ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Central venous catheters for acute and chronic hemodialysis access and their management

Central venous catheters for acute and chronic hemodialysis access and their management
Literature review current through: Jan 2024.
This topic last updated: Feb 07, 2023.

INTRODUCTION — Hemodialysis requires access to the central veins that can provide rapid extracorporeal blood flow ranging from 300 to 400 mL/min for three to four hours three times a week with minimal complications.

Hemodialysis catheters are appropriate when there is an acute need for hemodialysis (eg, acute kidney injury, thrombosed hemodialysis arteriovenous [AV] access, poisoning). In the inpatient setting, a nontunneled (temporary) hemodialysis catheter is often used, but if the duration of hemodialysis with a catheter is likely to exceed two weeks or if the patient will need chronic outpatient hemodialysis, a tunneled hemodialysis catheter should be placed instead, unless there is concern about infection risk. Ideally, if the patient's anatomy and physiology can support it, an AV access can be created, and once the AV access can be used reliably, the hemodialysis catheter is removed. Of note, compared with an AV access, hemodialysis catheters are associated with inferior clinical outcomes and may also generate higher costs [1].

The general features of nontunneled and tunneled hemodialysis catheters and the basic principles governing their use are reviewed here. Complications of central venous access and placement are discussed separately. (See "Central venous catheters: Overview of complications and prevention in adults" and "Vascular complications of central venous access and their management in adults".)

HEMODIALYSIS CATHETERS — The broad categories of catheters used for hemodialysis vascular access are nontunneled hemodialysis catheters and tunneled hemodialysis catheters, frequently referred to as simply tunneled dialysis catheters. Many hemodialysis catheter designs are available, and there are no convincing data that any one is superior to another. The selection of the appropriate catheter type is at the discretion of the practitioner. The operator should consider the need, requirements, and duration of the catheter as well as access site location. Often, the catheter type used in a dialysis program is based on historical practice, availability, and cost [1]. (See "Central venous access: Device and site selection in adults", section on 'Heparin bonding'.)

Hemodialysis catheters are composed of polyurethane, poly(carbonate)urethane, or silicone. Both nontunneled and tunneled catheters are mostly made of polyurethane, but the formation of polyurethane used for chronic hemodialysis catheters is purposefully designed to be softer due to the longer dwell times within the patient. Nontunneled hemodialysis catheters are designed to be slightly stiffer for ease of insertion but will soften upon exposure to body temperature.

Nontunneled hemodialysis catheters – Nontunneled catheters, which are often referred to as temporary catheters, have a conically pointed tip and can have two or three lumens.

Tunneled hemodialysis catheters – Tunneled hemodialysis catheters are designed to be inserted into the vein and then tunneled subcutaneously on the chest wall for the internal jugular site and thigh for the femoral site. A polyester cuff on the tunneled hemodialysis catheter provides a point for tissue ingrowth inside the resulting subcutaneous tunnel to secure the catheter and reduce the risk of infection. This cuff can effectively seal the intravascular portion of the catheter from the skin, providing a point of fixation to help prevent migration or accidental dislodgement and to reduce infection rates [2].

Catheter design — Hemodialysis catheters have two lumens for the dialysis circuit, attached to two ports (blue and red colored). By convention, the red port identifies the "arterial" lumen that draws blood from the patient, and the blue port identifies the "venous" lumen for return of blood from the dialysis machine back to the patient. This direction of flow may be reversed on dialysis if blood flow is limited in the conventional direction, although at the risk of increased recirculation, reduced clearance, and possibly inadequate dialysis depending on the configuration of the catheter tip [3-6].

Compared with a typical catheter used for central venous access, the hemodialysis catheter is larger to provide a higher rate of blood flow in the 300 to 375 mL/min range for most catheters [7]. Nontunneled hemodialysis catheters range in size from 8 to 14 Fr, while tunneled catheters range from 10 to 16 Fr. Catheters are available in a variety of configurations and tip designs, including double D, coaxial, shotgun, step tip, symmetric, and split tip, among others. Separation of the tips of the catheter can be achieved with a staggered tip design, use of a septum extruding beyond the openings, or splitting the catheter lumens distally. Some catheters are self-centering with a built-in curvature designed to push the tip of the catheter away from the wall of the vessel or heart chamber [5,8]. These designs are intended to maximize flow and, in some cases, reduce recirculation when used in a reverse configuration. Some randomized studies show some statistical differences in blood flow, clearance, or thrombolytic use, but the clinical significance of these differences is not clear, and other endpoints including patency are similar [3,9-11].

Surface-coated catheters — A variety of surface coatings (eg, silver, chlorhexidine, rifampin, and minocycline) have been used to prevent infection. In early studies, antimicrobial-coated hemodialysis catheters appeared to be effective in preventing intravascular catheter infections in the dialysis setting [12-21]. However, in a systematic review that evaluated 29 trials with 2886 patients and 3005 hemodialysis catheters, the incidence of catheter-related bacteremia and exit-site infections was similar for antimicrobial-coated hemodialysis catheters compared to noncoated catheters [19]. (See "Central venous access: Device and site selection in adults", section on 'Antimicrobial-impregnated catheters'.)

Heparin-coated catheters have also been used to decrease the incidence of catheter-related thrombosis. In observational studies, the frequency of catheter malfunction and overall catheter survival was similar [21,22]. (See "Central venous access: Device and site selection in adults", section on 'Coated and impregnated catheters'.)

