Complications of catheters: tunneled and nontunneled

Initial Experience of Using First-Person Wearable Video Recording Technology During Central Venous Catheter Placement in the Cardiac Operating Room

OBJECTIVE

The aim of this study was to use wearable video-recording technology to measure precisely the timing of discrete events during perioperative central venous catheter (CVC) placements.

DESIGN

A single-center, observational, exploratory study on the use of wearable video-recording technology during intraoperative CVC placement.

SETTING

The study was conducted at a University Hospital.

PARTICIPANTS

Clinical anesthesia residents, cardiothoracic anesthesia fellows, and attending anesthesiologists participated in this study.

INTERVENTIONS

Participants were asked to use eye-tracking glasses prior to the placement of a CVC in the cardiac operating rooms. No other instruction was given to the participants.

MEASUREMENTS AND MAIN RESULTS

The authors measured the total time to complete the CVC placement, phase-specific time, and specific times of interest. They compared these times across 3 training levels and tested differences with analysis of variance. The authors' findings indicated significant differences in total CVC placement time when the procedure included a pulmonary artery catheter insertion (1,170 ± 364, 923 ± 272, and 596 ± 226 seconds; F2,63 = 12.71, p < 0.0001). Additionally, they found differences in interval times and times of interest. The authors observed a reduction of variability with increasing experience during the CVC placement phase.

CONCLUSIONS

In this observational study, the study authors describe their experience using first-person wearable video-recording technology to precisely measure the timing of discrete events during CVC placement by anesthesia residents and anesthesiologists. Future work will leverage the eye-tracking capabilities of the existing hardware to identify areas of inefficiency to develop actionable targets for interventions that could improve trainee performance and patient safety.

Clinical Outcomes of Standardized Central Venous Catheterization Simulation Training: A Comparative Analysis

OBJECTIVE

A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital.

DESIGN AND PARTICIPANTS

A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022.

SETTING

A teaching hospital institution in Pennsylvania.

RESULTS

Results showed a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported.

CONCLUSION

These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

Prognosis of urgent initiation of peritoneal dialysis: a systematic review and meta-analysis

OBJECTIVES

Currently, there is no consensus on the optimal timing for the initiation of peritoneal dialysis (PD) after catheter placement.

DESIGN

Systematic review and meta-analysis.

EXACT DATE OF DATA COLLECTION

From inception till July 31, 2023.

MAIN OUTCOME MEASURES

To assess the outcomes and safety of unplanned PD initiation (<14/7 days after catheter insertion) in cohort studies.

RESULTS

Fifteen studies involving 3054 participants were included. (1) The risk of unplanned initiation of leakage and Obstruction was no difference in both the break-in period (BI) <14 and BI < 7 groups. (2) Catheter displacement was more likely to occur in the emergency initiation group with BI < 7. (3) No significant differences were observed between the two groups regarding infectious complications. (4) There was no difference in transition to HD between patients with BI < 7 and BI < 14 d.

CONCLUSION

Infectious complications of unplanned initiation of peritoneal dialysis did not differ from planned initiation. Emergency initiation in the BI < 7 group had higher catheter displacement, but heterogeneity was higher. There were no differences in leakage or obstruction in either group. Catheter survival was the same for emergency initiation of peritoneal dialysis compared with planned initiation of peritoneal dialysis and did not increase the risk of conversion to hemodialysis.

REGISTRATION

This meta-analysis was registered on PROSPERO (https://www.crd.york.ac.uk/PROSPERO/, number: CRD42023431369).

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

The effect of refined nursing education on improving the urination of patients after renal biopsy

BACKGROUND

To investigate the clinical effect of better nursing education on patients' postoperative urination after renal biopsy.

METHODS

In this study, patients who underwent renal biopsy in the Department of Nephrology at our hospital were selected as the observation group (July-December 2018, n = 120) and control group (January-June 2018, n = 110) and received refined nursing education and routine nursing education, respectively. Postoperatively, the causes of dysuria after puncture, the degree of postoperative pain, and the urination mode were compared between the two groups.

RESULTS

Six patients in the observation group and 23 patients in the control group needed urethral catheterization, accounting for about 5% and 15.2%, respectively. Therefore, the postoperative catheterization rate in the observation group was significantly lower than the control group, with a statistically significant difference.

CONCLUSION

The refined nursing education proposed in this study can effectively improve urinary dysfunction after renal biopsy and has a clinical promotional value.

Assessment of dysfunctional tunneled hemodialysis catheters and outcome of endovascular salvage techniques: a simple solution to a complex problem

Objective

The aim of this study was to evaluate the causes of the dysfunctional tunneled cuffed catheters (TCCs) using multi-spiral computed tomography venography (MSCTV), and to analyze the outcomes of endovascular salvage techniques.

Material and methods

This retrospective review data from 27 patients who experienced TCC dysfunction between July 1, 2016 and January 31, 2021 was conducted. Patients' demographic data, clinical signs and symptoms, and imaging data were collected from interventional radiology database.

Results

MSCTV showed a range of abnormalities in the hemodialysis (HD) patients, including central venous occlusion (n = 4), fibrin sheath formation (n = 3), malposition of the catheter tips (n = 4), central venous perforation (n = 1), thrombus formation (n = 12), regular catheter exchange without determined lesions (n = 3). Interventional catheter salvage procedures were performed, such as catheter exchange, balloon disruption of a fibrin sheath, angioplasty for central vein stenosis, and stent deployment. The technical success rate for catheter insertions was 100%, and no procedure-related severe complications were observed. The 30-day catheter patency for all assessable catheters was 85.2%.

