Dialysis Catheter – StatPearls – NCBI Bookshelf

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Introduction

Dialysis catheters are synthetic indwelling transcutaneous conduits which can be used to entry the intravascular house or the intraperitoneal house for renal substitute remedy (RRT). There are two broad sorts of dialysis catheter: these used for extracorporeal modes of RRT (equivalent to hemodialysis, hemofiltration, hemodiafiltration or ultrafiltration), and people used for peritoneal dialysis.[1]

  • Catheters for extracorporeal RRT are primarily wide-bore central venous traces that permit blood to be withdrawn from and returned to the affected person effectively. On this method, the affected person’s blood may be quickly faraway from the physique for processing in an extracorporeal RRT machine which can carry out any of hemodialysis, hemofiltration, hemodiafiltration or ultrafiltration as desired. Relying on the supposed length of remedy, the catheter can be inserted immediately by way of the pores and skin into the goal vein, or it could first go underneath the pores and skin by way of a brief subcutaneous tunnel earlier than it reaches the vein, with an integral felt cuff securing it to the native tissue.

  • Catheters for peritoneal dialysis permit fluid often called dialysate to be instilled into the intraperitoneal house, the place it stays in touch with the peritoneal membrane for a while earlier than being eliminated. On this type of remedy, dialysis happens immediately throughout the peritoneal membrane itself.

Anatomy and Physiology

Non-tunneled catheters for short-term extracorporeal RRT are preferentially inserted underneath ultrasound steering, as this enables subcutaneous buildings to be visualized and reduces the complication charges,[2] however they can be positioned utilizing solely floor anatomical landmarks. Potential placement websites embody the interior jugular vein, subclavian vein, and femoral vein. Tunneled cuffed catheters are inserted underneath fluoroscopic steering into the subclavian vein. For catheters positioned by way of the interior jugular vein or subclavian vein, the optimum tip location is on the junction of the superior vena cava and proper atrium, and catheters round 15cm in size are applicable.[2] The subclavian vein is much less generally used within the acute or emergency setting, as circulate charges could also be extra decreased, and this web site carries associations with subsequent subclavian vein stenosis; this might make the location of a tunneled cuffed catheter or a surgical arteriovenous fistula tougher ought to the affected person go on to require this.[3] Femoral vein catheters needs to be at the least 20cm in size in order that the tip of the catheter passes by way of the frequent iliac vein and reaches the inferior vena cava.

Tunneled cuffed catheters for longer-term use are inserted underneath fluoroscopic steering into the subclavian vein.

In contrast, peritoneal dialysis catheters goal the intraperitoneal house quite than a vascular construction. When accurately positioned, they need to traverse the anterior stomach wall with the distal tip resting superficial to the visceral peritoneum and deep to the parietal peritoneum, pointed within the path of the pelvis.[4] The borders of the rectus muscle are most well-liked insertion websites, away from the paths of the superficial and inferior epigastric arteries. With using a Tenckhoff catheter with two cuffs, the deeper cuff ought to relaxation inside the pre-peritoneal house within the rectus sheath, and the superficial cuff ought to lie 2 to 3cm medial to the superficial wound.[4] Inserting the deeper cuff exterior the rectus muscle could result in much less tissue ingrowth, growing the chance of leakage and herniation. If the superficial cuff placement is just too deep, serous fluid could gather within the house exterior of the cuff, resulting in pores and skin irritation and an infection.

Indications

Placement of a brand new dialysis catheter is invariably vital for beginning extracorporeal RRT within the emergency or acute settings (except for sufferers with end-stage renal illness who already occur to have a catheter in situ). Non-tunneled catheters are applicable for short-term, emergency or short-term use, and tunneled cuffed catheters could also be extra applicable for medium-term to long-term use the place there may be the anticipation of an ongoing want for RRT over weeks to months. Nevertheless, hemodialysis for sufferers with power renal failure is preferentially carried out utilizing an arteriovenous (AV) fistula, which consists of an appropriate artery and vein which were surgically connected, creating an “arterialized” vein that’s extra amenable to repeated venipuncture over protracted durations with wide-bore needles.[5] Needles are inserted into the fistula solely throughout dialysis classes, decreasing the chance of infections and different issues. Nevertheless, AV fistulas require a surgical process and should subsequently take weeks to months to mature to the purpose the place they’re prepared to be used. Catheters can be utilized instantly after insertion, so they’re usually required not just for emergencies but additionally for sufferers with subacute or power renal failure the place it’s not possible to determine an AV fistula upfront.

