transplantation. The present study aims to investigate using the external jugular vein (EJV) for Permcath placement in these patients.Materials and Methods:This descriptive and analytical study was conducted in Alzahra Medical Center, Isfahan, in 2012. Catheters were inserted by cutting down the right EJV. The patency rate and potential complications were studied. The obtained data was analyzed using SPSS 21.0.Results:Out of 45 live patients, within three months of surgery, 40 patients (81.6%) had no complications and dialysis continued through Permcath. Permcath Thrombosis occurred in two patients (4.4%). Catheter infection led to the removal of it in one patient (2.2%) 1.5 months after surgery. And accidental catheter removal occurred in one patient.Conclusion:Placement of the permcath in the external jugular vein can be a safe, uncomplicated, and reliable method for patients requiring hemodialysis, and can be a life-saving alternative in patients without accessible internal jugular vein.

Placement of a New Tunneled Hemodialysis Catheter Through the Old Exit Site with Simultaneous Disruption of a Fibroepithelial Sheath

Placement of a New Tunneled Hemodialysis Catheter Through the Old Exit Site with Simultaneous Disruption of a Fibroepithelial Sheath

Characterizing Cardiopulmonary Arrest during Interventional Radiology Procedures

Careful case selection and preparation can prevent most cardiopulmonary arrest (CPA) in the interventional radiology (IR) suite. A series of CPAs was analyzed to provide insight into risk factors for these events. A single-institution CPA database was used to identify all code team activations from January 1, 2005, to May 30, 2011, in the IR department. Medical records were searched for medical history, American Society of Anesthesiologists (ASA) classification, moderate sedation, and outcomes. Procedural data and procedure classification was acquired from the HI-IQ database. There were 36,489 procedures and 23 CPAs during the study period. Of the 23 patients with CPAs, 12 (52%) were male and 11 (48%) female, and average age was 57 years ± 19 (standard deviation). Risk factors included a 56% incidence of diabetes mellitus, 48% incidence of hypertension, and 78% incidence of renal failure. Of the patients with kidney disease, 56% were chronically dialysis-dependent, and an additional 9% were undergoing central venous catheter placement for new hemodialysis. Seventy-eight percent had ASA status of III or greater, and 57% underwent moderate sedation during the procedure. Relative risk of a CPA during dialysis shunt interventions versus arterial interventions was 3.6 (95% confidence interval, 1.0-11.3; P = .045). Eight of 23 (35%) died: one (12%) during resuscitation and seven (88%) after resuscitation (P = .070). The most common comorbidity of patients with CPA in IR was kidney disease, and the most patients who had CPA underwent dialysis access-related procedures.

A single institutional experience of conversion of non-tunneled to tunneled hemodialysis catheters: a comparison to de novo placement

To compare the outcomes of conversion of non-tunneled to tunneled hemodialysis catheters with de novo placement of tunneled catheters and to determine the effect of time to conversion of non-tunneled to tunneled catheters on the incidence of complications. A retrospective data analyses was performed on 1,154 patients who had de novo placement of tunneled hemodialysis catheters (control group) and 254 patients who underwent conversion of non-tunneled to tunneled catheters (study group). The outcomes including technical complications, infection, and catheter dysfunction were compared between the two groups. The technical success rate was 100 % in both the groups with no complications recorded at the time of procedure or within 24 h of insertion. The most common complication encountered in both the groups was catheter dysfunction (15.6 % in controls and 18.1 % in study). Infection rates/100 catheter days for the control and study groups were 0.17 and 0.19, respectively. Infection-free survival was not statistically different between the two groups. The time spent with non-tunneled catheter prior to conversion did not significantly alter the rates of catheter dysfunction and infection in the study group. The efficacy and safety of conversion of non-tunneled to tunneled hemodialysis catheters are similar to de novo placement with no difference in the rates of technical success, catheter dysfunction, or infection. However, the exchange of non-tunneled to tunneled catheter can help in preservation of veins for future vascular access, which is of vital importance in patients with chronic renal disease.

Temporary Hemodialysis Catheter Placement by Nephrology Fellows: Implications for Nephrology Training

The insertion of temporary hemodialysis catheters is considered to be a core competency of nephrology fellowship training. Little is known about the adequacy of training for this procedure and the extent to which evidence-based techniques to reduce complications have been adopted. We conducted a web-based survey of Canadian nephrology trainees regarding the insertion of temporary hemodialysis catheters. Responses were received from 45 of 68 (66%) eligible trainees. The median number of temporary hemodialysis catheters inserted during the prior 6 months of training was 5 (IQR, 2-11), with 9 (20%) trainees reporting they had inserted none. More than one-third of respondents indicated that they were not adequately trained to competently insert temporary hemodialysis catheters at both the femoral and internal jugular sites. These findings are relevant to a discussion of the current adequacy of procedural skills training during nephrology fellowship. With respect to temporary hemodialysis catheter placement, there is an opportunity for increased use of simulation-based teaching by training programs. Certain infection control techniques and use of real-time ultrasound should be more widely adopted. Consideration should be given to the establishment of minimum procedural training requirements at the level of both individual training programs and nationwide certification authorities.