Conclusion

The use of MSCTV showed abnormal findings in almost 88.9% of cases concerning dysfunctional TCC. In this study, the examined appropriate endovascular techniques were found to be safe and technically successful, with a low incidence of procedure-related complications.

Análisis de la influencia de la pandemia por el virus SARS-CoV-2 sobre la tasa de bacteriemia en catéteres venosos tunelizados en una unidad de hemodiálisis

Antecedentes: La infección relacionada con catéter venoso central (CVC) está asociada a una elevada morbimortalidad y se ha relacionado con la bacteriemia asociada a CVC, disfunciones de catéter, la manipulación y las medidas higiénicas tomadas durante la misma. Objetivo: El objetivo del presente estudio fue comparar la tasa de bacteriemia entre los años 2019 y 2020, primer año de pandemia por el virus SARS-CoV-2, en una unidad de hemodiálisis de un hospital de la Comunidad Autónoma de Madrid. Material y Método: Se ha llevado a cabo un estudio observacional retrospectivo transversal en el que se compararon datos relativos a la manipulación y al funcionamiento del catéter, y tasa de bacteriemias relacionadas con el catéter entre los años 2019 y 2020 a través de la base de datos de la unidad. Resultados: En 2019 se incluyeron 35 pacientes, que presentaron una tasa de bacteriemia de 1,42/1000 días de catéter y 29 pacientes en 2020, con una tasa de bacteriemia de 1,82/1000 días de catéter, no encontrándose diferencias significativas (p=0,54), no encontrando un riesgo de bacteriemia incrementado o disminuido durante el primer año de pandemia producida por el virus SARS-CoV-2. Conclusiones: Como principal conclusión de este estudio, podemos afirmar que no se ha evidenciado que la llegada de la pandemia producida por la enfermedad del coronavirus y las medidas adoptadas frente al virus SARS-CoV-2, tanto organizacionales como de prevención, sean un factor de riesgo o protección respecto a la tasa de bacteriemia, probablemente debido al bajo número de eventos encontrados.

Análisis de la influencia de la pandemia por el virus SARS-CoV-2 sobre la tasa de bacteriemia en catéteres venosos tunelizados en una unidad de hemodiálisis

Antecedentes: La infección relacionada con catéter venoso central (CVC) está asociada a una elevada morbimortalidad y se ha relacionado con la bacteriemia asociada a CVC, disfunciones de catéter, la manipulación y las medidas higiénicas tomadas durante la misma. Objetivo: El objetivo del presente estudio fue comparar la tasa de bacteriemia entre los años 2019 y 2020, primer año de pandemia por el virus SARS-CoV-2, en una unidad de hemodiálisis de un hospital de la Comunidad Autónoma de Madrid. Material y Método: Se ha llevado a cabo un estudio observacional retrospectivo transversal en el que se compararon datos relativos a la manipulación y al funcionamiento del catéter, y tasa de bacteriemias relacionadas con el catéter entre los años 2019 y 2020 a través de la base de datos de la unidad. Resultados: En 2019 se incluyeron 35 pacientes, que presentaron una tasa de bacteriemia de 1,42/1000 días de catéter y 29 pacientes en 2020, con una tasa de bacteriemia de 1,82/1000 días de catéter, no encontrándose diferencias significativas (p=0,54), no encontrando un riesgo de bacteriemia incrementado o disminuido durante el primer año de pandemia producida por el virus SARS-CoV-2. Conclusiones: Como principal conclusión de este estudio, podemos afirmar que no se ha evidenciado que la llegada de la pandemia producida por la enfermedad del coronavirus y las medidas adoptadas frente al virus SARS-CoV-2, tanto organizacionales como de prevención, sean un factor de riesgo o protección respecto a la tasa de bacteriemia, probablemente debido al bajo número de eventos encontrados.

Staphylococcus aureus accumulation at the tip of hemodialysis catheters with or without tip side holes in catheter related bloodstream infection in a large animal

BACKGROUND

Eighty percent of hemodialysis patients start their dialysis with a tunneled hemodialysis catheter. Catheter related bacteremia is the second most common cause of death in these patients. Side holes near the tips of the tunneled cuffed central venous catheters are associated with accumulation of thrombus, which can lead to catheter dysfunction and, possibly, also to catheter-related infection. To assess the hypothesis that a catheter without side holes would be associated with less bacterial growth, this study compared the susceptibility of a side-hole-free catheter to accumulation of pathogenic bacteria at the catheter tip with that of two catheters which have side holes.

METHODS

Eight tunneled cuffed double-lumen central venous catheters were inserted into both jugular veins of four sheep; one side-hole-free and one control catheter with side holes at the tip in each animal. Staphylococcus aureus bacteria were then infused intravenously to cause bacteremia. Six hours later, the catheters were removed, the clots that accumulated in their tips were collected and cultured, and the bacterial colonies were counted after additional 12 h of incubation.

RESULTS

Bacteria grew on culture plates seeded with the clot homogenate obtained from the tips of all catheters. The colony counts from the catheters with side holes at the tip exceeded the colony counts of bacteria accumulated in the tips of the side-hole-free hemodialysis catheters by one or more orders of magnitude, with a difference of at least two orders of magnitude observed in three of the four intra-animal comparisons.

CONCLUSIONS

In paired intra-animal post-inoculation comparison made in this limited study, fewer colony forming units of pathogenic bacteria accumulated at the tip of the side-hole-free catheters than at the tips of the catheters which have side holes. This may translate to a decreased rate of catheter-related blood stream infections in the side-hole-free catheters.

