How many of the nephrologists here are placing their own dialysis catheters? Anesthesiologist here in a private practice that currently places all of the dialysis catheters for our hospital. Reimbursement for this is mostly terrible now and it’s becoming a bit of a pain with how busy our OR’s and OB service has become. This is the only hospital I’ve worked at where we are asked to do this. Any insight? Our group is likely only going to continue this service if we get a stipend either from the nephrology group or the hospital. Thanks ahead for the input.
Dialysis catheters
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Hardly any. In 2 years of fellowship none of my attendings knew how to put a HD catheter. I always wanted to but no one other than ICU would supervise me. Other than some academic programs private practice nephrologists don’t have time to place catheters and then they lose practice and they couldn’t place a HD catheter in a pinch if they had to.
ICU usually will place HD catheters even on a floor as it is a service they provide to the hospital.
ICU usually will place HD catheters even on a floor as it is a service they provide to the hospital.
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stories from the older nephrologists were that the nephs did their own femoral lines all the time in the chronic HD units outpatient or in the inpatient HD unit when the AV fistula clotted or something. Put the catheter in. Finish HD and do a URR to make sure clearances were acceptable then remove it. Then get them declotted at IR.
In the modern era, the reason why nephrologists do not do their own temporary HD catheters boils down to
1) no time - you have so much HD notes to write and travel time between multiple centers (lol)
2) poor reimbursement / RVUs per line. it is not worth doing unless you do a lot of procedures like IR or the patient is unstable to move like in ICU.
3) safety / training - while a cocky 3rd year IM resident feels pretty confident with central lines with ultrasound guidance and probably has also done some temporary HD catheters under the ICU fellow/attending supervision, the renal attendings probably have not done any in a long time and will not want to sign off on being the supervising doctor.
4) malpractice - central lines may not be part of most nephrologist malpractice packages. as a result, hospitals will not grant privileges to this.
5) have you seen the thick pannuses in some of these patients these days? good luck with the femoral line. As for the IJ and subclavian sites, those should be reserved for intensivists or surgeons. My motto is "if you can't put in the chest tube yourself, then don't create a pneumothorax yourself."
In my renal fellowship (before PCCM fellowship), I was a cocky young fellow who had a lot of central line experience as a resident. While I was never allowed to do it on the floors or in the HD unit, I had cart blanche on weekend calls in the ICU and did it all the time. MICU consults for BUN 250 Cr 25 K 7.8 - no line - ICU fellow swamped with intubations or other crashing patient - HD nurses and staff all ready with the machine - patient obtunded out of his/her mind - two physician consent - i put in the femoral line under ultrasound guidance and have the ICU attendings sign off on it (keeping the renal attending out of it). The HD nurses said wow that's the fastest line to HD time.
Line removed the next day. Patient goes to IR for permacath.
In the modern era, the reason why nephrologists do not do their own temporary HD catheters boils down to
1) no time - you have so much HD notes to write and travel time between multiple centers (lol)
2) poor reimbursement / RVUs per line. it is not worth doing unless you do a lot of procedures like IR or the patient is unstable to move like in ICU.
3) safety / training - while a cocky 3rd year IM resident feels pretty confident with central lines with ultrasound guidance and probably has also done some temporary HD catheters under the ICU fellow/attending supervision, the renal attendings probably have not done any in a long time and will not want to sign off on being the supervising doctor.
4) malpractice - central lines may not be part of most nephrologist malpractice packages. as a result, hospitals will not grant privileges to this.
5) have you seen the thick pannuses in some of these patients these days? good luck with the femoral line. As for the IJ and subclavian sites, those should be reserved for intensivists or surgeons. My motto is "if you can't put in the chest tube yourself, then don't create a pneumothorax yourself."
In my renal fellowship (before PCCM fellowship), I was a cocky young fellow who had a lot of central line experience as a resident. While I was never allowed to do it on the floors or in the HD unit, I had cart blanche on weekend calls in the ICU and did it all the time. MICU consults for BUN 250 Cr 25 K 7.8 - no line - ICU fellow swamped with intubations or other crashing patient - HD nurses and staff all ready with the machine - patient obtunded out of his/her mind - two physician consent - i put in the femoral line under ultrasound guidance and have the ICU attendings sign off on it (keeping the renal attending out of it). The HD nurses said wow that's the fastest line to HD time.
Line removed the next day. Patient goes to IR for permacath.
