Temporary HD dialysis catheters

[Oggg]

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Anyone placing these in the hospital? My group is considering offering a daytime central line service and maybe doing temporary HD catheters. Most info online seems to be about tunneled catheters.

 

[somedumbDO]

Placed a bunch of quintons in residency, it's nothing more than a bigger cordis ... Just don't put it in the subclavian

 

[urge]

Just don't put it in the subclavian

Why is that?

 

[BLADEMDA]

Subclavian vein thrombosis. I recommend live/dynamic u/s placement via the IJ


I'm very glad not to be doing HD catheters on primarily medicaid patients.

 

[BLADEMDA]

Subclavian vein catheterization, the most commonly used temporary vascular access for hemodialysis, is associated with a variety of complications. This retrospective study was done on 96 patients who had 150 percutaneous subclavian vein catheterizations over a one year period using Quinton double lumen polyurethane catheters. A total of 56 complications were seen of which 12 were immediate and 44 delayed. Immediate complications seen were six cases of failure of insertion of catheter and three cases each of subclavian artery puncture and inadvertent entry of the catheter into the jugular vein. Delayed complications seen were infection in 33 cases, thrombosis of subclavian vein in six patients, delayed pneumothorax in four cases and hemothorax in one. One patient, who required repeated catheterizations since he refused creation of AV fistula, died of septicemia. The remaining patients responded well to the treatment of the respective complications.

 

[BobBarker]

I do not think the liability would be worth it to a private practice anesthesiologist. Lots of these patients are coagulopathic messes. Continual oozing around the catheter site is pleasant to deal with.

 

[Oggg]

That is an interesting point. If I put one in as requested by a nephrologist for an inpatient, I'd expect to be uninvolved in follow up care other than checking the chest X-ray. If the catheter subsequently thromboses or gets infected, or oozes or bleeds, would I be called back or held responsible? Or does the hospitalist and nephrologist take over? I would think it would be similar to putting in triple lumen catheter -- place it and the PCP owns it and the nurses run their protocols.

 

[Bostonredsox]

I do them routinely for the nephrologists. Live US jugular line as blade said. It's the exact same procedure as a IJ TLC...you just use a second, larger dilator, and then a larger diameter, dual lumen catheter. Takes me about 8 min.

IR then changes it out over a wire and converts it to a tunneled permcath at discharge

 

[deleted126335]

That is an interesting point. If I put one in as requested by a nephrologist for an inpatient, I'd expect to be uninvolved in follow up care other than checking the chest X-ray. If the catheter subsequently thromboses or gets infected, or oozes or bleeds, would I be called back or held responsible? Or does the hospitalist and nephrologist take over? I would think it would be similar to putting in triple lumen catheter -- place it and the PCP owns it and the nurses run their protocols.

If something bad (post insertion) happens, don't be surprised if nobody takes ownership and tries to leave you holding the bag. I have seen this personally.
You sure the PCP owns the triple lumen caths that you place?

 

[seinfeld]

Do them all the time, for those people who don't do critical care regularly i can see how you might be afraid of placing this line on sick patients. Unfortunately I must place them for the survival benefit of my patient and I must say that an IJ stick and the complications from it in my hands regardless of the INR, or platelet count is very low. I live in a reality where if i am placing a Central line the patients needs it regardless of the patients cormorbidities so whats the point in fussing about all the numbers BS. Besides i learned in residency while placing lines in a liver txp patient that it can be done.

 

[Bostonredsox]

Do them all the time, for those people who don't do critical care regularly i can see how you might be afraid of placing this line on sick patients. Unfortunately I must place them for the survival benefit of my patient and I must say that an IJ stick and the complications from it in my hands regardless of the INR, or platelet count is very low. I live in a reality where if i am placing a Central line the patients needs it regardless of the patients cormorbidities so whats the point in fussing about all the numbers BS. Besides i learned in residency while placing lines in a liver txp patient that it can be done.

/nod.

Early on as an intern I put an IJ in pretty terrible looking liver pt. about 45 min later I threw another into a septic old gomer. My attending didn't tell me anything about the pts beforehand just said right after they hit our door they need lines fast. Liver pt had a plt count of 8 and an INR of 2.4. The septic was a fib'r on warfarin with an INR of 7. After I finished both and sat down to dictate and enter the admission paperwork, I noticed both coagulopathies and asked my attending.....wtf?? His response was if I had told you the numbers, you would have panicked, and would have had a higher chance of making a mistake. Both pts needed the lines regardless of the numbers, so why tell you and make you panic.