Bleeding Complications in Uremic Patients After Ultrasound-Guided Central Venous Catheter Placement

Introduction

Bleeding associated with elevated blood urea nitrogen (BUN) is a known complication. Patients with uremia require a central venous catheter insertion by dialysis. The relation between BUN and bleeding complications during central venous catheter insertion is not yet clear.

Objective

We described the frequency of complications associated with central venous catheter implantation in uremic patients and evaluated the statistical relationship between bleeding complications and catheter type, number of punctures, and catheter insertion site. Also, we determined if any value of BUN is associated with bleeding complications.

Methods

We included patients with a serum value of BUN >70 mg/dl that required insertion of a central venous catheter. The quantitative variables were expressed through the measure of central tendency. A bivariate analysis and a ROC curve were performed.

Results

A total of 273 catheters were included in this study. Bleeding complications were detected in 69 cases (25.3%), and local bleeding was the most frequent complication in 51/69 cases. Statistically significant association was not established. We did not find a specific cut-off value directly related to BUN levels and the rate of complications.

Conclusion

Bleeding complications associated with the insertion of central venous catheter and the suspected disorder of hemostasis given by BUN levels >70 mg/dl are common. It was not possible to determine a BUN cut-off value to predict complications. The association analysis was not conclusive. High BUN levels should not be considered a high-risk condition for central venous cannulation under ultrasound guidance performed by trained personnel.

One patient, two malpositioned hemodialysis catheters, (hepatic vein and ascending lumbar vein), no fluoroscopy

Cuffed-tunneled hemodialysis catheter (CTHC) application via the femoral vein is a safe and effective alternative when peripheral vascular routes are exhausted for hemodialysis in patients with end-stage renal disease. Also, imaging methods have become more important for the diagnosis or prevention of the possible complications that may develop during or after catheter placements. Here, we present a case of hemodialysis catheter dysfunction due to the insertion of a CTHC tip into the hepatic vein, and into the left ascending lumbar vein at the next attempt. We think that the use of fluoroscopy, whether in the first catheter intervention or catheter change, is extremely important in preventing possible complications that may develop, or detecting them as soon as possible.

An unusual complication of prolonged tunneled cuffed hemodialysis catheter

A 57-year-old male patient visited our center owing to abnormal tunneled cuffed hemodialysis catheter (TC-HDC). He had been undergoing hemodialysis for 44 months. Hemodialysis was performed using a TC-HDC, which became dilatated between the hub and exit site 19 months after the initiation of hemodialysis. The first TC-HDC was exchanged using over the guidewire method. The second TC-HDC was maintained for 25 months after catheter exchange. However, the second TC-HDC was repeatedly dilatated 25 months later from the first catheter exchange. We re-exchanged the dilatated TC-HDC to the new TC-HDC using over the guidewire method. Our case presented general dilatation of both lumens without leakage. The portion of catheter dilatation was limited between the hub and exit site. The embedded segment of the catheter was preserved owing to encasement of the adjacent tissue. Our case showed that clinicians should inspect both exposed and embedded segments to prevent further catheter injury and exchange the catheter before the development of complications.

Erroneous Central Venous Catheter Placement: Multidisciplinary Primary Surgical Repair of the Vertebral Artery

Central venous catheters are a common practice in critical care medicine. These lines are of particular importance when a patient needs large volume resuscitation or medications that cannot be infused through a peripheral line. Even though central venous catheters are frequently utilized, they are associated with potentially significant risks that one must be aware of when attempting placement. The anatomy and pertinent complications are key for any healthcare professional to be aware of during this procedure. As such, vascular injury has been described in the literature, but vertebral artery injury and common repair techniques are less common. Primary repair of the second vertebral artery segment is infrequently detailed in the literature and this report describes pertinent case details and plan of action for identification and repair of iatrogenic vertebral artery injury following catheter placement.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Factors Affecting Cuff Extrusion of Tunneled Hemodialysis Catheters

PURPOSE

To identify patient and procedural factors associated with extrusion of the Dacron cuff from the subcutaneous tunnel of tunneled hemodialysis catheters (THDCs).

MATERIALS AND METHODS

Single center 5-year retrospective analysis of 625 catheters in 293 adult patients. Patient data included age, gender, body mass index (BMI), and common comorbidities. Procedural details included type of procedure (new insertion vs. exchange), operator seniority, side of insertion, catheter model and presence of catheter wings skin-sutures. Complications were reported as cumulative risk over time and Cox proportional hazards model was used to evaluate risk factors for cuff extrusion (CE).

RESULTS

Median patient follow-up was 503 days (188,913 catheter-days) and median catheter survival 163 days. CE occurred in 23.8% of catheters, at a rate of 0.79 per 1,000 catheter-days and a median time of 64 days. It was more common than infection (14.6%) and inadequate flow (15.5%). The 1-month and 12-month risk of CE was 5.9% and 21.3% respectively. A first episode of CE was a strong predictor of future CE episodes. The only patient factor that affected the risk of CE was BMI (Hazard Ratio 2.36 for obese patients). Procedural factors that affected the risk of CE, adjusted for BMI, were catheter model, type of procedure (lower risk for new insertions) and catheter wings skin-sutures; the latter reduced the 30-day CE risk by 76% without increasing catheter-related infections.

CONCLUSION

Cuff extrusion is common in long-term THDCs. The risk increases with obesity, history of previous cuff extrusion, certain catheter models and absence of wing-sutures.

