Section 12 Vascular Access for Hemodialysis - American ...

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Section 12. Vascular Access for Hemodialysis 2. Left internal jugular vein catheter placement potentially puts the left arm’s vasculature in jeopardy for a long-term access on the same side. It may also be associated with poorer blood flow rates and higher rates of stenosis and thrombosis than the RIJ due to the increased length. 3. Femoral placement is associated with the highest infection rates and the catheter tip must be in the inferior vena cava to avoid regional recirculation (see Figure 12.7). Placement of a femoral catheter in a transplant candidate should be avoided because of potential damage to blood vessels needed for the transplant. 4. Subclavian veins on either side must be strictly avoided due to risk of stenosis, which can permanently exclude the possibility of upper extremity long-term AVF or AVG (NKF KDOQI, 2006, CPG 2). They should be used only when all access sites are exhausted in the ipsilateral (same side) arm. Subclavian placement puts patient at greater risk for pneumothorax and/or hemothorax during insertion. 5. When all the above sites are exhausted, catheters may be inserted into the inferior vena cava using the translumbar or transhepatic approach. D. Advantages of catheters/ports. 1. Are universally applicable – anyone can have one. 2. Can be inserted into multiple sites relatively easily. 3. Require no maturation time. They can be used immediately (after tip position is confirmed by fluoroscopy or chest x-ray). 4. Cause no changes in cardiac output or myocardial load. 5. Can provide access over a period of months, permitting AVF maturation in patients who require immediate hemodialysis. 6. Percutaneous catheters only. a. Skin puncture not required for repeated vascular access for hemodialysis. b. Lower initial cost and replacement costs. Exit site Venous Arterial E. Disadvantages. 1. High morbidity due to thrombosis and infection (Oliver et al., 2004; Pastan et al., 2003). Patients receiving catheters have a relative risk (RR) of death (RR = 2.3 for patients with diabetes and 1.83 for those without) greater than those with an AVF (Dhingra et al., 2001). 2. Risk of permanent central venous stenosis or occlusion. 3. Percutaneous catheters only. a. Discomfort and cosmetic disadvantage of an external appliance. b. Safety concern with inadvertent dislodgment of external appliance as well as need for protection of exit site. c. Shorter expected use-life than other access types. d. Overall lower blood flow rates, requiring longer dialysis times. 4. Frequent episodes of occluded catheters due to thrombosis or fibrin sheaths may require use of a lytic agent or an interventional procedure to replace the catheter and possibly disrupt a sheath. These episodes may lead to reduced dialysis adequacy (lower BFRs and shortened or missed treatments) that is associated with increased morbidity and mortality. Figure 12.7. Femoral vein central venous catheter. 750 Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008
Chapter 59. Vascular Access Type and Site of Placement F. Complications. 1. Immediate/early. a. All catheters should be placed using imaging such fluoroscopy or ultrasound (NKF KDOQI, 2006, CPG 2) to assure correct tip placement and minimize complications such as: (1) Carotid or femoral artery puncture. (2) Pneumothorax. (3) Hemothorax. (4) Cardiac dysrhythmias. (5) Tissue perforation (e.g., brachial plexus, trachea, superior vena cava, myocardium). (6) Poor flow from malpositioned tip. b. Operating room conditions and practice must be used for placement to prevent infection. 2. Late complications. a. Infection. Local and systemic. (1) Causes. (a) Not using aseptic technique and appropriate cleansing for accessing catheter. (b) Poor patient hygiene. (c) Inadequate skin cleansing at dressing change. (2) Signs and symptoms. (a) Inflammation and pain around exit site and in tunnel. (b) Drainage at exit site or from tunnel. (c) Erosion of skin over catheter. (d) Fever and/or chills. (3) Treatment (NKF KDOQI, 2006, CPG 7). (a) IV broad spectrum or organism sensitive antibiotics for all infections except localized exit site where topical and/or oral antibiotics may be used. (b) Catheter exchange within 72 hours of initiating antibiotic therapy with follow-up cultures 1 week after antibiotic therapy. (c) Antibiotic lock therapy may be used instead of catheter exchange in cases where the patient is clinically stable and/or the catheter is reinfected with the same organism and catheter sites are limited (NKF KDOQI, 2006, CPR 7) (see Section 5, Table 5.6, for sample protocol). (d) Port pocket infections are treated with systemic antibiotics and pocket irrigation. b. Catheter dysfunction (BFR < 300 mL/min). Exceptions are for pediatric patients and small adults. Dysfunction for these categories is defined by a significant reduction in baseline flows. (1) Causes. (a) Mechanical. Line and catheter kinking, holes or cracks in catheter, drug precipitation. (b) Patient position. (c) Partial or complete occlusion due to intraluminal or mural thrombus or fibrin sheath. (2) Signs. (a) Inability to withdraw anticoagulant lock or blood. (b) Inability to maintain consistent BFR > 300 mL/min at an arterial < -250 mm/Hg. Arterial prepump pressure monitoring is mandatory. (c) Presence of leak from catheter. (3) Treatment. See algorithm in Nursing Process interventions (see Figure 12.8). c. Superior vena cava syndrome. Catheter insertion and long-term placement can cause endothelial injury, inflammation, stenosis, and occlusion of any vein. When this occurs in the superior vena cava, it has lifethreatening implications and constitutes an emergency to be reported to the physician. It can have slow or rapid onset. (1) Signs and symptoms. (a) Swelling of the chest/breast, arms, neck, and face with periorbital edema. (b) Visible collateral veins on chest wall and jugular vein distension (if patent). (c) CNS disturbances such as vision changes, dizziness, confusion, pain. (d) Dyspnea (difficulty breathing) and/or dysphagia (difficulty swallowing). (2) Treatment. (a) Removal of any obstruction including an indwelling catheter. (b) Lysing of thrombus with a thrombolytic infusion. (c) Angioplasty of identified stenoses. Stents could be placed for recoiling stenoses. (Figure 12.8 on next page) Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 751
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