Hemodialysis Catheter Problems (And What To Do About Them)

Hemodialysis Catheter Complications (And What To Do About Them)
April 29, 2019 0 Comments

Introduction

Ideally, sufferers with end-stage kidney illness would start hemodialysis with a mature, purposeful arteriovenous entry. Nonetheless, in sure subgroups of sufferers, central venous catheters (CVCs) are unavoidable. Even for sufferers who in the end use an arteriovenous fistula (AVF) or arteriovenous graft (AVG) for long-term dialysis, the numerous majority are uncovered to CVCs and their related dangers sooner or later of their lives.

CVC issues could also be broadly categorized as infectious or non-infectious. Infectious issues embody catheter-related bloodstream an infection (CRBSI) and tunnel or exit website infections. Non-infectious issues embody mechanical points (e.g., malpositioned or kinked catheter), central vein stenosis, or thrombosis. On this put up, we are going to discover some frequent CVC-related issues and how you can handle them.

Infectious Problems

Case 1: You’re notified by the dialysis nurse that your affected person didn’t fairly seem to be her regular self when she got here to dialysis immediately. Midway by way of her session, she complained of nausea and chills. Oral temperature is 101 F. She dialyzes by way of a CVC and also you instantly suspect CRBSI. The next step is to:

a. Instantly begin therapy with empiric broad-spectrum antibiotics
b. Order a STAT chest x-ray and urinalysis
c. Ask for blood cultures to be drawn from the peripheral veins
d. Ask for blood cultures to be drawn from the catheter lumen and the dialysis circuit

Case 1 presents an instance of CRBSI. The chance for creating CRBSI will increase the longer the catheter is used. Sufferers generally current with fever and chills, however often produce other non-specific signs resembling malaise or encephalopathy. Acquiring peripheral blood cultures in dialysis sufferers is usually difficult, and blood cultures drawn from the catheter hub and the dialysis circuit are most correct for diagnosing CRBSI within the hemodialysis inhabitants (selection d). Sufferers needs to be handled with empiric broad-spectrum antibiotics whereas awaiting tradition outcomes. Kind and period of antibiotic remedy needs to be tailor-made based mostly on antibiotic sensitivities. Catheter administration could differ relying upon the affected person’s response to antibiotics and the infecting organism (Determine 1 beneath).

Case 2: You’re requested to judge a CVC-dependent dialysis affected person who offered to the Emergency Division. He reviews subjective fevers over the past 3 days and notes that the world round his proper inside jugular CVC is pink and sore. You get hold of blood cultures and cultures of drainage on the exit website and begin empiric antibiotics. Cultures come again optimistic for methicillin-resistant Staphylococcus aureus. In addition to giving applicable antibiotics with dialysis, you propose to:

a. Take away the present catheter and place a brand new catheter at a unique location
b. Lock the catheter with an antibiotic resolution following dialysis
c. Order washout of the tunnel and guidewire catheter exchanged
d. Deal with the exit website an infection with topical mupirocin

Case 2 represents an exit website an infection with concurrent bacteremia. It’s seen nearly completely with Staphylococcal infections. Catheter salvage is cheap with Staphylococcus epidermidis, but when the infecting agent is Staphylococcus aureus, the catheter ought to promptly be eliminated and a brand new catheter positioned in a unique location as soon as bacteremia has cleared (selection a).

Determine 1. Prompt algorithm for the administration of catheter-related bloodstream an infection. Farrington and Allon, CJASN, 2019.

Non-Infectious Problems

Case 3: You’re rounding within the dialysis unit when the nurse approaches you a few CVC-dependent affected person whose machine retains alarming for prime arterial pressures. This has occurred earlier than and has normally improved with thrombolytics, however now he can solely obtain a most blood circulate fee of 200 mL/min regardless of a 1-hour alteplase dwell previous to dialysis. You resolve to:

a. Ask the nurse to reposition the affected person and attempt to reverse the dialysis ports
b. Refer the affected person for CVC change
c. Order a three-hour alteplase dwell
d. Order ultrasound vein mapping and surgical session for AVF placement

Case 3 suggests the presence of a fibrin sheath, which may start to kind as quickly as 24 hours following placement of the catheter. A fibrin sheath consists of fibrinogen, lipoproteins, albumin, and coagulation components. It has been present in as much as 70% of catheters being exchanged for malfunction. The only option for this affected person, who has failed to enhance following tPA dwell, is referral for CVC change with potential angioplasty and/or stripping of the fibrin sheath (selection b).