Bilateral pleural effusion and pneumomediastinum: rare complication resulting from punctured left subclavian vein following insertion of PICC line for total parenteral nutrition

This is a rare case of development of bi-lateral chylous pleural effusion (containing parenteral nutrition material) along with pneumomediastinum due to punctured left subclavian vein following insertion of a peripherally inserted central venous catheter (PICC) line. Parenteral nutrition is usually preferred for patients unable to tolerate enteral feeding. Due to hypertonicity of the total parenteral nutrition material, it is usually administered via internal jugular or subclavian vein which have a rapid blood flow; therefore, resulting in adequate mixing. Literature studies are yet to clearly explain the communications between two pleural cavities; therefore, development of bilateral pleural effusions in association with pneumomediastinum makes this case more intriguing. We present the journey of a 43-year-old woman who required insertion of bilateral chest drains, followed by sternotomy and repair of the left subclavian vein after she was found in hypoxic respiratory failure 2 days following insertion of PICC line into her left subclavian vein.

Life-Threatening Mediastinal Hematoma Formation After Removal of the Hemodialysis Catheter in a Boxer: A Case Report

A 4-year-old female Boxer was referred for renal replacement therapy 2 days after observed grape ingestion. An 11-French dual-lumen dialysis catheter was placed into the right jugular vein and continuous renal replacement therapy was initiated for 66 h. Afterwards the patient received enoxaparin subcutaneously as a thromboprophylaxis. Four hours after removal of the dialysis catheter the patient developed severe dyspnea with hypercapnia and signs of hemorrhagic shock. Bedside ultrasound and X-rays of the thorax revealed a soft tissue opacity dorsally of the trachea, located in the mediastinum. The findings were consistent with mediastinal bleeding and hematoma formation. Blood gas examination indicated hypoventilation. The dog was managed conservatively with multiple blood transfusions and mechanical ventilation. The patient survived to discharge, and the hematoma was fully absorbed in the radiographs after 17 days. Patients with impaired kidney function should receive individualized enoxaparin dosage adjusted to anti-Xa levels and should be strictly monitored for complications. Mediastinal hemorrhage and hematoma formation should be considered as a potential complication in patients receiving a jugular vein catheter.

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

PURPOSE

To determine the rate of recurrent infection of ICU patients who underwent tunneled dialysis catheter (TDC) exchange or removal for bloodstream infection.

MATERIALS AND METHODS

Forty 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.

RESULTS

There 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.

CONCLUSIONS

High 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.

Wireless, implantable catheter-type oximeter designed for cardiac oxygen saturation

Accurate, real-time monitoring of intravascular oxygen levels is important in tracking the cardiopulmonary health of patients after cardiothoracic surgery. Existing technologies use intravascular placement of glass fiber-optic catheters that pose risks of blood vessel damage, thrombosis, and infection. In addition, physical tethers to power supply systems and data acquisition hardware limit freedom of movement and add clutter to the intensive care unit. This report introduces a wireless, miniaturized, implantable optoelectronic catheter system incorporating optical components on the probe, encapsulated by soft biocompatible materials, as alternative technology that avoids these disadvantages. The absence of physical tethers and the flexible, biocompatible construction of the probe represent key defining features, resulting in a high-performance, patient-friendly implantable oximeter that can monitor localized tissue oxygenation, heart rate, and respiratory activity with wireless, real-time, continuous operation. In vitro and in vivo testing shows that this platform offers measurement accuracy and precision equivalent to those of existing clinical standards.

Bedside Tunneled Hemodialysis Catheter Placement in Patients with COVID-19

Background

COVID-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.

Methods

A 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.

Results

Of 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%.

Conclusions

Bedside 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.

Complications of Peripherally Inserted, Large-Bore, Rapid-Infusion Catheters in Orthotopic Liver Transplant Patients

BACKGROUND

At our institution, peripherally inserted, 8.5-French rapid-infusion catheters (RICs) are placed for high-flow administration of intravenous fluids and blood products during liver transplant (LT). We sought to estimate the incidence of RIC placement-associated complications in LT patients.

METHODS

Electronic health records of all patients who underwent LT from January 2008 through December 2017 were retrospectively reviewed. RIC-related complications were deemed clinically significant if they required surgical consultation or intervention due to infiltration. Univariable and multivariable logistic regression analyses were used to evaluate associations between patient characteristics and RIC complications.

RESULTS

In total, 839 LT patients who received RICs were identified; of these, 14 (1.67%) had RIC-related complications, and 7 (0.83%) required surgical consultation. No patients needed fasciotomy or wound débridement due to a RIC complication, and no patients had permanent sequelae. In the multivariable logistic regression analysis, only an increase in international normalized ratio (INR) from 1.4 to 2.2 (equivalent to the interquartile range of observed INR values) increased the odds of complications due to RIC placement (odds ratio [95% CI], 1.98 [1.10-3.56]; P = .02).

CONCLUSIONS

We observed a low incidence of perioperative RIC-related complications (1.7%). No patients had permanent RIC-related complications.

Solutions to stuck tunneled cuffed catheters in patients undergoing maintenance hemodialysis

OBJECTIVE

To study and discuss treatments for stuck tunneled cuffed catheter in patients undergoing maintenance hemodialysis.