For peritoneal dialysis, the location of a catheter is at all times vital. Peritoneal dialysis could also be notably applicable the place vascular entry is troublesome; in hemodynamically labile sufferers with poor cardiovascular operate who could tolerate hemodialysis poorly; or in pediatric sufferers.

Contraindications

Contraindications for extracorporeal RRT catheters embody native an infection over the insertion web site, thrombosis or stenosis inside the goal vein, distorted anatomy, or native vascular damage. Peritoneal dialysis catheters could also be contraindicated the place the peritoneum isn’t intact, equivalent to the place there was latest trauma, sepsis or surgical procedure to the stomach. Peritoneal dialysis itself could also be inappropriate the place the metabolic derangements are too excessive (equivalent to in extreme hyperkalemia), or in extreme acute respiratory misery syndrome (ARDS) the place the peritoneal fluid could splint the diaphragm and intervene with the work of respiration. It’s unclear whether or not peritoneal dialysis or extracorporeal RRT correlates with fewer dangers within the presence of coagulopathy.

Tools

Catheters for Extracorporeal RRT

The catheters used for hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration are central venous traces with broad inside lumens. Externally, the catheter is connected to the RRT machine utilizing color-coded Luer taper connectors: the facet the place blood will get withdrawn from the affected person is often coloured crimson, with the facet the place blood is returned being blue.[6] Charges of blood circulate by way of every connector may be modified by adjusting the adjoining clamps. Most catheters are dual-lumen, incorporating each entry and return limbs within the one gadget, however single-lumen catheters additionally exist; if these are used, two might be required. There are additionally triple-lumen catheters which embody a 3rd slim lumen that can be utilized for different functions (equivalent to proper atrial strain monitoring or administering drugs) with out disrupting the continuing RRT.[2]

Early dual-lumen catheters had a coaxial design, with blood being eliminated by way of a big outer cannula and returned down the middle by way of a slim internal cannula; the internal cannula was changed anew for every session of dialysis. Most trendy catheters as a substitute have the 2 lumens sitting in parallel facet by facet.[2][6] Contained in the affected person, the return lumen opens on the distal tip of the catheter (that’s, on the finish nearer to the guts), and the opening of the withdrawal lumen is bodily separated from the return lumen by a brief distance. This setup reduces the chance that purified blood returning to the affected person will instantly be sucked again out into the extracorporeal RRT machine, a phenomenon often called “recirculation” which might lower the effectivity of the RRT session.[2]

Each non-tunneled catheters and tunneled cuffed catheters exist. (A 3rd class – implantable vascular entry units, with subcutaneous ports – noticed restricted use within the Nineties, however are not available on the market.)[7] Insertion of non-tunneled catheters is immediately by way of the pores and skin into the goal vein. Tunneled cuffed catheters are completely different in that they’ve an extended shaft incorporating an artificial felt cuff; they’re additionally inserted by way of the pores and skin, however they’re then handed by way of a brief subcutaneous tunnel earlier than getting into the goal vein. The cuff finally ends up underneath the pores and skin close to the entry level and stimulates an area fibroblastic response, resulting in ingrowth of the encircling tissue over time which secures the gadget extra firmly. Collectively, the cuff and tunnel act as limitations to microbial migration alongside the surface of the catheter, decreasing the danger of catheter-associated bloodstream infections in comparison with non-tunneled catheters.[6]

When accurately positioned, the tip of the catheter ought to relaxation in the midst of a big central vein away from the vessel wall, in order that the opening of the withdrawal lumen – which is underneath unfavourable strain – doesn’t develop into occluded because of the vessel wall being sucked throughout it. The clinician putting the catheter ought to think about how the tip place could change when the affected person strikes. By the Hagen-Poiseuille equation, circulate is inversely proportional to size,[8] so the chosen catheter needs to be lengthy sufficient that the tip can attain the supposed goal web site, but it surely ought to in any other case be as brief as doable to attenuate resistance to circulate. Some dual-lumen catheters substitute the only withdrawal opening close to the tip with a number of facet holes alongside the size of the catheter; this enables extra flexibility in positioning the catheter close to the vessel wall, however it could improve turbulence resulting in poorer circulate charges. Alternatively, if the lumens are in parallel, the 2 finish holes could also be organized in order that the withdrawal lumen is on the within of the catheter’s curve farther from the vessel wall, with the return lumen on the surface of the curve.[9]

The next tools is required to put a non-tunneled catheter for extracorporeal renal substitute remedy:

  • Native anesthetic (generally lidocaine 1% or 2%), with syringe and needle

  • Introducer needle (or introducer cannula with trocar) and syringe

  • Seldinger guidewire

  • Pores and skin dilator

  • Silk suture

  • Scalpel

  • Bungs for catheter

  • Heparin resolution (relying on native observe)

  • Sterile regular saline

  • Pores and skin dressing

If utilizing ultrasound, the machine would require a linear probe, sterile probe cowl, and sterile aqueous gel.