I've always kept that night in the back of my mind. If the pt needs the line, especially if they need one to be urgently dialyzed, who gives a damn about the coagulopathy.

 

[deleted126335]

/nod.

Early on as an intern I put an IJ in pretty terrible looking liver pt. about 45 min later I threw another into a septic old gomer. My attending didn't tell me anything about the pts beforehand just said right after they hit our door they need lines fast. Liver pt had a plt count of 8 and an INR of 2.4. The septic was a fib'r on warfarin with an INR of 7. After I finished both and sat down to dictate and enter the admission paperwork, I noticed both coagulopathies and asked my attending.....wtf?? His response was if I had told you the numbers, you would have panicked, and would have had a higher chance of making a mistake. Both pts needed the lines regardless of the numbers, so why tell you and make you panic.

I've always kept that night in the back of my mind. If the pt needs the line, especially if they need one to be urgently dialyzed, who gives a damn about the coagulopathy.

I would want to know. I would go femoral in the setting of the coagulopathies you just mentioned.

 

[BLADEMDA]

Do them all the time, for those people who don't do critical care regularly i can see how you might be afraid of placing this line on sick patients. Unfortunately I must place them for the survival benefit of my patient and I must say that an IJ stick and the complications from it in my hands regardless of the INR, or platelet count is very low. I live in a reality where if i am placing a Central line the patients needs it regardless of the patients cormorbidities so whats the point in fussing about all the numbers BS. Besides i learned in residency while placing lines in a liver txp patient that it can be done.

I've paced about a hundred HD catheters. These were the pre-u/s days. So, I know all about risk in these patients.

I agree with Seinfeld that this stuff must get done by somebody at the hospital. That said, I prefer it be a hospitalist or Intensivist over me. It's a simple matter of risk vs reward. The monetary payment is minimal and the risk is high.

I do like to know my coags, platelets, etc prior to any procedure as this provides additional risk/benefit information.

 

[Stank811]

IJ or femoral....able to obtain higher more consistent flow rates for CRRT. Subclavian in my experience results in more problems with low flow rates and clotted filters which is less efficient. And as also mentioned subclavian thrombosis and stenosis will affect future AV fistulas for HD if the patient needs it. As far as a procedure not any more difficult than any other central line just obviously a bigger line which can result in larger bleeds or suck more air into the right heat if not placed or removed carefully.

 

[Bostonredsox]

I would want to know. I would go femoral in the setting of the coagulopathies you just mentioned.

i woud do the opposite. its easy to compress the jugular and IMO the least liky site to bleed heavily with US. double points for ij if theyre on the vent and the airway is already protected. femoral is A bigger vessel and often much deeper in fatty diabetic dialysis pts. harder to reliably compress IMO

 

[seinfeld]

i woud do the opposite. its easy to compress the jugular and IMO the least liky site to bleed heavily with US. double points for ij if theyre on the vent and the airway is already protected. femoral is A bigger vessel and often much deeper in fatty diabetic dialysis pts. harder to reliably compress IMO

I agree, I question how much safer a femoral stick is compared to an IJ. Seen too many people having retroperitoneal bleeds and SQ thigh hematomas that go unrecognized. Also have seen femoral thrombosis after femoral artery punctures where pressure is held for extended periods. ICU patients have there head up most all day. With a pressure of 15 or less (CVP) not much bleeding happens unless you're the type who likes to make an incision in the skin instead of letting the dilators do their job of dilating, i like it tight 😎

 

[Bostonredsox]

I agree, I question how much safer a femoral stick is compared to an IJ. Seen too many people having retroperitoneal bleeds and SQ thigh hematomas that go unrecognized. Also have seen femoral thrombosis after femoral artery punctures where pressure is held for extended periods. ICU patients have there head up most all day. With a pressure of 15 or less (CVP) not much bleeding happens unless you're the type who likes to make an incision in the skin instead of letting the dilators do their job of dilating, i like it tight 😎

completely agree. HD dilators are huge and one often has to dissect through a lot of thigh fat to get the dilators in without kinking the wire. IJ is silky smooth in comparison and even kn fattys requires a lot less skin tract dilation.

 

[fakin' the funk]

I do them routinely for the nephrologists. Live US jugular line as blade said. It's the exact same procedure as a IJ TLC...you just use a second, larger dilator, and then a larger diameter, dual lumen catheter. Takes me about 8 min.

Just to put some facts on figures on these lines on the table...