METHOD

Retrospectively analyzing clinical data of 13 patients with stuck tunneled cuffed catheter in the Kidney Disease Center of the First Affiliated Hospital, College of Medicine, Zhejiang University in the period between September 2012 and October 2018. All patients failed to remove hemodialysis catheters by regular technique. The stuck catheters were treated by thoracotomy, endoluminal percutaneous transluminal angioplasty with blunt dissection or embedded and left in situ.

RESULTS

In 13 patients, one was successfully treated by thoracotomy, one failed to remove the catheter by regular technique and blunt dissection, and the stump of the catheter was clamped and buried in the subcutaneous fascia of the neck, and the other 11 were treated by endoluminal percutaneous transluminal angioplasty with blunt dissection. The average time of catheter removal procedure is 25 min, the overall success rate is 92.3%, and the success rate of percutaneous transluminal angioplasty is 100%.

CONCLUSION

Thoracotomy is an efficient way to treat stuck catheter but is limited by its high risk and complications. Leaving part of catheter in situ may increase the risk of central vein stenosis. Comparing to the former two, endoluminal percutaneous transluminal angioplasty is a safe, efficient, and practical way for stuck catheters and should be recommended as the first choice.

Comparative Study on the Outcomes of Elective-Start versus Urgent-Start Peritoneal Dialysis Catheter Placement

The aim of this study is to compare the outcomes of the elective-start versus urgent-start use of peritoneal dialysis (PD) catheters using percutaneous radiologic or laparoscopic techniques. Patients having their first peritoneal dialysis catheter placed and used between January 2005 and January 2018 were identified, and their medical records were retrospectively reviewed. Two groups were identified: elective-start (n = 211) and urgent-start (n = 29). Patient's demographics were similar between the two groups with the exception of age, which was higher in the elective-start group. The catheter complication rates and catheter removal rates at 3 and 12 months, mean days-to-first complication, mean days-to-catheter removal, and overall patient survival at 12 months were analyzed. Catheter complication rates at 3 and 12 months were similar between the two groups (27.8% and 48.9%, respectively, in the elective-start group versus 35.9% and 54.2%, respectively, in the urgent-start group, p=0.415). The catheter removal rates at 3 and 12 months were also similar between the two groups (p=0.088). Catheter leak was higher in the urgent-start group (13.8% versus 3.3%, respectively, p=0.011). There was no difference between the elective-start and the urgent-start groups in the mean days-to-first complication (95 vs 69, p=0.086), mean days-to-catheter removal (145 vs 127, p=0.757), and overall patient survival at 12 months (100% vs 97%, p=0.41). In conclusion, apart from catheter leak, there were similar rates of catheter complication and removal for PD catheter used for the elective-start compared to the urgent-start PD. Furthermore, the technique of placement did not affect the outcomes.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Improvement of catheter-related outcomes after application of tunneled cuffed hemodialysis catheter insertion without fluoroscopy

BACKGROUND

Non-tunneled catheters (NTCs) are used for hemodialysis (HD) in many centers in which fluoroscopy is not easily accessed despite high complication rates and conditions requiring long-term HD. Therefore, here we aimed to evaluate the superiority of catheter-related outcomes after the application of tunneled cuffed catheter (TCC) without fluoroscopy versus unconditioned NTC insertion.

METHODS

We divided the participants into two phases: those receiving NTCs between March 2010 and February 2011 (phase I), and those receiving TCCs or NTCs between March 2011 and February 2012 (phase II). Catheter survival, nurse satisfaction, and reasons for catheter removal were analyzed.

RESULTS

Two hundred and sixty patients in phase I and 300 patients in phase II were enrolled in this study. The success rate of TCC insertion was 99.2%. The catheter survival rate in phase I was 65.5% at 1 month, while that in phase II was 74.9% at 1 month (p=0.023). We compared catheter survival between TCCs and NTCs for all periods regardless of phase. The TCC survival rate was higher than the NTC survival rate (p<0.001). Catheter-associated problems led to catheter removal in 97 patients (26.6%) in phase I and 68 patients (18.5%) in phase II (p=0.009). Among 14 HD nurses, all reported being satisfied with manipulation during pre-/post-HD, manupulation during HD, and overall. Eleven HD nurses (78.6%) reported being satisfied with the workload.

CONCLUSION

Compared with unconditional NTC insertion for HD, TCC insertion without fluoroscopy improved the overall catheter survival and nurse satisfaction rates.

(F)utility of "routine" postprocedural chest radiograph after hemodialysis catheter (central venous catheter) insertion

A routine postprocedural chest radiograph had been a safe, checklist-based final step of the procedure, since the start of central venous catheter insertion for hemodialysis to check the position of the catheter tip and to rule out complications. However, the chest radiograph is a suboptimal method to rule out complications like pneumothorax and is not a reliable test to confirm its position. Although it is relatively inexpensive, it is labor-intensive and exposes patient to unnecessary radiation exposure, cost, and often results in delayed use of the catheter. Various studies question the value of a routine chest radiograph as a screening test to rule out the mechanical complications of catheter insertion. We, in this brief viewpoint, present evidence to support the futility of a routine postprocedural chest radiograph in majority of asymptomatic patients and support Choosing Wisely Initiative to avoid low-value studies. However, it should be considered under specific indications, as discussed.