INDICATIONS AND DURATION OF USE

Nontunneled hemodialysis catheters — Nontunneled catheters are indicated when there is an acute need to establish vascular access for hemodialysis, including acute kidney injury, thrombosed hemodialysis arteriovenous (AV) access, and to treat poisoning. Nontunneled femoral catheters are often used in bedbound critically ill patients. The nonavailability of vascular surgeons or interventional radiologists or nephrologists after hours or on weekends may also dictate temporary catheter use. Nontunneled femoral catheters should be avoided in ambulatory patients to avoid damage or thrombosis of the femoral vein and kinking of the catheter.  

In general, nontunneled catheters should be used for less than two weeks to avoid bacteremia. Outpatient use is discouraged [23]. In a study of 318 new hemodialysis catheter insertions, at the end of one, two, three, and four weeks, the incidences of bacteremia for femoral vein catheters were 3, 11, 18, and 29 percent, respectively, and for internal jugular catheters, the incidences were 2, 5, 5, and 10 percent, respectively [24]. Rarely, femoral catheter may be required for a single dialysis session in ambulatory patients, inserted before and removed after the dialysis session, but this practice should be avoided to minimize patient discomfort [25-28].

Tunneled hemodialysis catheters — Tunneled hemodialysis catheters are frequently used to establish acute vascular access for hemodialysis and can be used in the outpatient setting. Given the risk of catheter-related bloodstream infections with nontunneled devices, it is our practice to recommend placement of a tunneled hemodialysis catheter for inpatients without bacteremia if the duration of hemodialysis is expected to be longer than two weeks (even in the intensive care unit setting), unless the patient is unstable or otherwise cannot be transported to a procedure room for catheter placement. Ideally, when permanent hemodialysis access is required, an AV fistula or graft is placed, though this typically requires a maturation period before use. Once the AV fistula or AV graft can be used reliably, the hemodialysis catheter is removed. (See "Approach to the adult patient needing vascular access for chronic hemodialysis", section on 'Strategy for lifelong hemodialysis access'.)

However, a tunneled central venous catheter can be used for indefinite periods of time in some patients, such as those with multiple failed AV accesses with no available options, limited life expectancy, or anatomic issues that prevent appropriate combinations of inflow artery and outflow veins or those who simply opt, after being well informed, not to have an AV access created and choose instead long-term catheter-based hemodialysis [23].

Patients should be informed that the risk of catheter complications is cumulative over time. In a prospective multicenter study from Canada, at one year, risks for tunneled hemodialysis catheter-related bacteremia, malfunction, and symptomatic central stenosis were 9, 15, and 2 percent, respectively [29]. The risk for any catheter-related complications at one and two years was 30 and 38 percent, respectively. These risks are from Canadian programs in which catheter use is generally high [30,31]. Each hemodialysis program should assess its local catheter-related risk with long-term use to inform patients.

Catheter life — The overall survival of tunneled hemodialysis catheters is highly variable because while studies may report primary or assisted patency, they vary in outcomes that terminate patency (eg, dysfunction only versus any catheter event including infection) and treat inclusion or exclusion or exiting events such as transplantation, death, or conversion to AV access differently. With these considerations, one randomized trial of 302 tunneled catheters reported six-month assisted patency ranging from 77 to 87 percent and 12 month patency ranging from 72 to 76 percent [11]. In another trial of 86 catheters, dysfunction-free survival, excluding other causes of catheter removal, was high at 92 to 98 percent at three months [10].

CATHETER PLACEMENT — Central venous catheters, including nontunneled and tunneled hemodialysis catheters, are placed using a stepwise approach under sterile conditions. When placed by experienced practitioners, periprocedural complications are uncommon. Catheter placement and complications related to placement are reviewed separately. (See "Placement of jugular venous catheters" and "Placement of femoral venous catheters" and "Central venous catheters: Overview of complications and prevention in adults" and "Vascular complications of central venous access and their management in adults".)

Access site — The right internal jugular vein is the preferred vein for hemodialysis access (nontunneled and tunneled hemodialysis catheters) in ambulatory patients because the vein takes a straight path directly into the superior vena cava (figure 1), leading to improved blood flow rates [7]. If the right internal jugular vein cannot be used, then placement into the left internal jugular vein may be necessary. Insertion can be more difficult on the left, and there is a higher incidence of catheter dysfunction (image 1) [32,33]. This is because placement of catheters into the left internal jugular vein requires that the catheter negotiate significant angulations present at the transition from the left internal jugular vein to the left brachiocephalic vein and then again when arriving at the superior vena cava. The femoral vein is a common location for nontunneled catheter placement in the intensive care setting for patients who cannot get up from bed. Tunneled catheters are placed into the femoral vein usually when central venous thrombosis or stenosis prevents internal jugular placement. The subclavian vein should be avoided to prevent subclavian stenosis, which would compromise future ipsilateral upper extremity arteriovenous hemodialysis access if the patient has or is at risk for developing end-stage renal disease [34]. In rare cases, catheter placement using a translumbar or transhepatic approach is possible if no other access is possible [35-37]. (See "Central vein obstruction associated with upper extremity hemodialysis access".)

To determine the appropriate length, the practitioner should consider the height of the patient and the location from which the catheter is being inserted. Catheters inserted from the left internal jugular vein need to be longer than right-sided internal jugular catheters as they have a greater distance to traverse. Catheters inserted from the groin are also longer to reach the inferior vena cava.

For nontunneled catheters, right internal jugular (precurved) catheters range from 12 to 15 cm. Left internal jugular catheters range from 20 to 24 cm. While short catheters that are 12 to 20 cm in length can be placed in the femoral position, lengths of at least 24 cm are commonly required to reach the inferior vena cava.