These temporary HD catheters have a bunch of different names. Trialysis, Mahurkar, etc, etc. They have at least 2 lumens, some have a third "pigtail" lumen for infusions/draws etc. The actual dialysis/plasmapheresis lumens are big and have multiple apertures along the catheter itself -- like fenestrations along the shaft.

Most of these that I've seen are 12fr. That's big. They come in various lengths for the different height and placement sites. We have 12cm, 16cm, and 20cm lengths.

As mentioned these come with two dilators. It seems like a lot of the time the 2nd, larger dilator isn't necessary, maybe because these catheters have a tapered tip and are pretty stiff.

Because the catheters are pretty stiff it makes the RIJ an even better site than the LIJ. But you gotta do what you gotta do.

I personally don't know why an IR guy would use a dirty old percutaneous central line to place a semipermanent tunneled cath. Why not just a fresh stick?

 

[FutureInternist]

Just make sure to put heparin or citrate into the ports
The hub should state on it how many mls to put in

 

[Bostonredsox]

Just to put some facts on figures on these lines on the table...

These temporary HD catheters have a bunch of different names. Trialysis, Mahurkar, etc, etc. They have at least 2 lumens, some have a third "pigtail" lumen for infusions/draws etc. The actual dialysis/plasmapheresis lumens are big and have multiple apertures along the catheter itself -- like fenestrations along the shaft.

Most of these that I've seen are 12fr. That's big. They come in various lengths for the different height and placement sites. We have 12cm, 16cm, and 20cm lengths.

As mentioned these come with two dilators. It seems like a lot of the time the 2nd, larger dilator isn't necessary, maybe because these catheters have a tapered tip and are pretty stiff.

Because the catheters are pretty stiff it makes the RIJ an even better site than the LIJ. But you gotta do what you gotta do.

I personally don't know why an IR guy would use a dirty old percutaneous central line to place a semipermanent tunneled cath. Why not just a fresh stick?

We have Marukhar's. The neck catheters are curved exit lumens so thye dont stick out into the patients face, they iinstead curve around and the tips are pointed caudally, which is nice, They are 15cm. I generally always put them into the RIJ for the reasons you mentioned, but I have put them in the left.

We have 20 and 24cm Femoral catheters. they are dual lumen or triple lumen, with the additional 5mm side port coming in handy for ICU pts on alot of drips who need HD. They are straight, no curves.

They are all 12 french. In the leg I absilutely use both dilators. Even doing so, have bent many wires tryign to tunnel through 60 pounds of thigh fat in some of the biggys. The neck line I sometimes use the second dilator, depends on how close to the skin surface the jugular lies.

And as for the IR exchange, I am not sure. Never actually seen them do it. But I have been told that they just use my line and exchange over it. Probably to minimize the chance of complications while sticking, as they are so paranoid if any complication. As I said, they wont place them if the noncoagulopathic pt has had their morning plavix dose....

 

[Oggg]

One of our surgeons will sometimes convert a temporary to tunneled in the OR.

 

[cchoukal]

i woud do the opposite. its easy to compress the jugular and IMO the least liky site to bleed heavily with US. double points for ij if theyre on the vent and the airway is already protected. femoral is A bigger vessel and often much deeper in fatty diabetic dialysis pts. harder to reliably compress IMO

For all these reasons, I choose the IJ in these cases. I would add that the IJ is also less "dependent" from a gravity perspective, making it less likely to bleed than the femoral site, and also easier to identify when bleeding is occurring.

 

[Random Anesthesiologist]

Just to put some facts on figures on these lines on the table...

These temporary HD catheters have a bunch of different names. Trialysis, Mahurkar, etc, etc. They have at least 2 lumens, some have a third "pigtail" lumen for infusions/draws etc. The actual dialysis/plasmapheresis lumens are big and have multiple apertures along the catheter itself -- like fenestrations along the shaft.

Most of these that I've seen are 12fr. That's big. They come in various lengths for the different height and placement sites. We have 12cm, 16cm, and 20cm lengths.

As mentioned these come with two dilators. It seems like a lot of the time the 2nd, larger dilator isn't necessary, maybe because these catheters have a tapered tip and are pretty stiff.

Because the catheters are pretty stiff it makes the RIJ an even better site than the LIJ. But you gotta do what you gotta do.

I personally don't know why an IR guy would use a dirty old percutaneous central line to place a semipermanent tunneled cath. Why not just a fresh stick?

Doing my PGY1 as a surgical intern. We are responsible for most central line and vascath placements on the floors/ICUs. Typically we use a 13.5f 15 or 20cm double-lumen vascath. I go for IJ access first, mostly because so many of those needing emergent/urgent HD tend to be horrible vasculopaths making femoral a nightmare. Probably why some IR guys will over-wire and be done with it. Or maybe laziness, IDK.

