Microsoft PowerPoint - CVC toolkit Titleslide 1
description
Transcript of Microsoft PowerPoint - CVC toolkit Titleslide 1
![Page 1: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/1.jpg)
Tunneled Hemodialysis
Catheters:
Placement and complications
Arif Asif, M.DDirector, Interventional Nephrology
Associate Professor of Medicine
University of Miami, FL
Tunneled Hemodialysis
Catheters:
Placement and complications
Asif, M.D.Director, Interventional Nephrology
Associate Professor of Medicine
University of Miami, FL
![Page 2: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/2.jpg)
Tunneled Hemodialysis Catheters: Placement and Complications
![Page 3: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/3.jpg)
21% Chronic caths
Despite the highest risk of mortality, a significant number of chronic hemodialysis patients continue to receive dialysis
using a tunneled hemodialysis catheters.
![Page 4: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/4.jpg)
While there are many disadvantages, there are some advantages of tunneled hemodialysis catheters
• Relative simple insertion procedure• Can be insert into multiple sites even in
patients with exhausted upper and lower extremity veins
• Compared to an arteriovenous fistula or a graft, no maturation time or prolonged healing period is not required
• Some of the complications could be handled relatively easily
![Page 5: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/5.jpg)
Problems
Thrombosis, infection, stenosis
The access does not last as long as a fistula or a graft
Lower blood flow rates
![Page 6: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/6.jpg)
Catheter design• Diameter is major factor
– 19 % diameter increase - flow increases 2X– 50 % diameter increase - flow increases 5X– Increasing from 2.0mm to 2.1mm increases flow
21%
• Catheter length is less important– l9% increase in diameter will compensate for doubling of length
Slide from Gerald Beathard, M.D.
![Page 7: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/7.jpg)
Optimal Catheter design
• Use largest diameter available
• Use shortest length compatible with proper placement
![Page 8: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/8.jpg)
Tunneled Catheter Placement:While anatomical landmarks are important to identify internal jugular
vein, ultrasound should be strongly considered to identify the vein and reduce complications. In fact, ultrasound is considered mandatory by
many leaders in catheter insertion.
Courtesy of Tony Samaha, M.D.
![Page 9: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/9.jpg)
Courtesy of Tony Samaha
A micropuncture needle could be used to enter the internal jugular vein.
![Page 10: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/10.jpg)
Courtesy of Tony Samaha
Local anesthesia is infiltrated and a tunnel created for the catheter
![Page 11: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/11.jpg)
Courtesy of Tony Samaha
Catheter insertion can be accomplished with or without a peel-away sheath.
![Page 12: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/12.jpg)
Optimal site
• Right internal jugular vein
![Page 13: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/13.jpg)
Other Sites• Femoral • Left internal jugular• Trans-lumbar (IVC)• Subclavian
• High risk for stenosis • Acceptable only if no further arm access
planned
![Page 14: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/14.jpg)
Cannulation of the Vein• Ultrasound guided cannulation should be
mandatory
![Page 15: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/15.jpg)
Location of Internal Jugular
Slide form Gerald Beathard
![Page 16: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/16.jpg)
Slide form Gerald Beathard
![Page 17: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/17.jpg)
Tip Position
• Fluoroscopy is mandatory for tip position
![Page 18: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/18.jpg)
Placement without fluoroscopy
Slide form Gerald Beathard
![Page 19: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/19.jpg)
Optimum Catheter Tip Position:
![Page 20: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/20.jpg)
Optimal tunneled HD catheter• Place in right internal
jugular• Use ultrasound for
cannulation• Use fluoroscopy for
placement• Place tip well within
atrium
![Page 21: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/21.jpg)
Complicating Issues
![Page 22: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/22.jpg)
Catheter Dysfunction
• Thrombosis and sheath formation are the most common cause of catheter dysfunction and access loss1,2
– Occurs in 30% to 40% of patients undergoing hemodialysis3,4
1. Blankestijn. In Hemodialysis Vascular Access: Practice and Problems. 2001; 2. NKF. Am J Kidney Dis. 2001;37(suppl 1); 3. Little. Am J Kidney Dis. 2002; 4. Moss. Am J Kidney Dis. 1988; 5. Feldman. J Am Soc Nephrol. 1996; 6. Feldman. Kidney Int. 1993.
![Page 23: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/23.jpg)
Impact of blood flow on Dialysis Dose
Held et al. Kidney Int. 1996;50:550-556; Hakim et al. Am J Kidney Dis. 1994;23:661-669; Owen. JAMA. 1998;280:1764-1768.