Tunneled hemodialysis catheters usually need to be longer to account for the tunneled portion. Typical lengths from the tip to the cuff are as follows: right internal jugular 19 to 23 cm, left internal jugular 23 to 31 cm, and femoral 35 cm or greater.

Imaging guidance — Ultrasound imaging is critical to ensure safe performance of hemodialysis catheter placement. Ultrasound is used to assess vein size and patency prior to venous puncture. In a study of 143 hemodialysis patients with a history of prior hemodialysis catheter placement, 25.9 percent had jugular vein thrombus, and 62 percent of these were occluded [38]. Ultrasound guidance during venipuncture minimizes the incidence of venous access-related complications, decreases procedure time, and increases the rate of initial technical success [39]. Ultrasound-guided venous access also decreases the likelihood of arterial puncture or pneumothorax in patients undergoing hemodialysis catheter placement [39-43].

Nontunneled (temporary) catheters are placed at the bedside or in a procedure room using local anesthesia. Ultrasound guidance during venous cannulation should be used.

Tunneled catheters are placed in an angiography suite or appropriately equipped operating room using local anesthesia with or without sedation. Ultrasound guidance for venous cannulation should be used, and fluoroscopic guidance is necessary to guide proper catheter positioning due to their larger caliber. Catheter malposition is a common problem (25 to 40 percent) when fluoroscopy is not used for guidance; accurate catheter positioning can be achieved in 95 to 100 percent of cases with fluoroscopy [44]. Fluoroscopy also allows direct imaging of the wires and dilators to minimize the potential for injury.

Catheter positioning — Confirmation of the catheter tip position, removal of the guidewire, and absence of a pneumothorax must be documented using fluoroscopy or chest radiography prior to use of the catheter. The ideal position of the catheter is as follows:

The tip of nontunneled internal jugular hemodialysis catheters should be positioned in the distal superior vena cava. Because of the stiffness of short-term access catheters and risk for complications, atrial placement should be avoided [45].

The tip of tunneled hemodialysis catheters should be positioned within the right atrium when placed with the patient supine. As the patient transitions to the upright position, the catheter will tend to retract 2 to 4 cm. Retraction of the catheter is greater for left-sided placement. In a retrospective review of 532 internal jugular hemodialysis catheters, left-sided catheters initially terminating in the superior vena cava or peri-cavoatrial junction had significantly more episodes of catheter dysfunction or infection compared with left-sided catheters terminating in the mid- to deep right atrium (0.84 versus 0.35), whereas no significant difference was identified for right-sided catheters based on tip position [33].

The tip of femoral hemodialysis catheters (nontunneled or tunneled) should be placed in the inferior vena cava.

ROUTINE CARE AND ACCESS FOR HEMODIALYSIS — The routine care and maintenance of hemodialysis catheters is similar to that of other central venous catheters (nontunneled, tunneled) with any differences noted below. (See "Routine care and maintenance of intravenous devices".)

After catheter insertion, nontunneled catheters are secured to the skin with a suture. Tunneled catheters should be secured with sutures to prevent migration and facilitate ingrowth into the subcutaneous cuff. The catheter is flushed with saline to clear any residual blood and is often locked with a heparin or citrate-based solution to prevent thrombosis unless a contraindication exists (eg, heparin-induced thrombocytopenia [HIT]). A sterile dressing is placed at the catheter exit site. The catheter exit site is then sterilely dressed. (See "Routine care and maintenance of intravenous devices", section on 'Dressing and securement'.)

Subsequently, the hemodialysis catheter is accessed for hemodialysis using established routines that aim to prevent thrombosis and catheter-related bacteremia and bloodstream infection.

Access, flushing, and catheter locking — All hemodialysis personnel accessing the catheter should be trained in proper techniques for handling or manipulating vascular access catheters. Universal care strategies should be used to prevent infection and include hand hygiene and using an aseptic no-touch technique. Hemodialysis catheters should not be accessed by nonhemodialysis personnel, except in an emergency. (See "Routine care and maintenance of intravenous devices", section on 'Universal care strategies'.)

To initiate hemodialysis using a hemodialysis catheter, a disinfecting agent (eg, chlorhexidine) should be used to clean the catheter hubs. Once the hubs are removed, the lock solution is aspirated from each hub, and the catheter is flushed with saline. The catheter hubs should then be immediately connected to the dialysis machine to avoid prolonged exposure to air. The connection of the blood lines to the catheter hubs should remain visible during the dialysis treatment.

Once hemodialysis is complete, the catheter is flushed with saline to clear any residual blood. The usual rinse with saline at the end of dialysis is important to clear blood from the blood lines and dialyzer, but it is not very efficient in completely clearing all blood from the catheter or dislodging any small thrombi that might be present. A turbulent method of flushing with saline using the push-pause technique can be used, but practice may vary among hemodialysis units to clear the catheter walls and lumen of residual blood prior to instilling a locking solution. (See "Routine care and maintenance of intravenous devices", section on 'Hubs, needleless connectors, and line access'.)

The catheter is often locked with a heparin- or citrate-based solution to prevent thrombosis; other solutions including saline, other antithrombotic agents, and antimicrobial agents have also been used. Taurolidine-containing catheter lock solutions may be chosen when chlorhexidine-coated catheter caps (ClearGuard) cannot be used. (See 'Dressings' below and "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Methods we use'.)

Typical hemodialysis catheter volumes are 1.2 to 1.8 mL for short nontunneled catheters and 1.9 to 3.1 mL for larger tunneled catheters. When heparin is used, the catheters should not be overfilled. When citrate is used, 10 percent overfill is recommended. In vitro studies demonstrate leaking of the locking solution can occur after instillation of the catheter [46].  