Risk of Complications and Survival of Patients Dialyzed with Permanent Catheters

Background and Objectives: An increase in the incidence of end-stage renal disease (ESRD) is associated with the need for a wider use of vascular access. Although arteriovenous (A-V) fistula is a preferred form of vascular access, for various reasons, permanent catheters are implanted in many patients. Materials and Methods: A retrospective analysis of clinical data was carried out in 398 patients (204 women) who in 2010-2016 were subjected to permanent dialysis catheters implantation as first vascular access or following A-V fistula dysfunction. The factors influencing the risk of complications related to vascular access and mortality were evaluated and the comparison of the group of patients with permanent catheter implantation after A-V fistula dysfunction with patients with first-time catheter implantation was carried out. Results: The population of 398 people with ESRD with mean age of 68.73 ± 13.26 years had a total of 495 permanent catheters implanted. In 129 (32.6%) patients, catheters were implanted after dysfunction of a previously formed dialysis fistula. An upward trend was recorded in the number of permanent catheters implanted in relation to A-V fistulas. Ninety-two infectious complications (23.1%) occurred in the study population in 65 patients (16.3%). Multivariate analysis showed that permanent catheters were more often used as the first vascular access option in elderly patients and cancer patients. Mortality in the mean 1.38 ± 1.17 years (min 0.0, max 6.70 years) follow-up period amounted to 50%. Older age and atherosclerosis were the main risk factors for mortality. Patients with dialysis fistula formed before the catheter implantation had a longer lifetime compared to the group in which the catheter was the first access. Conclusion: The use of permanent catheters for dialysis therapy is associated with a relatively high incidence of complications and low long-term survival. The main factors determining long-term survival were age and atherosclerosis. Better prognosis was demonstrated in patients after the use of A-V fistula as the first vascular access option.

Totally percutaneous endoluminal ballooning of stuck hemodialysis catheters: One-year experience of a referral center

The stuck catheter is an uncommon but dreaded complication of dialysis line placement. It always finds the operator unaware and often requires procedure modification or reschedule. Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from wall adhesions. The purpose of the current study was to present a totally percutaneous variation of endoluminal stuck catheters ballooning, along with our experience in terms of safety and feasibility. A major difference presented in respect to previous techniques is that this modification does not require isolation of the distal line stump at the venous entry point by tissue dissection, thus reducing procedural time and difficulty. We presented a case series of five lines that were ballooned by navigating low-profile material directly from the cutaneous exit of the lines, with optimal results (100% success). The findings of this investigation provide additional evidence with respect to the safety and effectiveness of endoluminal ballooning of Tesio lines and offer a new variation of endoluminal ballooning which we found easy to perform, safe, and effective.

Inadvertent Central Arterial Catheterization: An Unusual Cause of Ischemic Stroke

Central venous catheter (CVC) insertion is extensively utilized in Intensive Care Units for evaluation of hemodynamic status, administration of intravenous drugs, and for providing nutritional support in critically ill patients. Unfortunately, CVC use is associated with complications including lung injury, bleeding, infection, and thrombosis. We present a patient with an acute ischemic stroke from an inadvertently placed CVC into the right common carotid artery. A 57-year-old male presented to our institution for left hemiplegia and seizures 2 days after a CVC was placed. He was found to have a right frontal ischemic stroke on computed tomography (CT). CT angiography noted that the catheter was arterial and had a thrombosis around it. He was started on a low-dose heparin infusion. A combination of cardiothoracic surgery and interventional cardiology was required to safely remove the catheter. Central arterial catheterization is an unusual cause for acute ischemic stroke and presents management challenges.

Central Line Catheters and Associated Complications: A Review

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Safety of Pediatric Peripheral Blood Stem Cell Harvest in Daycare Setting: An Institutional Experience

Introduction

Children serving as a donor for their siblings will require anesthesia or sedation. In view of shortage of time and space in operating room setting, peripheral blood stem cell (PBSC) harvest is performed as a daycare procedure.

Aim

This study aims to find out whether performing PBSC harvest in hematology blood collection area as a daycare procedure is safe or not.

Settings and Design

This secondary analysis included 164 pediatric PBSC harvest (154 pediatric donors, of which 10 had repeat harvesting done) donors, performed under anesthesia, in the Department of Hematology, between January 2009 and June 2017.

Materials and Methods

Donors were examined, informed consent was obtained, and adequate premedications were ensured. Induction was intravenous for cooperative donors or inhalational sevoflurane followed by intravenous maintenance infusion using either face mask or a laryngeal mask airway (LMA). During the procedure, vitals are monitored with a noninvasive monitor. Normal hemodynamics were ensured before transferring the children to the ward.

Statistical Analysis

Statistical analysis was performed using SPSS 16.0 statistical software. Descriptive statistics and frequencies were used for the data description.

Results

A total of 137 donors (median age of 5 years) were induced with sevoflurane and LMA was used in 84 children and face mask in 53. Twenty-seven children cooperated for intravenous induction. Various combinations of propofol, dexmedetomidine, and ketamine were used with respiratory and hemodynamic stability. The median duration of anesthesia was 250 (165-375) min. The recovery from anesthesia was smooth with a median wake-up time of 20 (5-60) min.

Conclusion

This retrospective analysis demonstrates that nonoperating room anesthesia for pediatric age group for PBSC harvest can be safely and successfully accomplished outside the operation room setting by a consultant anesthesiologist.

Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis

OBJECTIVE

While placement of tunneled dialysis catheters for hemodialysis access is considered a routine procedure, it is associated with a small chance of mechanical complications. Because the literature examining these issues is not recent and our impression of the incidence of these postprocedural complications is at variance with the existing literature, we decided to review our experience.

METHODS

Since 1998, our vascular service has placed 1766 tunneled hemodialysis catheters in 1065 patients for hemodialysis access. All catheters were placed with ultrasound guidance for the puncture, with selective use of a micropuncture set for patients with low-volume status. All patients underwent chest radiography at the end of each procedure.

