Dialysis catheter placement

Overview

• Procedure similar to central line placement
  • Precise procedural differences will depend on type of line used
• Generally, HD lines have larger diameters (12-14Fr) than TLCs and require additional dilation
• Length varies based on site of insertion
  • Right Internal Jugular: 12-15 cm
  • Left Internal Jugular: 15-20 cm
  • Femoral Vein: 19-24 cm
• HD catheters also tend to be more firm and unforgiving than TLCs, so use caution and ultrasound!
• Location selection
  • Consider coagulopathy, prior surgeries, altered anatomy, ability to tolerate lying flat etc.
  • Generally, RIJ > LIJ > Femoral > subclavian
  • RIJ
    • Direct line to caval-atrial junction --> higher blood flow
    • Less complications such as kinking, obstruction, stenosis
    • Use 13.5Fr, 15cm catheter generally
  • LIJ
    • Tortuosity--> reduced flows
    • Long catheter (19.5cm usually) required
  • Femoral vein
    • Easier/faster but reduces patient mobility, higher risk of infection in longer term
    • Use longest possible catheter to ensure tip reaches distal IVC
  • Subclavian
    • Least preferred site because it is noncompressible
• Dialysis catheters typically have 2 lumens (exceptions exist such as Trialysis catheters)
  • Red lumen= "arterial" = carries blood away from patient to HD machine
  • Blue lumen= "venous" = carries blood from machine back to patient
• Types of dialysis catheters include:
  • Shiley
  • Niagara
  • Trialysis
  • Quinton

Indications

"AEIOU":

• Acidosis that is severe/refractory to medical management
• Electrolyte derangement, typically severe, refractory hyperkalemia
• Ingestion; severe or otherwise untreatable overdose with dialyzable drugs (e.g. methanol, ethylene glycol, lithium, salicylates)
• Overload of volume (e.g. hypervolemia) refractory to medical management
• Uremia

Contraindications

Absolute

• Infection over the placement site
• Anatomic obstruction (thrombosis of target vein, other anatomic variance)
• Site-specific
  • Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs

Relative

• Coagulopathy (see below)
• Distortion of landmarks by trauma or congenital anomalies
• Prior vessel injury or procedures
• Morbid obesity
• Uncooperative/combative patient

Central line if coagulopathic

• Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible, though IJ preferred over subclavian)
• No benefit to giving FFP unless artery is punctured
  • However, consider giving FFP if patient has hemophilia

Equipment Needed

• HD line kit
• Sterile gown, cap, mask, gloves
• Biopatch
• Tegaderm
• Sterile saline flush
• Sterile caps for lumen ports

Procedure

• Identical to CVC placement with exception that second dilator is used prior to inserting line
• Must ensure adequate flow with 20-ml syringe due to high flow through dialysis machine

External Links

• http://maryland.ccproject.com/2014/03/11/vascular-access-renal-replacement-therapy/
• http://www.laminatemedical.com/hemodialysis-catheter-placement/
• https://intensiveblog.com/mastering-vascath/