Heparin concentrations vary from 10 to 10,000 units per mL. The American Society of Diagnostic and Interventional Nephrology position paper recommends a heparin lock concentration of 1000 units/mL [47,48]. Some acute hemodialysis programs prefer to use a heparin concentration of 100 units per mL. Higher heparin concentration levels have been associated with inadvertent systemic anticoagulation and clinical episodes of bleeding due to leaking of the anticoagulant into the patient, particularly if the catheter lumen was overfilled with heparin [47,49,50].

Citrate provides an effective alternative for patients with suspected or confirmed heparin-induced thrombocytopenia and may help avoid heparin-associated bleeding complications [51-54]. In Canada, 4% citrate is the most commonly used locking solution. High-dose citrate (30 to 47 percent) should be avoided because if inadvertently injected, it can cause severe hypocalcemia, cardiac dysrhythmias, and death [55].

Antithrombotic agents other than heparin or citrate have also been used. In addition, agents meant to reduce infection include sodium citrate, hypertonic saline, ethanol (30 to 100 percent), methylene blue, ethylene diamine tetra-acetic acid (EDTA), antibiotics like gentamicin alone or with other agents (cefazolin or vancomycin), trimethoprim/sulfamethoxazole (TMP-SMX; also known as co-trimoxazole), and minocycline. The Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update states that selective use of specific prophylactic antibiotic locks can be considered in patients in need of long-term central venous catheters who are at high risk of catheter-related bloodstream infection [23]. Despite these benefits and guidelines, concerns still persist about antimicrobial resistance with long-term use and possible ototoxicity from catheter leakage with gentamicin [56]. In the United States, reimbursement policies do not provide payment for these agents, thereby placing a financial burden on dialysis units.

A systematic review identified 27 trials [56-79] assessing alternative locking solutions or systemic agents for the prevention of catheter malfunction (defined as a catheter blood flow of ≤200 mL/minute or as defined by the study authors) or for the occurrence of bacteremia [80]. In a meta-analysis of 16 of these, the incidence of catheter malfunction was not significantly different for alternative anticoagulant locking solutions, systemic agents, or low- or no-dose heparin compared with conventional care, which predominantly consisted of instilling a heparin solution into each catheter port.

One trial demonstrated that once-weekly instillation of tissue plasminogen activator (tPa, alteplase) significantly lowered catheter malfunction (20 versus 35 percent) and catheter-related bacteremia (4.5 versus 13 percent). The reduction in bacteremia from thrombolytic locks indicates a relationship between thrombosis and infection [76]. Use is likely limited due to cost, but it may be useful for patients at high risk for dysfunction or bacteremia and with limited access to options.

A review that included 1350 hemodialysis catheters showed that use of a gentamicin-heparin lock was associated with a significantly reduced risk of all-cause mortality compared with standard heparin locks (hazard ratio 0.36, 95% CI 0.22-0.58) [81]. The reduction was primarily due to reduction of sepsis events that resulted in death.

The available data from randomized trials and observational studies do not support routine systemic antithrombotic agents to prevent hemodialysis catheter dysfunction, due to increased risks of harm and unclear benefit with respect to patency [23,80,82,83]. The KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update recommends against the use of systemic anticoagulants for the sole purpose of maintaining central venous catheter patency [23].

Dressings — Catheter dressings should be changed weekly or if they are dislodged, unclean, or stained with blood or discharge. Routine dressing changes are reviewed separately. (See "Routine care and maintenance of intravenous devices", section on 'Dressing and securement'.)

Antibiotic ointment may be applied at the catheter exit site to prevent infection [19,84-90]. Based on low-to-moderate quality evidence, antibiotic ointment is included as a core intervention by the Centers for Disease Control and was endorsed in the KDOQI Vascular Access Guidelines to prevent infection [23,91]. A joint working group led by the Society of Critical Care Medicine and the Infectious Diseases Society of America recommends the use of povidone-iodine ointment or triple antibiotic (bacitracin/gramicidin/polymyxin B) ointment at the exit site after catheter insertion and at the end of each hemodialysis session, provided the ointment does not adversely interact with the catheter material according to manufacturer recommendations [92]. In meta-analyses of trials comparing various antibiotic ointments (eg, mupirocin, Polysporin, povidone-iodine) with no ointment or placebo, the use of exit-site antimicrobial agents significantly reduced catheter-related bacteremia (five trials; relative risk [RR] 0.26, 95% CI 0.15-0.46), exit site infection (four trials; RR 0.20, 95% CI 0.09-0.45), and requirement for catheter removal (four trials; RR 0.35, 95% CI 0.25-0.5) [84]. However, concerns have been raised about the emergence of mupirocin resistance and the occurrence of fungal infections, so antibiotic ointment may not be used by all programs consistently [93,94]. Exit-site antibiotic ointment may be more commonly used after catheter placement, during exit site healing, after catheter exchange, or if signs of infection are present.

Two large, multicenter, cluster randomized studies have shown a benefit of an antibacterial barrier cap device (ClearGuard) that contains a rod coated with chlorhexidine compared with standard best-use practices/policies for central venous catheters [95,96]. The two studies were carried out in multiple dialysis units at the two largest dialysis providers in the United States. In both studies, there was a significant decrease in the rate of catheter-related bloodstream infections and hospitalizations for the chlorhexidine-coated catheter cap. There was no reported improvement in other complications or dysfunctions such as thrombosis rates. (See "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Methods we use'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access" and "Society guideline links: Dialysis" and "Society guideline links: Hemodialysis vascular access".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)" and "Patient education: Hemodialysis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Hemodialysis catheters – Hemodialysis catheters are designed to maximize flow and, in some cases, reduce recirculation. There are no convincing data that any one catheter is superior to others. Selection is at the discretion of the clinician or institution based on familiarity, cost, and availability. (See 'Hemodialysis catheters' above and 'Indications and duration of use' above.)

