Brief pathway to handle temporary HD catheter

Mohammed Wahba

Lecturer of internal medicine and nephrology

MNDU.NET

Agenda:o Indications of temporary HD catheter.o Types of temporary HD catheters.o Precautions before insertion.o Some comments on insertion.o Care after insertion (doctor, nurse and patient)o Common complications and how to interfere with

them.o Home message.

Indications of temporary HD catheter:• AKI

• Bridge to renal transplantation.

• ESRD and with following conditions:o AVF not ready and patient is indicated for HD.

o Complicated AVF.

o Contraindications for AVF.

Types of temporary HD catheters:

Types of temporary HD catheters:

Types of temporary HD catheters:

Precautions before insertion:

• Adequate documentation of care/ competency of operator.

• Revision of infection control precautions and bleeding pathway.

• Optimal catheter type and site of insertion selection.

Anatomic varieties of IJ & Rt femoral v.

Selected factors favoring different temporary (non-tunneled) hemodialysis catheter insertion sites

Right internal jugular site Critically ill and bed-bound with body mass index >28 Postoperative aortic aneurysm repair Ambulatory patient/mobility required for rehabilitation

Femoral sites Critically ill and bed-bound with body mass index <24 Tracheostomy present or planned in near-term Need for long-term hemodialysis access present, highly likely or planned Emergency dialysis required plus inexperienced operator and/or no access to ultrasound

Left internal jugular site Contraindications to right internal jugular and femoral sites

Subclavian sites Contraindications to internal jugular and femoral sites Right side to be used preferentially

Some comments during insertion• Benefits of US guided insertion in both IJ and

femoral access.• Confirmation of guide wire removal.• Sharps management.• Dressing.• Catheter locking (citrate vs heparin, use of local

ab & TPA)

Care after insertion:• Hand hygiene.• Exit site dressing.• Nasal mupirocin 2%.• Replacement of unnecessary catheter.• Instructions to patient.• Preferred time to remove temporary catheter.

Complications of temporary catheters:

Some definitions: • Catheter mechanical dysfunction was defined as inability to

achieve blood flow rate of >250 mL/min or high blood pump pressures despite attempts to improve flow such as patient repositioning or reversal of catheter lumen

• Definite CRB was defined as fever with temperature >38°C with isolation of identical micro-organism from cultures of blood and catheter tip and no other obvious focus of infection.

• Possible CRB was defined as fever with temperature >38°C and no other obvious focus of infection and where the microbiological criteria were insufficient to make a diagnosis of definite CRB.

• Exit site infection was defined as the development of cellulitis or purulent discharge at the site of catheter insertion.

How to deal with catheter infection?o When suspected CRB (culture, salvage pathway, treatment).

o Choice of empirical ab : combination of • Vancomycin plus

o Meropenem, imipenem or etrapenem.o Gentamicino Pipracillin/tazobactamo fluconazole

o Confirmed infection (culture, removal, duration of ttt)• Metastatic complications 4-6 ws• Staph. Aureus &MDR bacilli more than 14 ds.• Enterococci 7-14 ds.• Candida 14 ds since last negative culture.• Uncomplicated 7 days only.

Home message:• AVF is the preferred venous access to ESRD who are

expected to have HD unless contraindicated.• When expected to have HD more than 3 ws, cuffed

tunneled HD catheter is the preferred.• In AKI, tunneled is better than NTHDC.• Follow bundle for care and maintenance of HD

catheter.• Don’t miss the role of nursing and patient.