Mediastinal Haematoma Caused by Subclavian Catheterisation for Haemodialysis

A 59 year old woman developed a mediastinal haematoma after placement of a subclavian haemodialysis catheter. Vascular perforation by the guide wire used during catheterisation was the probable cause. The use of guide wires with a flexible J-shaped terminal portion is recommended to minimise this risk.

Cardiac Perforation by a Guide Wire during Subclavian Catheter Insertion

We report a patient in whom cardiac perforation was directly caused by a straight soft tipped guide wire used to introduce a subclavian dialysis catheter. We recommend the use of J tip guide wires to avoid this life threatening complication.

Perforation of the Superior Vena Cava by a Subclavian Hemodialysis Catheter: Early Detection by Angiography

A dual-lumen subclavian catheter was placed for temporary dialysis access in a 36-year-old woman. Clinical suspicion for a possible vena caval perforation by the catheter tip was confirmed by injection of contrast through the catheter. This technique allowed rapid diagnosis and prevented further potential complications related to catheter malposition.

Efficacy and Safety of a Retrograde Tunneled Hemodialysis Catheter: 6-Month Clinical Experience with the Cannon Catheter™ Chronic Hemodialysis Catheter

Purpose

Tunneled catheters play an important role in the delivery of hemodialysis, for both temporary and long-term vascular access. Proper catheter tip positioning is critical for optimal blood flow and performance. The modular Cannon Catheter™ II Chronic Hemodialysis Catheter is placed tip first, then tunneled back to the exit site, in a simple technique (retrograde tunneling) that provides precise tip placement within the right atrium. This retrospective study evaluated 6-month efficacy and safety of the Cannon catheter in 38 patients.

Methods

Monthly mean flow, pressure, Kt/V, and URR were determined. Safety parameters included early and late device-related complications, device removals, and device survival.

Results

87% of subjects had history of vascular access failure. Cannon catheters were inserted via an internal jugular vein with retrograde tunneling in all patients without insertional complication. Mean flow ranged from 369.0 to 404.8 ml/min, with a trend for increasing flow over time. High flow allowed delivery of correspondingly high clearance. Mean URR remained ≥71%; mean weekly Kt/V ranged between 1.55 and 1.60, above current K/DOQI adequacy guidelines. There were no device-related hospitalizations or deaths. Catheter-related bacteremia occurred in 3 patients over the 6 months (0.62 bacteremias/1,000 patient-days), resolving through outpatient treatment. The Cannon catheter provided extended high flow vascular access (≥6 months or until hemodialysis catheter-based access was no longer needed) in 95% of patients.

Conclusion

Retrograde tunneling of the Cannon Catheter™ II Chronic Hemodialysis Catheter allowed optimal tip placement and high flow rates, as well as safe, reliable, extended use.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Direct peripheral venopuncture: another new choice of temporary vascular access

BACKGROUND

Femoral, subclavian, and internal jugular veins access have been widely used for temporary vascular access for hemodialysis, but their use has been associated with a significant complication rate. We report in three selected hemodialysis patients with the procedure of direct peripheral venopuncture as temporary vascular access to reduce complications.

METHODS

We have demonstrated hemodialysis via direct puncture of peripheral veins of the antecubital fossa (cephalic vein in the process of arterial inflow to dialyzer and venous outflow from dialyzer to basilic vein) as temporary vascular access for these patients.

RESULTS

Renal function of case 1 and case 2 progress to normal status after several sessions of dialytic therapy as well as quit hemodialysis, and case 3 successfully shifts to peritoneal dialysis following four sessions of dialytic therapy.

CONCLUSIONS

We recommend this short-term access contribute a important additional new choice in selected patients with acute, reversible renal failure, obstructive uropathy, initiation of peritoneal dialysis, patients on peritoneal dialysis with peritonitis, or under plasmapheresis therapy.

A new vascular access catheter for hemodialysis

A new vascular access catheter has been developed (Cook Critical Care, Bloomington, IN) that is suitable for both short-term and long-term hemodialysis. Designed primarily for the internal jugular vein, it emerges through a subcutaneous tunnel on the anterior chest wall. With parallel cylindrical lumens to provide blood flows of 400 mL/min, it is compressible during insertion and can be placed percutaneously in the vein through a 13-French peel-away sheath. This allows repeated insertions at different times in the same patient. In 80 catheter insertions, we have found one case of jugular vein thrombosis attributable to the catheter and no subclavian vein thrombosis. After 15 months of use, the bloodstream infection rate was one per 19.7 patient-months. Using this device, it should be possible to stop the subclavian vein damage and perforating injuries that have been the most important complications of semistiff, tapered, subclavian catheters.

[Venous thrombosis after catheterization of the subclavian vein for hemodialysis]

The authors report six cases of subclavian vein thrombosis after transcutaneous catheterization in a group of 70 patients treated by periodical haemodialysis over a 7-year period in a Nephrology department at Casablanca. The subclavian vein has become the favourite access route in most haemodialysis centres because it can be utilized for a longer time, carries a lower risk of infection and is more comfortable for the patient than the other routes. Two main factors facilitate the occurrence of thrombosis: a long duration of catheter insertion and repeated catheterizations.

Temporary vascular access in British hemodialysis units

A questionnaire, designed to determine the current habits of British nephrologists regarding temporary vascular access for hemodialysis, was sent to 62 renal units. Forty-six (74%) completed questionnaires were returned. Cannulation of the subclavian vein with a single-lumen catheter is the most popular technique. There is only limited use of double- or dual-lumen catheters in the United Kingdom. Previously unreported fatal complications of subclavian hemodialysis catheters are described.