Bedside Tunneled Hemodialysis Catheter Placement in Patients with COVID-19

Validating the anatomical landmark technique for bedside tunneled central venous catheter placement in the medical intensive care unit

BACKGROUND

A non-tunneled dialysis catheter (nTDC) is often the vascular access of choice to initiate dialysis in an intensive care unit (ICU). In the absence of contraindications, if a patient remains dialysis dependent beyond 2-weeks, the options are either to replace the nTDC with another nTDC or convert to a tunneled dialysis catheter (TDC). As a standard of care, TDCs are placed under fluoroscopic guidance.

OBJECTIVES

To determine if TDCs and other tunneled central venous catheters (tCVC) can be placed safely using anatomical landmark techniques without the use of fluoroscopy.

RESEARCH DESIGN

Subjects that met a predetermined selection criteria underwent placement of tunneled catheters with the use of the anatomical landmark technique. We looked at various outcomes to determine the safety and effectiveness of this technique.

SUBJECTS

One hundred eleven TDCs and other tCVCs were placed using the anatomical landmark technique in the intensive care unit.

RESULTS

All but one (110/111) of the catheters placed had recommended tip placement confirmed by at least one blinded physician. Major complications encountered were bleeding (two cases), pneumothorax (one case), and line associated blood stream infection (one case). We did find a higher-than-expected rate of "unnecessary procedures" with 18/111 lines placed in patients who did not survive beyond 7 days after placement of the catheter.

CONCLUSIONS

Using the anatomical landmark technique for bedside tunneled catheter placement can be an effective approach in the right population.

Global challenges with providing vascular access care during COVID era

BACKGROUND

The COVID-19 pandemic has adversely affected health care systems and dialysis access care in the US and across the globe. Beyond the initial challenges posed by the pandemic and despite the actions taken by health care leaders/organizations/professional societies such as the "Maintaining Lifelines for ESKD Patients" joint statement, there continues to be delays in providing timely care and performing elective and emergent dialysis access procedures worldwide. The aim of this study was to assess the global challenges associated with providing dialysis vascular access care across the international vascular access community during the pandemic.

METHODS

The American Society of Diagnostic and Interventional Nephrology (ASDIN) conducted an online survey in 2021, that was administered to an expert panel of dialysis vascular access specialists and global leaders spanning across the international community. The respondents who are members of ASDIN, Association of Vascular Access and InTerventionAl Renal physicians (AVATAR), Asia Pacific Society of Dialysis Access (APSDA), Peruvian Vascular Access Society (APDAV), and Australia/New Zealand Society of Interventional Nephrology (ANZSIN) reported their experiences in the care of dialysis vascular access, practice patterns, and challenges faced during the COVID pandemic.

RESULTS

Of the 53 individual surveys sent, 16 were opened and 11 (69%) responses were received from across the world and from different practice settings. The survey revealed the continued challenges facing the international community, the stark disparities in care delivery, supply chain disruption and logistical, regulatory, and financial issues that the global community continues to face in the ongoing pandemic.

CONCLUSIONS

The COVID19 pandemic is far from over, and the challenges and barriers to providing dialysis access care seen on the initial ASDIN survey in the US seem to extend across the globe. We describe those results and discuss options, opportunities, and innovative tools to provide dialysis and access care during these trying times.

Safety and durable patency of tunneled hemodialysis catheter inserted without fluoroscopy

BACKGROUND

A tunneled hemodialysis (HD) catheter is preferred due to its lower incidence of infection and malfunction than non-tunneled ones. For safer insertion, fluoroscopic guidance is desirable. However, if the patient is unstable, transfer to the fluoroscopy may be impossible or inappropriate.

METHODS

From June 2019 to September 2022, 81 tunneled HD catheter insertion cases performed under ultrasound guidance without fluoroscopy and 474 cases with fluoroscopy in our institutional HD catheter cohort were retrospectively compared.