Catheters for Peritoneal Dialysis

Peritoneal dialysis catheters are single-lumen indwelling transcutaneous cannulas which permit dialysate fluid to be instilled into and faraway from the intraperitoneal house. They’ve a single lumen, with a number of facet holes current on the intraperitoneal part. Inflexible catheters are usable within the acute setting; nonetheless, for power renal failure or sufferers with a number of organ failure, the most typical sort in modern use are Tenckhoff catheters (named for Henry Tenckhoff who pioneered their use).[10] They differ in that their composition is of soppy, versatile silicone, they incorporate one or two artificial felt cuffs alongside the shaft (just like the cuffs seen on the tunneled cuffed catheters used for extracorporeal RRT), and they’re inserted utilizing a particular trocar or by the Seldinger method. They are often positioned both by an open surgical method or by laparoscopy; percutaneous strategies with or with out fluoroscopy are much less invasive however could also be related to extra issues.[10] The guidelines of Tenckhoff catheters could also be straight or coiled, with coiled catheters probably being much less prone to blockage.

For acute intermittent peritoneal dialysis, the dialysate fluid (roughly 2000mL for an grownup, or 20 to 50mL/kg for a kid) is instilled by way of the catheter into the peritoneal cavity and is left there for 30 to 60 minutes earlier than being drained out by gravity. Some newer strategies like continuous-flow peritoneal dialysis require the presence of separate catheters for simultaneous influx and outflow of fluid.

The next tools is required to put a Tenckhoff peritoneal dialysis catheter utilizing the Seldinger method:

  • Native anesthetic, with syringe and needle

  • Cannula and syringe

  • Warmed sterile regular saline

  • Seldinger guidewire

  • Scalpel

  • Sheath with introducer

  • Tenckhoff catheter

Personnel

The presence of a devoted expert assistant throughout catheter insertion is useful, however it’s not completely vital so long as affected person positioning is appropriate, the affected person is calm and cooperative, and all required tools is out there.

Preparation

The place possible, knowledgeable consent needs to be obtained from the affected person after explaining the advantages and threat of the process, and this needs to be documented appropriately within the medical notes. IV entry needs to be obtained, and monitoring commenced by ECG, blood strain, and pulse oximetry. For peritoneal dialysis catheters, the affected person ought to empty their bowels and bladder earlier than the process. The affected person ought to then lie supine on the therapy mattress. Inside jugular or subclavian vein catheters needs to be positioned with the affected person within the Trendelenburg place, and with the top going through ahead neutrally. Trendelenburg positioning isn’t required for femoral vein catheters; as a substitute, the inguinal space needs to be uncovered. The chosen insertion web site is painted as for a surgical process with an antiseptic equivalent to povidone-iodine or 2% chlorhexidine. The clinician ought to don a hat and face masks (ideally with an eye fixed protect or goggles), carry out correct hand hygiene for asepsis, and placed on a sterile robe and gloves. A sterile drape is positioned on the affected person in order that the aperture exposes the chosen web site.

Method

Catheters for Extracorporeal RRT

Insertion of catheters for hemodialysis, hemofiltration, hemodiafiltration or ultrafiltration is basically just like different types of central venous entry. The native floor anatomy is recognized; if ultrasound is out there, gel and a sterile cowl are utilized over the probe, and the gadget is used to visualise the subcutaneous buildings to find out the path to the goal vein. An area anesthetic is injected on the insertion web site, first superficially to lift a subcutaneous wheal, after which extra deeply to anesthetize tissues within the path of the vein.

The introducer needle is connected to a syringe after which inserted slowly by way of the pores and skin in the direction of the vein, making use of fixed unfavourable strain to the plunger of the syringe. When a flash of blood is aspirated, the clinician stops advancing the needle and detaches the syringe, overlaying the aperture of the needle to forestall air from getting into. An alternate model of this course of entails a cannula loaded over the needle; if utilizing this system, the cannula is threaded into the vein at this level, and the needle and syringe are each eliminated. The guidewire is then gently superior by way of the needle (or cannula); if resistance is encountered, the operator ought to cease and ensure the place of the needle tip earlier than repeating. One other variation of the process makes use of a Raulerson syringe, a particular commercially-available syringe with a built-in channel by way of the plunger, which means the guidewire may be inserted immediately by way of the needle with no need to detach the syringe.