RESULTS

The average age of the patients was 61 ± 21 (standard deviation) years. Among the 1065 patients, 44% were female; 93% of catheters were placed in the right internal jugular vein and 7% in the left internal jugular vein. The prevalence of diabetes and hypertension in our population of patients was 52% and 72%, respectively. In this consecutive series, no case of postprocedure hemothorax or pneumothorax was encountered. Two cutdowns had to be performed because of injury to branches of the external carotid artery. Three patients had to have a subsequent revision because of malpositioning of the catheter.

CONCLUSIONS

Using modern-day techniques, the incidence of mechanical complications during placement of tunneled catheters can be diminished. Hence, routine use of ultrasound guidance for insertion of tunneled dialysis catheters should become the standard of care.

Spontaneous bleeding of thoracoacromial artery mimicking tunneled cuffed catheter-related complication: A case report

RATIONALE

The chronic complications caused by the tunneled cuffed catheter in chronic dialysis patients are infection and catheter dysfunction. While bleeding due to this access can occur occasionally.

PATIENT CONCERNS

We present a 92-year-old woman with a 6-year history of regular hemodialysis (HD). For the past 2 years, she has been receiving HD via a tunneled cuffed catheter placed in the right internal jugular vein. She suffered from a right chest subcutaneous hematoma near the catheter without recent trauma. The increasing size of hematoma after dialysis, and the oozing from the outlet of the catheter were also observed.

DIAGNOSIS

Computed tomography of chest and angiography were done and showed that the hematoma was caused by thoracoacromial artery bleeding, which was near the puncture site of the tunneled cuffed catheter.

INTERVENTIONS

Fluid resuscitation, blood transfusion, surgical drainage, and parenteral antibiotics were prescribed.

OUTCOMES

Patient recovered fully without any further sequelae.

LESSONS

Spontaneous bleeding of thoracoacromial artery is rare and clinicians should keep in mind as a differential diagnosis in patient with new-onset hematoma over anterior chest wall. Early diagnosis and treatment are important in such cases.

Delayed malposition of a double-lumen hemodialysis catheter that caused hemorrhage and hypovolemic shock: A case report

RATIONALE

Double-lumen hemodialysis catheters are commonly used as temporary hemodialysis routes. Complications include infection, thrombosis, cardiac arrhythmia, entrapped guide wire, and malposition. We report a rare complication of delayed hemodialysis catheter malposition that caused retroperitoneal hemorrhage and hypovolemic shock during hemodialysis.

PATIENT CONCERNS

A 72-year-old female patient who was receiving hemodialysis was referred to our emergency department because of general discomfort and decreased blood pressure (BP) after her regular hemodialysis. She had undergone surgery for a left forearm arteriovenous pseudoaneurysm and received a temporary hemodialysis catheter insertion via the left femoral vein 2 weeks before. The initial blood examination revealed a mildly decreased baseline hemoglobin level (7.2 g/dL) and hyperkalemia (5.9 mmol/L). Her BP recovered after fluid resuscitation. She was administered hemodialysis again, following which her BP reduced and a change in consciousness developed.

DIAGNOSIS

Chest and abdominal computed tomographies were performed to exclude acute vascular problems and showed a hemodialysis catheter tip protruding from the left iliac vein and hematoma in the left retroperitoneal space and pelvic cavity.

INTERVENTIONS

Intubation, fluid resuscitation, vasopressor administration, and blood transfusion were performed. She was admitted to the intensive care unit. The left femoral hemodialysis catheter was removed.

OUTCOMES

Follow-up computed tomography revealed resolution of the retroperitoneal space hematoma. She was transferred to the ordinary ward 18 days later with a stable hemodynamic status. Unfortunately, she developed hospital-acquired pneumonia and arteriovenous shunt infection, and died from respiratory failure and sepsis on the 34th day in our hospital.

LESSONS

Femoral double-lumen catheter malposition is rare and potentially fatal. Emergency physicians should be aware of situations wherein a patient's BP declines markedly soon after a hemodialysis initiation.

Outcomes of tunneled internal jugular venous catheters for chronic haemodialysis at the University College Hospital, Ibadan, Nigeria

Introduction

vascular access is an important aspect of haemodialysis treatments and determinant of patient outcomes. Arteriovenous (AV) fistula has been described as the preferred haemodialysis vascular access for patients on chronic dialysis. There continues to be a challenge with the creation of AV fistula, due to shortage of vascular surgeons skilled in the AV fistula creation particularly in source limited setting. We described the outcomes of the tunneled internal jugular venous catheters amongst our patients at the University College Hospital (UCH) Ibadan.

Methods

a retrospective study of patients on maintenance haemodialysis at the UCH, Ibadan, we reviewed the records of all patients on chronic dialysis over a period of 5 years. Information obtained include demographics, types and aetiology of renal failure, types of vascular access, observed complications and outcomes.

Results

a total number of 147 catheters were inserted during the period under review, 94 were males while 53 were females. The age range was 18-85 years while the mean age was 46.3 ± 17.2 years. The range and mean duration for Tunneled Dialysis Catheter (TDC) carriage were (30 - 1,440) and 220±185 days respectively. The observed immediate complications of TDCs were failed first attempt 7(4.7%), reactionary haemorrhage 5(3.4%), arrhythmia 3(2.0%), haemothorax 2(1.4%) while death during catheter placement was recorded in 2(1.4%) cases. Catheter related infection was the commonest long-term complications and occurred in 15 cases (10.1%), while being diabetic increased the risk of developing catheter related complications. One tenth of our patients with End Stage Renal Disease on TDC had kidney transplantation while catheter related mortality was 16.3%.