There are two main types of hemodialysis catheters: nontunneled (temporary) hemodialysis catheters and tunneled hemodialysis catheters, which are frequently referred to as simply tunneled dialysis catheters.

Acute hemodialysis – Nontunneled hemodialysis catheters are appropriate when there is an acute need for hemodialysis (eg, acute kidney injury, thrombosed hemodialysis arteriovenous [AV] access, poisoning). Nontunneled hemodialysis catheters are often used in the inpatient setting.

Chronic hemodialysis – Unless there is concern about infection, a tunneled hemodialysis catheter should be placed if the duration of hemodialysis will be for more than two weeks or if the patient will be maintained chronically as an outpatient. For some patients, a tunneled hemodialysis catheter may be needed for an indefinite period.

Catheter placement – Central venous catheters, including nontunneled and tunneled hemodialysis catheters, are placed under sterile conditions with a stepwise approach that uses a modified Seldinger technique. Nontunneled (temporary) catheters are inserted at the bedside or in a procedure room using local anesthesia. Tunneled catheters are inserted in an angiography suite or appropriately equipped operating room using local anesthesia with or without sedation. When placed by experienced practitioners, complications are uncommon. (See 'Catheter placement' above.)

Access site selection – (See 'Access site' above.)

-For ambulatory patients, the right internal jugular vein (IJV) is the preferred access site for hemodialysis access (nontunneled and tunneled hemodialysis catheters). Placement into the left IJV may be necessary if the right internal jugular vein cannot be used; however, insertion can be more difficult on the left, and there is a higher incidence of catheter dysfunction.

-For nonambulatory patients, the femoral vein is a common location for nontunneled catheter placement, particularly in the intensive care unit setting if central venous thrombosis or stenosis prevents internal jugular vein placement.

-The subclavian veins should be avoided. Subclavian venous access is associated with a high incidence of subclavian venous stenosis and thrombosis, which compromises subsequent access options.

Ultrasound guidance – Prior to venous puncture, ultrasound should be used to assess vein size and patency. Ultrasound guidance should also be used during venipuncture, which increases the rate of initial technical success, decreases procedure time, and minimizes the incidence of access-related complications, including arterial puncture. (See 'Imaging guidance' above.)

Catheter tip positioning – (See 'Catheter positioning' above.)

-The tip of nontunneled internal jugular hemodialysis catheters should be positioned in the distal superior vena cava; atrial placement is avoided due to the stiffness of nontunneled catheters.

-The tip of tunneled hemodialysis catheters should be positioned within the right atrium when placed with the patient supine. The catheter tip will retract 2 to 4 cm with upright positioning.

-The tip of femoral hemodialysis catheters (nontunneled or tunneled) should be placed in the inferior vena cava.

Routine care and maintenance – The routine care and maintenance of hemodialysis catheters is similar to that of other central venous catheters (nontunneled, tunneled). Hemodialysis catheters are accessed using established routines to prevent thrombosis and catheter-related bacteremia or bloodstream infection. These include adherence to an aseptic no-touch technique when connecting and disconnecting from the dialysis machine and to flushing, locking, and access site dressing protocols. Hemodialysis catheters should not be accessed by nonhemodialysis personnel, except in an emergency. Catheter dressings should be changed weekly and whenever they become loose or soiled. (See 'Routine care and access for hemodialysis' above.)

Hemodialysis catheters are often locked with a heparin- or 4% citrate-based solution to prevent thrombosis; other solutions such as saline, other antithrombotic agents, and antimicrobial agents have also been used. Heparin is typically dosed at a concentration of 1000 IU/mL, but other concentrations, sometimes as low as 10 IU/mL, have also been used. When heparin is used, the catheters should not be overfilled, to avoid systemic anticoagulation.

We suggest using antibiotic ointment at the exit site after catheter insertion and at the end of each hemodialysis session, rather than no such application (Grade 2C). Application of these agents reduces the risk of exit-site and catheter-related bloodstream infection. It is also reasonable to limit their use to after catheter insertion while the exit site is healing, after catheter exchange, or if signs of infection are present.

Concerns about the emergence of resistant organisms and fungal infections have been raised with both antimicrobial locking solution and exit-site ointments, which may limit their use in some hemodialysis programs.

ACKNOWLEDGMENTS — The editorial staff at UpToDate acknowledges Steve J Schwab, MD, Karen Woo, MD, and Steven J Bander, MD, who contributed to earlier versions of this topic review.

