Venous catheter, hemodialysis access

Special attention in such patients focuses on the presence and function of preexisting arteriovenous fistulae, hemodialysis central venous catheters, or access for peritoneal dialysis. Arms with vascular accesses are kept free from blood pressure cuffs, pulse oximeters, tourniquets and peripheral venous cannulae. 

Thrombosis associated with hemodialysis most commonly occurs in patients with venous catheter access for dialysis and is a common cause of catheter failure. However, thrombosis can occur in synthetic grafts and less frequently in AV fistulas. 

Blood cultures should be obtained for any patient receiving hemodialysis who develops a fever. Nonpharmacologic management of infections involves preventive measures with sterile technique, proper disinfection, and minimizing the use and duration of venous catheters for hemodialysis access. 

Central venous catheters are reluctantly used as blood access for hemodialysis because of safety concerns and frequent complications, for example sepsis, thrombosis, and vessel stenosis. Nevertheless, 20% or more of all patients rely on atrial catheters for chronic dialysis because of lack of other access. Potentially fatal risks related to central venous catheters include air embolism (1), severe blood loss (2), and electric shock (3). These specific risks have been substantially eliminated by the inherent design and implantation of Dialock (Biolink Corporation, USA). Dialock is a subcutaneous device consisting of a titanium housing with two passages with integrated valves connected to two silicone catheters. The system is implanted subcutaneously below the clavicle. The tips of the catheters are placed in the right atrium. The port is accessed percutaneously with needle cannulas. 

Due to fewer complication and longer survival rates, the native arteriovenous fistula is the preferred access for hemodialysis. Venous catheters are plagued by complications such as infection and thrombosis and often deliver relatively poor blood flow rates. 

The anatomic location for temporary central venous catheter (CVC) insertion and placement can be dictated by certain patient or disease restrictions, but the most common sites are the internal jugular vein (neck), the femoral vein (groin), and the subclavian position (upper chest). The internal jugular approach is the first choice for placement of a hemodialysis CVC, while femoral placement is favored when rapid insertion is essential (Canaud et al., 2000). Subclavian vein access has fallen from favor because of a higher incidence of thrombosis and stenosis associated with this site, which can ultimately prevent use of the veins in the downstream vascular tree for high-flow applications such as dialysis (Cimochowski et al., 1990 Schillinger et al., 1991). 

In patients with CKD, preservation of the integrity of peripheral and central veins is of vital importance for future hemodialysis access. Avoid i.v. infusion or vein puncture in the forearm and upper arm veins at both arms whenever possible. Insertion of venous access devices carries the risk to injure the veins and thereby incite phlebitis, sclerosis, stenosis or thrombosis and has to be avoided. Whenever a central venous catheter is needed, catheterization of the internal jugular or femoral vein is always preferred. Use of subclavian vein should be... 

Dialysis vascular access is currently the lifeline for hemodialysis patients. Unfortunately, due to the many complications associated with dialysis vascular access, it is also the Achilles heel of hemodialysis. A relatively ignored aspect of dialysis vascular access pertains to patient safety. The first part of this chapter will describe patient safety issues in the traditional context of arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs) and tunneled central venous catheter (tCVC). In the second half of this chapter, however, we will make the case that a nontraditional approach which emphasizes (a) individualization of care, and (b) patient preferences and patient involvement maybe our best opportunity to improve patient safety in hemodialysis patients. 

Hemodialysis (HD) catheter-associated bloodstream infections (BSls) are a type of CLABSI due to a central venous catheter (CVC) specifically designed for HD. In 2002, it was estimated that 50,000 CLABSIs occur in dialysis patients in the US annually. A more recent surveillance study found the rate of access-related BSIs to be 0.73 events per 100 patient-months [5]. Aside from catheters, patients in need of renal replacement therapy should eventually use arteriovenous fistula (AVF) or arteriovenous grafts (AVG) for HD, or alternatively, may receive peritoneal dialysis. All renal replacement therapies are associated with a risk of infection however, this risk varies with the method selected. Data from a CDC surveillance program display nicely how the type of access influences the BSI rate per 100 patient-months 0.5 (for AVFs), 0.9 (AVG), 4.2 (permanent CVCs), and an impressive 27.1 for temporary CVCs [6]. Another, more practi-... 

Polkinghorne KR, Seneviratne M, Kerr PG Effect of a vascular access nurse coordinator to reduce central venous catheter use in incident hemodialysis patients a quality improvement report. Am J Kidney Dis 2009 53 99-106. 

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Torosian MH, Meranze S, McLean G, Mullen JL (1986) Central venous access with occlusive superior central venous thrombosis. Ann Surg 203 30-33 Trerotola SO, Johnson MS, Harris VJ, Shah H, Ambrosius WT, McKusky MA, Kraus MA (1997) Outcome of tunneled hemodialysis catheters placed via the right internal jugular vein by interventional radiologists. Radiology 203 489-495... 

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