Conclusion

internal jugular tunneled dialysis catheters despite its shortcomings, has been a safe procedure with good outcomes among our patients on maintenance haemodialysis.

Agitated saline bubble-enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease

BACKGROUND

In patients with end-stage renal disease, the use of cuffed, tunneled dialysis catheters for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique.

METHODS

From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with end-stage renal disease who required tunneled dialysis catheter placement.

RESULTS

The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (±0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (±38) mL/min. The total number of catheter days was 7451, with a mean of 133 days and a range of 46-322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively.

CONCLUSION

Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology. Future research should further develop and confirm these initial findings.

Studying alternative approaches for placement of cuffed hemodialysis catheters in hemodialysis patients with bilateral internal jugular vein occlusion

Introduction:

Internal jugular vein occlusion often makes necessary the use of less desirable routes as external jugular, subclavian, and femoral vein approaches in addition to inferior vena cava approaches. This a prospective cross-sectional follow-up study of the alternative approaches for placement of cuffed hemodialysis catheters in end-stage renal disease patients with bilateral internal jugular vein occlusion from the interventional nephrology point of view.

Method:

The study was conducted on 134 end-stage renal disease patients who were referred for insertion of a challenging hemodialysis catheter due to bilateral internal jugular vein occlusion. Ultrasound Doppler guided catheter insertion was used as a routine practice in addition to fluoroscopy or post insertion X-ray to localize catheter tip position and exclude complications. Follow-up of patients was conducted until the end of the study or catheter removal.

Findings:

The most highly prevalent alternative approach is the trans-external iliac vein inferior vena cava approach (43.28%) followed by external jugular vein approach (14.93%), innominate vein approach (10.18%), internal jugular vein collaterals by interventional radiology (7.46%), femoral vein approach (7.46%), transhepatic approach (5.97%), subclavian vein approach (5.22%), and finally the retrograde femoral vein approach (1.49%).

Discussion:

End-stage renal disease patients maintained on regular hemodialysis who have bilateral internal jugular vein obstruction and non-functioning arteriovenous fistula/graft is a daily scenario in nephrology practice. Our study showed that there is a variety of approaches for the insertion of cuffed hemodialysis catheters other than occluded internal jugular veins. Interventional nephrologists have a major role in solving the problem of poor hemodialysis vascular access. These alternative approaches can conserve the anatomically limited number of percutaneous access sites in each patient.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Placement of tunneled cuffed catheter for hemodialysis: Micropuncture kit versus Angiocath IV catheter

INTRODUCTION

Tunneled cuffed catheters provide stable, instantaneous, long-term intravenous access for hemodialysis. Because catheterization is often performed in emergency situations, speed and accuracy are emphasized.

METHODS

We retrospectively compared the Micropuncture kit with the standard 18-gauge Angiocath IV catheter for tunneled cuffed catheter insertion in the right jugular vein. From June 2016 to May 2017, 31 tunneled cuffed catheters were successfully inserted via the Micropuncture kit and another 31 via the Angiocath IV catheter. All patients underwent the same ultrasound-guided procedure performed by a single experienced interventionalist. Procedure time was the time from draping of the patient to the completion of povidone dressing after the catheterization. In our center, the Angio Lab nurse maintains records, including procedure time and method for every procedure. All patient records were retrospectively tracked through electronic medical record review. The primary outcome was procedure time and the secondary outcomes were complications and cost-effectiveness.

RESULTS

There were no significant differences in the patients' demographic data between the two groups. However, procedure time was significantly shorter in the Angiocath group than in the Micropuncture group (12.4 ± 3.5 vs 17.6 ± 6.9 min, p = 0.001); there were no serious complications, such as hemorrhage, pneumothorax, or hematoma, in both groups. Moreover, cost-effectiveness was better in the Angiocath group than in the Micropuncture group (0.34 vs 52 US$, p < 0.01).

CONCLUSIONS

Using the Angiocath IV catheter can reduce procedure time and cost with no severe complications. Moreover, experienced practitioners can reduce the risk of complications when using Angiocath. There are several limitations to this study. First, it was retrospective; second, it was not randomized; and finally, it was conducted by only one experienced interventionalist.

Hemodialysis catheter-associated fibrin sheath in a dog

OBJECTIVE

To describe an intravascular fibrin sheath associated with a hemodialysis catheter in a dog.

CASE SUMMARY

A 4-year-old dog presented for hemodialysis to treat acute kidney injury. Hemodialysis catheter dysfunction during the course of treatment was temporarily alleviated using a tissue plasminogen activator. A thrombus composed of fibrin and granulation tissue creating a sheath around the catheter and focally adherent to the vessel wall was identified on postmortem evaluation.

NEW OR UNIQUE INFORMATION PROVIDED

Fibrin sheath formation is a commonly recognized problem of central venous catheters used for hemodialysis in people and is likely a common problem in veterinary patients undergoing dialysis as well. This report provides a description of the clinical features of the catheter dysfunction, response to treatment, postmortem radiographic and direct imaging, and histology of the fibrin sheath, and also provides a brief review of potential management techniques that have been described in people.

Recommended Clinical Trial End Points for Dialysis Catheters

Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.

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

Background

Acute 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.

Methods

We 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.

Results

Patients 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.

Conclusions

Compared 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.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0760-x) contains supplementary material, which is available to authorized users.