  1. Al-Balas A, Lee T, Young CJ, et al. The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter. J Am Soc Nephrol 2017; 28:3679.
  2. Parvulescu F, Oliver MJ, Reyna ME, et al. Factors Affecting Cuff Extrusion of Tunneled Hemodialysis Catheters. Can Assoc Radiol J 2022; 73:410.
  3. Silverstein DM, Trerotola SO, Clark T, et al. Clinical and Regulatory Considerations for Central Venous Catheters for Hemodialysis. Clin J Am Soc Nephrol 2018; 13:1924.
  4. Pannu N, Jhangri GS, Tonelli M. Optimizing dialysis delivery in tunneled dialysis catheters. ASAIO J 2006; 52:157.
  5. Vesely TM, Ravenscroft A. Hemodialysis catheter tip design: observations on fluid flow and recirculation. J Vasc Access 2016; 17:29.
  6. Tal MG. Comparison of recirculation percentage of the palindrome catheter and standard hemodialysis catheters in a swine model. J Vasc Interv Radiol 2005; 16:1237.
  7. Oliver MJ, Edwards LJ, Treleaven DJ, et al. Randomized study of temporary hemodialysis catheters. Int J Artif Organs 2002; 25:40.
  8. Ash SR. Advances in tunneled central venous catheters for dialysis: design and performance. Semin Dial 2008; 21:504.
  9. Nadolski GJ, Redmond J, Shin B, et al. Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter, Randomized Trial. J Vasc Interv Radiol 2020; 31:1148.
  10. McGarry JG, Given MF, Whelan A, et al. A prospective comparison of the performance and survival of two different tunnelled haemodialysis catheters: SplitCath® versus DuraMax®. J Vasc Access 2017; 18:334.
  11. Van Der Meersch H, De Bacquer D, Vandecasteele SJ, et al. Hemodialysis catheter design and catheter performance: a randomized controlled trial. Am J Kidney Dis 2014; 64:902.
  12. Trerotola SO, Johnson MS, Shah H, et al. Tunneled hemodialysis catheters: use of a silver-coated catheter for prevention of infection--a randomized study. Radiology 1998; 207:491.
  13. Crabtree JH, Burchette RJ, Siddiqi RA, et al. The efficacy of silver-ion implanted catheters in reducing peritoneal dialysis-related infections. Perit Dial Int 2003; 23:368.
  14. Schindler R, Heemann U, Haug U, et al. Bismuth coating of non-tunneled haemodialysis catheters reduces bacterial colonization: a randomized controlled trial. Nephrol Dial Transplant 2010; 25:2651.
  15. Chatzinikolaou I, Finkel K, Hanna H, et al. Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections: a prospective, randomized study. Am J Med 2003; 115:352.
  16. Dwyer A. Surface-treated catheters--a review. Semin Dial 2008; 21:542.
  17. Alderman RL, Sugarbaker PH. Prospective nonrandomized trial of silver impregnated cuff central lines. Int Surg 2005; 90:219.
  18. Kamal GD, Pfaller MA, Rempe LE, Jebson PJ. Reduced intravascular catheter infection by antibiotic bonding. A prospective, randomized, controlled trial. JAMA 1991; 265:2364.
  19. Rabindranath KS, Bansal T, Adams J, et al. Systematic review of antimicrobials for the prevention of haemodialysis catheter-related infections. Nephrol Dial Transplant 2009; 24:3763.
  20. Dahlberg PJ, Agger WA, Singer JR, et al. Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable silver-impregnated cuff for prevention of catheter-related infections. Infect Control Hosp Epidemiol 1995; 16:506.
  21. Jain G, Allon M, Saddekni S, et al. Does heparin coating improve patency or reduce infection of tunneled dialysis catheters? Clin J Am Soc Nephrol 2009; 4:1787.
  22. Clark TW, Jacobs D, Charles HW, et al. Comparison of heparin-coated and conventional split-tip hemodialysis catheters. Cardiovasc Intervent Radiol 2009; 32:703.
  23. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1.
  24. Oliver MJ, Callery SM, Thorpe KE, et al. Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study. Kidney Int 2000; 58:2543.
  25. Cheesbrough JS, Finch RG, Burden RP. A prospective study of the mechanisms of infection associated with hemodialysis catheters. J Infect Dis 1986; 154:579.
  26. Weijmer MC, Vervloet MG, ter Wee PM. Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use. Nephrol Dial Transplant 2004; 19:670.
  27. Dugué AE, Levesque SP, Fischer MO, et al. Vascular access sites for acute renal replacement in intensive care units. Clin J Am Soc Nephrol 2012; 7:70.
  28. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1:S176.
  29. Poinen K, Quinn RR, Clarke A, et al. Complications From Tunneled Hemodialysis Catheters: A Canadian Observational Cohort Study. Am J Kidney Dis 2019; 73:467.
  30. Malas MB, Canner JK, Hicks CW, et al. Trends in incident hemodialysis access and mortality. JAMA Surg 2015; 150:441.
  31. Yuo TH, Chaer RA, Dillavou ED, et al. Patients started on hemodialysis with tunneled dialysis catheter have similar survival after arteriovenous fistula and arteriovenous graft creation. J Vasc Surg 2015; 62:1590.
  32. Shingarev R, Barker-Finkel J, Allon M. Natural history of tunneled dialysis catheters placed for hemodialysis initiation. J Vasc Interv Radiol 2013; 24:1289.
  33. Engstrom BI, Horvath JJ, Stewart JK, et al. Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc Interv Radiol 2013; 24:1295.
  34. Hernández D, Díaz F, Rufino M, et al. Subclavian vascular access stenosis in dialysis patients: natural history and risk factors. J Am Soc Nephrol 1998; 9:1507.