When the guidewire is in place, the needle or cannula is eliminated. The clinician subsequent makes use of a scalpel to make a small nick within the pores and skin on the web site of the guidewire, and the pores and skin dilator is then superior over the guidewire by way of the pores and skin into the goal vein to open up a tract for the catheter, utilizing fixed rotation whereas advancing it to cut back the chance of kinking the wire. The dilator is eliminated whereas maintaining mild strain over the positioning, and the dialysis catheter is then superior over the wire into the specified depth, ensuring to maintain maintain of the wire always to keep away from unintended inward migration. The wire is then eliminated and the catheter secured to the pores and skin utilizing suture materials and a dressing. For inside jugular or subclavian traces, a chest radiograph needs to be obtained to substantiate the place and rule out pneumothorax.

Catheters for Peritoneal Dialysis

Within the percutaneous Seldinger method, an area anesthetic is first injected on the chosen midline insertion web site, roughly 1 to 2cm beneath the umbilicus, by way of the complete depth of the pores and skin and stomach wall right down to the parietal peritoneum. A scalpel is used to make a nick on the insertion web site, and a mosquito forceps is used to dissect bluntly right down to the linea alba. Gripping onto the rectus sheath with the forceps, the stomach wall is lifted to carry it taut away from the underlying bowel, and the cannula and needle are handed by way of the linea alba, stopping when there’s a lack of resistance. The cannula is superior, and the needle eliminated. The peritoneal house is then primed by instilling warmed fluid (equivalent to 500mL of regular saline), which ought to run in easily if the cannula tip is within the intraperitoneal house and isn’t kinked. This creates a fluid-filled house into which the catheter may be handed. The guidewire is then gently superior, and the cannula is withdrawn. A specially-designed perforated sheath is inserted as a substitute utilizing a particular introducer earlier than the guidewire and introducer are then eliminated.

After lubricating the catheter tip with gel and soaking the cuffs in saline, the catheter is slowly inserted into the stomach by way of the sheath till the primary cuff is within the pre-peritoneal house; the sheath is progressively break up open alongside its perforations whereas the catheter is inserted earlier than it’s ultimately damaged away fully and eliminated. Dialysate ought to circulate freely into the intraperitoneal house if the catheter tip positioning is appropriate.

A extra native anesthetic is injected underneath the pores and skin laterally to the midline wound, and a small nick is made with a scalpel at this web site. A subcutaneous tunnel is long-established by passing a particular software into the midline wound, by way of the subcutaneous tissue, and exiting on the lateral wound. The proximal finish of the catheter is then handed again by way of the tunnel; when accurately positioned, the second cuff ought to come to relaxation underneath the pores and skin about 2 to 3cm medial to the exit web site. The 2 wounds are then closed and dressed, and the catheter is fastened to the pores and skin with suture materials.

Inflexible catheters are additionally inserted within the midline. The stomach should first be primed with a bolus of dialysate fluid – roughly 2000mL for an grownup – that’s instilled by way of a wide-bore needle inserted on the midline wound web site beneath the umbilicus. After priming, the needle is eliminated, and the catheter with its trocar is inserted by way of the stomach wall with a rotatory movement. The trocar is barely withdrawn, and the remainder of the catheter is then superior alongside the midline within the path of the coccyx, with the catheter’s exterior bead coming to relaxation on the pores and skin. The trocar is withdrawn earlier than warmed dialysate fluid, and a set bag is connected to the three-way faucet, and fluid is then instilled to substantiate patency. The catheter is then sutured to the pores and skin and dressed.

Issues

Catheters for extracorporeal RRT share the issues of different central venous traces, together with morbidity and mortality from thrombosis and an infection, trauma to adjoining buildings such because the pleura (inflicting pneumothorax) or arteries, stenosis of the central veins, and failure of the gadget resulting in decrease blood circulate charges and a shorter useful survival life within the affected person.[11] Dialysis catheter dysfunction could come up as a result of poor placement (equivalent to kinking on the level of getting into the vein, poor place of the tip inside the blood vessel, or selecting a blood vessel that’s too slim for the gadget); stasis of blood; and hypercoagulability situations of the blood. These can all predispose to the formation of a fibrin sheath round a catheter, enormously decreasing its performance.[12] Numerous surgical strategies have been developed to revive patency and performance in failing tunneled cuffed catheters. These embody an over-the-wire trade of 1 catheter for an additional, stripping the fibrin sheath from across the gadget (by getting into the vasculature by way of the femoral vein), and eradicating the catheter adopted by balloon dilatation of the fibrin sheath and re-implanting one other catheter in the identical location.[12] A possible short-term technique to enhance circulate charges in a failing catheter is reversing the bloodlines within the circuit – in order that blood will get eliminated by way of the blue return lumen, and returned by way of the crimson withdrawal lumen – however this doesn’t at all times work, and is on the expense of upper recirculation which is able to make the RRT session much less environment friendly.