Case 4: You’ve got a affected person with a historical past of two failed proper higher extremity AVFs and who’s at the moment dialyzing by way of a left subclavian vein CVC. She had a brand new AVF positioned within the left higher arm 6 weeks in the past. Primarily based on a current ultrasound, the AVF is mature, however it’s too deep and must be superficialized earlier than it may be used. She has been complaining of left arm ache and swelling throughout her previous couple of dialysis classes. You’re involved for:

a. Left higher extremity AVF stenosis
b. Left higher extremity deep vein thrombosis
c. Central vein stenosis
d. Proper higher extremity deep vein thrombosis

Case 4 is in step with central vein stenosis (selection c). Subclavian catheters are related to a better threat of creating central vein stenosis in contrast with inside jugular catheters, as are left-sided catheters, a historical past of peripherally inserted central catheters (PICCs), recurrent catheter placements, and longer catheter use. Signs are likely to come up when there’s a purposeful AV entry on the identical aspect because the catheter.

Angiography is the popular technique for prognosis. Sufferers with central vein stenosis could also be asymptomatic and don’t all the time require catheter removing until issues develop. Angioplasty (with or with out stenting) is the therapy of selection, adopted by surgical procedure for recurrent vein stenosis the place angioplasty has failed.

Prevention of Thrombotic Problems

Heparin or citrate resolution could also be used to lock the catheter between dialysis classes to assist stop catheter-related thrombosis. Routine prophylactic use of systemic antiplatelet brokers or warfarin has not been confirmed to assist stop thrombotic issues, and should improve the affected person’s bleeding threat. Avoiding catheters altogether or eradicating catheters as applicable is the easiest way to forestall catheter-related thrombosis.

Abstract

Basic bedside administration for non-infectious catheter issues contains repositioning the affected person, forceful flushing of saline by way of the catheter, tPA dwell previous to dialysis, or acquiring a chest x-ray to rule out catheter kinks or malpositioning. If conservative measures fail to enhance catheter perform, the affected person ought to rapidly be referred to an interventional radiologist or nephrologist for additional analysis.

Discovering PotentialIndicators/Signs What To Do If Suspected


Fibrin sheath. Vachharajani, Atlas of Dialysis Vascular Entry, 2010.
Issue aspirating from the catheter
Excessive arterial and/or venous pressures on dialysis
Poor blood flows
Laboratory proof of decreased clearance (URR < 65% or Kt/V < 1.2)
Reposition the affected person

Acquire a chest x-ray to verify for catheter kinks

Forceful saline flush
Try thrombolytics (tPA 1 mg per lumen)

If thrombolytics are ineffective, seek the advice of interventional radiology or nephrology for catheter change with potential angioplasty/stripping of the fibrin sheath


Kinked dialysis catheter. Vachharajani, Atlas of Dialysis Vascular Entry, 2010.
Issue aspirating and flushing the catheter
Poor blood flows
Acquire a chest x-ray

Launch tight sutures

Seek the advice of interventional radiology or nephrology for catheter reposition or guidewire catheter change


Malpositioned dialysis catheter. Vachharajani, Atlas of Dialysis Vascular Entry, 2010.
Issue aspirating from the catheter
Excessive arterial or venous pressures on dialysis
Poor blood flows
Acquire a chest x-ray to verify the placement of the catheter

Seek the advice of interventional radiology or nephrology for guidewire catheter change


Uncovered cuff. Vachharajani, Atlas of Dialysis Vascular Entry, 2010.
Seen cuff exterior of the exit website Don’t use catheter for dialysis

Seek the advice of interventional radiology or nephrology for guidewire catheter change


Central vein stenosis. Vachharajani, Atlas of Dialysis Vascular Entry, 2010.
Ipsilateral arm swelling, breast swelling, facial swelling
Dilated collateral veins within the chest, shoulder, or higher arm
Potential superior vena cava syndrome
Seek the advice of interventional radiology or nephrology for angiogram with potential angioplasty and catheter change

Elimination of catheter if applicable (i.e., affected person has a purposeful AV entry)


Catheter-related atrial thrombus. Yang et al., JVS, 2018.
Often asymptomatic, incidental discovering on imaging (95-99% of instances) Systemic anticoagulation with warfarin or novel anticoagulant as for therapy of DVT

Catheter removing or change (Determine 2)

Desk 1. Non-infectious hemodialysis contraindications and their advised administration.

Publish by:
Crystal Farrington, ASDIN Fellow

Acknowledgements: This put up is a part of a collaboration between the Renal Fellow Community and the American Society of Diagnostic and Interventional Nephrology (ASDIN), whose mission is to supply excellence in dialysis entry care to enhance outcomes for sufferers with kidney illness. Particular due to Michael Allon, Tushar Vachharajani, Aisha Shaikh, Edgar Lerma, and the ASDIN Schooling Committee. For extra details about the ASDIN mission or membership, click on right here.

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