Patie
nt h
ealth
; QO
L
300 mL/minQB
Increasing BFRIncreasing BFR Decreasing BFRDecreasing BFR
Kt/V ⇒
Morbidity &
Mortality ; QOLDose Decay Progression
![Page 24: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/24.jpg)
Inadequate Dialysis Dosing Increases HD Treatment Time and Costs
• Every 0.1 in Kt/V is independently associated with– 11% more hospitalizations
– 12% more hospital days
– $940 increase in Medicare inpatient expenditures
United States Renal Data System, 2003; Sehgal et al. Am J Kidney Dis. 2001;37(6):1223-1231.
![Page 25: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/25.jpg)
Thrombolytics have been used to treat catheter thrombosis
• High level of safety and efficacy– Efficacious as lytic to restore flow1
– Efficacious to maintain blood flow2
• Lower incidence of complications
• Cost-effective
1.1. PrabhuPrabhu 1997; Atkinson 1990; Paulsen 1993; 1997; Atkinson 1990; Paulsen 1993; CrowtherCrowther 200020002.2. Twardowski 1998; Dowling 2000; Spry 2001; Twardowski 1998; Dowling 2000; Spry 2001; EyrichEyrich 20022002
![Page 26: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/26.jpg)
rTPA protocol for intraluminal thrombus
• 2mg tPA mixed with NS to total volume of catheter lumen
• Fill lumens with mixture to “fill volume”and wait 15min
• Inject 0.3ml of saline to move active enzyme toward the tip of catheter every 5 min X 3
• Aspirate from catheter• If aspirates easily, do forceful flush• If cannot aspirate easily, may repeat
procedure• If still unsuccessful, probably dealing
with fibroepithelial sheth
Adapted from Beathard G., Seminars in Dial 14:441-45, 2001Adapted from Beathard G., Seminars in Dial 14:441-45, 2001
![Page 27: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/27.jpg)
Fibroepithelial Sheath
• Fibroepithelial sheath is major problem
• Catheter exchange is solution
• tPA is of short term value only Photo Courtesy: G. Beathard
![Page 28: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/28.jpg)
Treatment of Fibrin Sheath
• Sheath mostly associated with venous stenosis
• Treatment of stenosis will obliterate sheath
![Page 29: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/29.jpg)
Fibroepithelial Sheath:Pre and post treatment
Sheath
Left IJ catheter
Right atrium
![Page 30: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/30.jpg)
Catheters can cause central venous stenosis
![Page 31: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/31.jpg)
SVC
Right Atrium
BRCHPH
BRCHPH
SVCComplete occlusion of superior vena cava
![Page 32: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/32.jpg)
Balloon angioplasty can be successful in selected cases
![Page 33: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/33.jpg)
SVC
RA
BRCHPH
BRCHPH
SVC
Post angioplasty
![Page 34: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/34.jpg)
Pre-angioplasty of central venous occlusion
Post-angioplasty of central venous occlusion
![Page 35: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/35.jpg)
Catheter can be accidentally dislodged
![Page 36: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/36.jpg)
In some cases of a new catheter could be inserted through the same exit site after
sterile preparation
Asif et al: Seminars in Dialysis 2007Funaki et al: JVIR 1998
![Page 37: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/37.jpg)
Wire insertion
![Page 38: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/38.jpg)
Imager over the wire
![Page 39: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/39.jpg)
Angiography is then performed to confirm central veins and the atrium
![Page 40: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/40.jpg)
A new catheter is then fed onto theWire and into the atrium
![Page 41: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/41.jpg)
![Page 42: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/42.jpg)
New tunnel creation is usually performed for the following
conditions• Badly placed catheter with a kink• Infected exit site
![Page 43: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/43.jpg)
Kink
Infected exit site
![Page 44: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/44.jpg)
Site of new tunnel drawn
![Page 45: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/45.jpg)
New tunnel created underLocal anethesia
![Page 46: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/46.jpg)
Wire insertion throughthe new tunnel
![Page 47: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/47.jpg)
Catheter insertionthrough the new tunnel
![Page 48: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/48.jpg)
Kink New Tunnel
Kink
![Page 49: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/49.jpg)
Catheter can cause exit site infection, endocarditis and discitis
Image from Tony Samaha
![Page 50: Microsoft PowerPoint - CVC toolkit Titleslide 1](https://reader034.fdocuments.in/reader034/viewer/2022042521/549cda5dac7959b02a8b4837/html5/thumbnails/50.jpg)
Conclusions• At present tunneled dialysis catheters play a major
role in providing dialysis therapy• Right internal jugular vein continues to be the
preferred site• Ultrasound and fluoroscopy are mandatory• Thrombosis, stenosis and infection remain the most
important problems associated with catheters• Due to these problems, catheter continue to be
associated with the highest risk of mortality compared to fistulae and grafts in hemodialysis patients