When putting catheters for peritoneal dialysis, misplacement of the needle throughout priming of the peritoneal cavity could lead to dialysate getting into the bowel or bladder, which can provide rise to the sudden onset of diarrhea or a sudden improve in urine circulate respectively. Bowel perforation happens in roughly 1% of circumstances,[4] and injury to intraabdominal buildings could reveal itself by the presence of fecal matter or vital quantities of blood within the effluent fluid. An infection of the cutaneous wound is much less frequent early on, however peritonitis could ultimately happen, which might require therapy with antibiotics, discontinuation of peritoneal dialysis and switching the affected person to extracorporeal RRT. Catheters could develop into obstructed over time as a result of malposition, kinking, adhesions, clots or formation of a fibrin sheath. Irrigation with saline or urokinase, or repositioning of the catheter, could restore circulate.[4] Laparoscopy and omentectomy could finally be required.[13] Fluid could leak by way of the cutaneous wound; that is extra frequent with inflexible catheters than tunneled Tenckhoff catheters.

Scientific Significance

Catheters inserted for power renal failure may have to stay useful for a number of months and needs to be cleaned and cared for utilizing applicable substances. Many dialysis catheters are created from polyurethane, which is a thermoplastic and turns into softer at physique temperature whereas retaining tensile energy. Nevertheless, it’s weakened by alcohol (a commonly-used disinfectant), by most antibiotics aside from triple antibiotic ointment, and by polyethylene glycol which is a standard element in ointments.[9] Some newer catheters are created from silicone, which is extra versatile and softer than polyurethane, and consequently requires that the catheter have thicker partitions to keep away from collapse or kinking of the road. It’s extra appropriate with ointments however is weakened by publicity to iodine, one other generally used disinfectant.[9]

Enhancing Healthcare Crew Outcomes

Groups inserting and managing dialysis catheters are an interprofessional and might embody nephrologists, anesthesiologists, intensivists, dialysis nurses, essential care nurses, and superior non-medical practitioners. They need to be aware of the variations and particular indications for the various kinds of dialysis catheters accessible available on the market; whereas most of them operate equally, all of them are additionally liable to a variety of particular technical challenges and issues. The nurse taking care of the affected person is often in command of the continuing care of the catheter.

Issues arising from vascular entry in dialysis sufferers are a big explanation for morbidity and mortality, notably when evaluating the long-term use of transcutaneous central venous catheters to different modalities of vascular entry. In the US, the variety of dialysis sufferers requiring hospitalization for infections associated to vascular entry greater than doubled between 1993 and 2006, though the quantity has since plateaued.[9] A excessive proportion of end-stage renal illness sufferers – in extra of fifty% in some collection – find yourself requiring renal substitute remedy to be began urgently by a central venous catheter.[14] The Kidney Illness Consequence High quality Initiative at the moment recommends that lower than 10% of power hemodialysis sufferers ought to obtain therapy by way of central venous catheters and that this modality needs to be a consideration provided that different modalities equivalent to AV fistulas and grafts are inappropriate, or have failed.[15] In healthcare organizations offering dialysis companies, the place the case combine features a decrease proportion of sufferers utilizing catheter-based dialysis, these sufferers could expertise increased charges of catheter-associated infections.[16] An infection management measures could also be stronger in organizations coping with increased proportions of this affected person group.

General, peritoneal dialysis seems to correlate with decrease necessities for hospitalization than hemodialysis.[9] Success for peritoneal dialysis could also be optimized by good an interprofessional communication, monitoring of renal operate, cautious affected person choice and early placement of the catheter; rapid initiation of dialysis after placement needs to be prevented.[17]

Persevering with Training / Evaluate Questions

References

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Lorenzo Sellarés V. Evaluation of emergency Division Frequentation amongst sufferers with superior CKD (power kidney illness): Classes to optimise scheduled renal substitute remedy initiation. Nefrologia. 2018 Nov – Dec;38(6):622-629. [PubMed: 30219338]
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