Like the other poster said - it gets a little messy for those who need them for emergent dialysis with much less than ideal anticoagulation 😱

 

[BobBarker]

The dilators are stiff enough not only to tear a vein but they can also perforate the ventricle. I am as much of a cowboy as anyone but I can not stress the care that must be taken when placing these things. Interns placing them, listen! These things are orders of magnitud more risky than a standard TLC even though the procedure is very similar.

 

[Oggg]

Yes. It seems like a extra extra large Cordis. I can imagine you could shove a dilator thru the back wall of the IJ or rip the innominate. Maybe end up in the thorax. Seems unlikely you'd reach the ventricle though.

 

[Oggg]

15cm for right IJ, 20cm for everywhere else?

 

[Bostonredsox]

15cm for right IJ, 20cm for everywhere else?

essentially yes

I do 15cm right or left IJ....only because the 20cm dont come with the turned down curved ports so if you use one they stick out up to the pts ear. but depth wise yes 15 on right 20 on left.

I use 24cm triple lumen with the 5mm sideport for groin. 20cm is fine, but our 20s dont have a side port and most of these pts are horrible vascular access pts so the extra lumen can help out the nurse alot.

I also second barker, the dilators are big, stiff and can be very nasty. I always make a skin nick with these. Have watched people stick the bigger dilator in with no nick, crush down the skin and break off the wire trying to force the dilator in. especially in the groin with all the extra subq. I make a generous (for an internist) incision, small dilator, big dilator, catheter. gentle rolling in of the dilators. I could totally see a posterior wall blowout with one of these if your not careful in addition to a broken wire migrating its way into the RV.

 

[Bostonredsox]

http://www.bardaccess.com/dial-niagara.php

not thje same brand we use, this is Bard not Marukhar, but this is what I am talking about when I say curved neck catheters for those who dont know. Much more comfortable for the pts then a huge straight catheter sticking up 6 inches out of the neck into their ear.

 

[deleted87051]

Seems unlikely you'd reach the ventricle though.

Uhh....you can easily reach the ventricle especially in short little ladies. Personal experience inserting a cordis😱....I am very careful not to advance dilator more than necessary.

 

[dhb]

The dilators are stiff enough not only to tear a vein but they can also perforate the ventricle. I am as much of a cowboy as anyone but I can not stress the care that must be taken when placing these things. Interns placing them, listen! These things are orders of magnitud more risky than a standard TLC even though the procedure is very similar.

+1 very rigid caths, i hate them

 

[Oggg]

I need to open up one of the hospitals HD catheter kits to see what it's all about

 

[Random Anesthesiologist]

The dilators are stiff enough not only to tear a vein but they can also perforate the ventricle. I am as much of a cowboy as anyone but I can not stress the care that must be taken when placing these things. Interns placing them, listen! These things are orders of magnitud more risky than a standard TLC even though the procedure is very similar.

Oh goodness, yes.

 

[RxBoy]

Ive placed probably 10 TLC like ones in the SICU as a resident. They're not that tough to place. But I once placed this really weird looking one with a surgery resident assisting. I dont remember what it is called, but it involved peeling a sheath. It was scary.

Also did a sedation case as a resident with IR placing a Quinton. The Quinton tore the SVC and the pt coded within minutes. Was a complete disaster. Think Belmounts, chest tubes, blood everywhere. Was never able to return a pulse.

I would never place one as an attending anesthesiologist unless it was life or death.

 

[Arch Guillotti]

Anyone placing these in the hospital? My group is considering offering a daytime central line service and maybe doing temporary HD catheters. Most info online seems to be about tunneled catheters.

Central lines can be a pain to put in off-site when you are busy running rooms in the OR. Wouldn't be too bad if the patients were brought to us. I know one group that puts in HD catheters. Not something I have any interest in placing.

 

[Oggg]

Trying to balance Being more useful to the hospital vs. Increased Liability.

 

[badasshairday]

I'm surprised that radiology hasn't jumped all over the line placement in some of the examples given here. Everywhere I have been have had a hospital line service done by radiology.

 

[Oggg]

Radiology does them but they are swamped and often booked up. Also a big waste of time and money to use the IR suite for these, IMHO.

 

[BobBarker]

At the hospital I did my intern year, IR had a crew of PAs who placed the lines at bedside under US. Interns did it at night, weekends, etc