  35. Freeman BM, Tingen JS, Cull DL, Carsten CG 3rd. The inside-out technique for tunneled dialysis catheter placement with central venous occlusion. J Vasc Surg Cases Innov Tech 2019; 5:350.
  36. Nadolski GJ, Trerotola SO, Stavropoulos SW, et al. Translumbar hemodialysis catheters in patients with limited central venous access: does patient size matter? J Vasc Interv Radiol 2013; 24:997.
  37. Herscu G, Woo K, Weaver FA, Rowe VL. Use of unconventional dialysis access in patients with no viable alternative. Ann Vasc Surg 2013; 27:332.
  38. Wilkin TD, Kraus MA, Lane KA, Trerotola SO. Internal jugular vein thrombosis associated with hemodialysis catheters. Radiology 2003; 228:697.
  39. Geddes CC, Walbaum D, Fox JG, Mactier RA. Insertion of internal jugular temporary hemodialysis cannulae by direct ultrasound guidance--a prospective comparison of experienced and inexperienced operators. Clin Nephrol 1998; 50:320.
  40. Kwon TH, Kim YL, Cho DK. Ultrasound-guided cannulation of the femoral vein for acute haemodialysis access. Nephrol Dial Transplant 1997; 12:1009.
  41. Kumwenda MJ. Two different techniques and outcomes for insertion of long-term tunnelled haemodialysis catheters. Nephrol Dial Transplant 1997; 12:1013.
  42. Lin BS, Huang TP, Tang GJ, et al. Ultrasound-guided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron 1998; 78:423.
  43. Prabhu MV, Juneja D, Gopal PB, et al. Ultrasound-guided femoral dialysis access placement: a single-center randomized trial. Clin J Am Soc Nephrol 2010; 5:235.
  44. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123.
  45. Shamir MY, Bruce LJ. Central venous catheter-induced cardiac tamponade: a preventable complication. Anesth Analg 2011; 112:1280.
  46. Sungur M, Eryuksel E, Yavas S, et al. Exit of catheter lock solutions from double lumen acute haemodialysis catheters--an in vitro study. Nephrol Dial Transplant 2007; 22:3533.
  47. Moran JE, Ash SR, ASDIN Clinical Practice Committee. Locking solutions for hemodialysis catheters; heparin and citrate--a position paper by ASDIN. Semin Dial 2008; 21:490.
  48. Thomson PC, Morris ST, Mactier RA. The effect of heparinized catheter lock solutions on systemic anticoagulation in hemodialysis patients. Clin Nephrol 2011; 75:212.
  49. Ivan DM, Smith T, Allon M. Does the heparin lock concentration affect hemodialysis catheter patency? Clin J Am Soc Nephrol 2010; 5:1458.
  50. Holley JL, Bailey S. Catheter lock heparin concentration: effects on tissue plasminogen activator use in tunneled cuffed catheters. Hemodial Int 2007; 11:96.
  51. Ash SR, Mankus RA, Sutton JM, et al. Concentrated sodium citrate as catheter lock solution. J Am Soc Nephrol 1999; 10:272A.
  52. Weijmer MC, van den Dorpel MA, Van de Ven PJ, et al. Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 2005; 16:2769.
  53. Ashman N. Efficacy of sodium citrate antimicrobial locks for reducing rates of catheter-related bacteremia. Am J Kidney Dis 2009; 54:1185; author reply 1185.
  54. Shanks RM, Sargent JL, Martinez RM, et al. Catheter lock solutions influence staphylococcal biofilm formation on abiotic surfaces. Nephrol Dial Transplant 2006; 21:2247.
  55. Polaschegg HD, Sodemann K. Risks related to catheter locking solutions containing concentrated citrate. Nephrol Dial Transplant 2003; 18:2688.
  56. Dogra GK, Herson H, Hutchison B, et al. Prevention of tunneled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: a randomized controlled study. J Am Soc Nephrol 2002; 13:2133.
  57. Bleyer AJ, Mason L, Russell G, et al. A randomized, controlled trial of a new vascular catheter flush solution (minocycline-EDTA) in temporary hemodialysis access. Infect Control Hosp Epidemiol 2005; 26:520.
  58. Maki DG, Ash SR, Winger RK, et al. A novel antimicrobial and antithrombotic lock solution for hemodialysis catheters: a multi-center, controlled, randomized trial. Crit Care Med 2011; 39:613.
  59. Betjes MG, van Agteren M. Prevention of dialysis catheter-related sepsis with a citrate-taurolidine-containing lock solution. Nephrol Dial Transplant 2004; 19:1546.
  60. Buturović J, Ponikvar R, Kandus A, et al. Filling hemodialysis catheters in the interdialytic period: heparin versus citrate versus polygeline: a prospective randomized study. Artif Organs 1998; 22:945.
  61. Campos RP, do Nascimento MM, Chula DC, Riella MC. Minocycline-EDTA lock solution prevents catheter-related bacteremia in hemodialysis. J Am Soc Nephrol 2011; 22:1939.
  62. Macrae JM, Dojcinovic I, Djurdjev O, et al. Citrate 4% versus heparin and the reduction of thrombosis study (CHARTS). Clin J Am Soc Nephrol 2008; 3:369.
  63. Colì L, Donati G, Cianciolo G, et al. Anticoagulation therapy for the prevention of hemodialysis tunneled cuffed catheters (TCC) thrombosis. J Vasc Access 2006; 7:118.
  64. Broom JK, Krishnasamy R, Hawley CM, et al. A randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients--the HEALTHY-CATH trial. BMC Nephrol 2012; 13:146.
  65. Broom JK, O'Shea S, Govindarajulu S, et al. Rationale and design of the HEALTHY-CATH trial: a randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients. BMC Nephrol 2009; 10:23.
  66. Hendrickx L, Kuypers D, Evenepoel P, et al. A comparative prospective study on the use of low concentrate citrate lock versus heparin lock in permanent dialysis catheters. Int J Artif Organs 2001; 24:208.