RESULTS

Immediate complications, later catheter-associated problems, including infections and catheter dysfunction, were comparable between the two groups (p = 0.20 and p = 0.37, respectively). The patency of tunneled catheters inserted without fluoroscopy was comparable to the patency of tunneled catheters inserted with fluoroscopic guidance (p = 0.90).

CONCLUSION

Tunneled HD catheter insertion without fluoroscopy can be performed safely and has durable patency compared to the insertion with fluoroscopy. Therefore, this method can be considered for the selected unstable patients (e.g., ventilator care) in the intensive care unit.

Placing an appropriate tunneled dialysis catheter in an appropriate patient including the nonconventional sites

Hemodialysis remains the most frequently chosen kidney replacement modality across the world. A well-functioning dialysis vascular access is critical to providing successful dialysis therapy. Despite its drawbacks, central venous catheter is commonly used as a vascular access to initiate hemodialysis therapy in acute and chronic settings. The growing recognition of providing patient centric care and per recommendations from the recently published Kidney Disease Outcome Quality Initiative (KDOQI) Vascular Access Guidelines, selecting the appropriate patient population for a central venous catheter placement involves implementing the End Stage Kidney Disease (ESKD) Life-Plan strategy. The current review examines the circumstances and challenges that increasingly lead to the hemodialysis catheter being the default and the only available choice for patients. The current review outlines the clinical scenarios for selecting an appropriate patient for hemodialysis catheter use for short-term or long-term needs. The review further discusses clinical pointers to assist with the decision-making process on estimation on prospective catheter length selection, particularly in the intensive care unit setting without the aid of conventional fluoroscopic guidance. A hierarchy of conventional and non-conventional access sites is proposed based on KDOQI guidance and multi-disciplinary author experience. Non-conventional sites are reviewed, including complications and technical guidance, for trans-lumbar IVC, trans-hepatic, trans-renal, and other exotic sites.

Safety of Bedside Placement of Tunneled Hemodialysis Catheters in the Intensive Care Unit: Translating from the COVID-19 Experience

Background: Critically ill patients with coronavirus disease 2019 (COVID-19) and kidney dysfunction often require tunneled hemodialysis catheter (TDC) placement for kidney replacement therapy, typically under fluoroscopic guidance to minimize catheter-related complications. This entails transportation of patients outside the intensive care unit to a fluoroscopy suite, which may potentially expose many healthcare providers to COVID-19. One potential strategy to mitigate the risk of viral transmission is to insert TDCs at the bedside, using ultrasound and anatomic landmarks only, without fluoroscopic guidance. Methods: We reviewed all COVID-19 patients in the intensive care unit who underwent right internal jugular TDC insertion at the bedside between April and December 2020. Outcomes included catheter placement-related complications such as post-procedural bleeding, air embolism, dysrhythmias, pneumothorax/hemothorax, and catheter tip malposition. TDC insertion was considered successful if the catheter was able to achieve blood flow sufficient to perform either a single intermittent or 24 h of continuous hemodialysis treatment. Results: We report a retrospective, single-center case series of 25 patients with COVID-19 who had right internal jugular TDCs placed at the bedside, 10 of whom underwent simultaneous insertion of small-bore right internal jugular tunneled central venous catheters for infusion. Continuous veno-venous hemodialysis was utilized for kidney replacement therapy in all patients, and a median catheter blood flow rate of 200 mL/min (IQR: 200–200) was achieved without any deviation from the dialysis prescription. No catheter insertion-related complications were observed, and none of the catheter tips were malpositioned. Conclusions: Bedside right internal jugular TDC placement in COVID-19 patients, using ultrasound and anatomic landmarks without fluoroscopic guidance, may potentially reduce the risk of COVID-19 transmission among healthcare workers without compromising patient safety or catheter function. Concomitant insertion of tunneled central venous catheters in the right internal jugular vein for infusion may also be safely accomplished and further help limit personnel exposure to COVID-19.