  67. Hryszko T, Brzosko S, Mysliwiec M. Low concentration of heparin used for permanent catheters canal locking is effective and diminishes the risk of bleeding. Int Urol Nephrol 2013; 45:825.
  68. Kaneko Y, Iwano M, Yoshida H, et al. Natural saline-flush is sufficient to maintain patency of immobilized-urokinase double-lumen catheter used to provide temporary blood access for hemodialysis. Blood Purif 2004; 22:473.
  69. Mokrzycki MH, Jean-Jerome K, Rush H, et al. A randomized trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed hemodialysis catheters. Kidney Int 2001; 59:1935.
  70. Moran J, Sun S, Khababa I, et al. A randomized trial comparing gentamicin/citrate and heparin locks for central venous catheters in maintenance hemodialysis patients. Am J Kidney Dis 2012; 59:102.
  71. Mozafar M, Samsami M, Sobhiyeh MR, et al. Effectiveness of aspirin on double lumen permanent catheter efficacy in ESRD. Nephrourol Mon 2013; 5:762.
  72. Nori US, Manoharan A, Yee J, Besarab A. Comparison of low-dose gentamicin with minocycline as catheter lock solutions in the prevention of catheter-related bacteremia. Am J Kidney Dis 2006; 48:596.
  73. Pervez A, Ahmed M, Ram S, et al. Antibiotic lock technique for prevention of cuffed tunnel catheter associated bacteremia. J Vasc Access 2002; 3:108.
  74. Power A, Duncan N, Singh SK, et al. Sodium citrate versus heparin catheter locks for cuffed central venous catheters: a single-center randomized controlled trial. Am J Kidney Dis 2009; 53:1034.
  75. Hemmelgarn BR, Moist L, Pilkey RM, et al. Prevention of catheter lumen occlusion with rT-PA versus heparin (Pre-CLOT): study protocol of a randomized trial [ISRCTN35253449]. BMC Nephrol 2006; 7:8.
  76. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. N Engl J Med 2011; 364:303.
  77. de Oliveira Ramos Netto M, de Campos Nogueira MJ, Guedes EA. [Study of breast feeding]. Rev Esc Enferm USP 1978; 12:77.
  78. Filiopoulos V, Hadjiyannakos D, Koutis I, et al. Approaches to prolong the use of uncuffed hemodialysis catheters: results of a randomized trial. Am J Nephrol 2011; 33:260.
  79. Malo J, Jolicoeur C, Theriault F, et al. Comparison between standard heparin and tinzaparin for haemodialysis catheter lock. ASAIO J 2010; 56:42.
  80. Wang Y, Ivany JN, Perkovic V, et al. Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end-stage kidney disease. Cochrane Database Syst Rev 2016; 4:CD009631.
  81. Moore CL, Besarab A, Ajluni M, et al. Comparative effectiveness of two catheter locking solutions to reduce catheter-related bloodstream infection in hemodialysis patients. Clin J Am Soc Nephrol 2014; 9:1232.
  82. Zellweger M, Bouchard J, Raymond-Carrier S, et al. Systemic anticoagulation and prevention of hemodialysis catheter malfunction. ASAIO J 2005; 51:360.
  83. Gallieni M, Giordano A, Rossi U, Cariati M. Optimization of dialysis catheter function. J Vasc Access 2016; 17 Suppl 1:S42.
  84. McCann M, Moore ZE. Interventions for preventing infectious complications in haemodialysis patients with central venous catheters. Cochrane Database Syst Rev 2010; :CD006894.
  85. Battistella M, Bhola C, Lok CE. Long-term follow-up of the Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) Study: a quality improvement report. Am J Kidney Dis 2011; 57:432.
  86. Rosenblum A, Wang W, Ball LK, et al. Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative. Am J Kidney Dis 2014; 63:259.
  87. O'Grady S, Hirji Z, Pejcic-Karapetrovic B, et al. A double-blind, randomized, controlled trial of topical polysporin triple compound versus topical mupirocin for the eradication of colonization with methicillin-resistant Staphylococcus aureus in a complex continuing care population. Can J Infect Dis Med Microbiol 2009; 20:e49.
  88. Lok CE, Stanley KE, Hux JE, et al. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 2003; 14:169.
  89. Johnson DW, van Eps C, Mudge DW, et al. Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of catheter-associated infections in hemodialysis patients. J Am Soc Nephrol 2005; 16:1456.
  90. James MT, Conley J, Tonelli M, et al. Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-related infections. Ann Intern Med 2008; 148:596.
  91. Centers for Disease Control and Prevention (CDC). Dialysis Safety. Core Interventions. 06/15/2016. Available at: https://www.cdc.gov/dialysis/prevention-tools/core-interventions.html (Accessed on June 15, 2016).
  92. O'Grady NP, Alexander M, Burns LA, et al. Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis 2011; 52:1087.
  93. Farr BM. Mupirocin to prevent S. aureus infections. N Engl J Med 2002; 346:1905.
  94. Deshpande LM, Fix AM, Pfaller MA, et al. Emerging elevated mupirocin resistance rates among staphylococcal isolates in the SENTRY Antimicrobial Surveillance Program (2000): correlations of results from disk diffusion, Etest and reference dilution methods. Diagn Microbiol Infect Dis 2002; 42:283.
  95. Hymes JL, Mooney A, Van Zandt C, et al. Dialysis Catheter-Related Bloodstream Infections: A Cluster-Randomized Trial of the ClearGuard HD Antimicrobial Barrier Cap. Am J Kidney Dis 2017; 69:220.
  96. Brunelli SM, Van Wyck DB, Njord L, et al. Cluster-Randomized Trial of Devices to Prevent Catheter-Related Bloodstream Infection. J Am Soc Nephrol 2018; 29:1336.
Topic 1843 Version 27.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