Traditional and non-traditional strategies to optimize catheter function: go with more flow

Abstract

In the United States, over 340,000 patients have end-stage renal disease treated by hemodialysis (HD) and are dependent on a reliable vascular access. In over 80% of patients initiating HD, this access is the central venous catheter (CVC). Although the CVC has many advantages that make it desirable for dialysis initiation-ease of insertion, unnecessary maturation time, and availability for immediate use-it is not without significant disadvantages. The substantial morbidity and mortality associated with CVC use has been well documented in the literature. Initiating and maintaining HD patients using a CVC is suboptimal from the perspective of both patient care and associated long-term costs. Yet, in the United States, the most common HD access-related event is replacement of any vascular access type with a CVC. Although in recent years greater effort has be made to reduce CVC use, some patients are unable to have a functioning arteriovenous fistula or graft created due to exhaustion of vessels from previous permanent accesses or limiting comorbidities. In patients dependent on long-term CVC use, the primary problems are due to malfunction ('poor flows') or infection. Catheter malfunction leads to inadequate dialysis, the need for costly and inconvenient intervention, and reduced quality of life. This review will focus on the etiology, prevention, and management of CVC-related malfunction.

Vascular access: choice and complications in European paediatric haemodialysis units

“…Poor initial CVC positioning or kinking could lead to poor blood flows that usually result in early failure of the CVC (<7 days) following insertion [6]. In our survey, catheter changes due to malfunction were double the rate of changes due to infection, with 2.1 and 0.9 CVC changes/1000 catheter days for malfunction and infection, respectively.…”

“…Although the use of anaesthetic creams and other agents has helped to reduce the pain of venipuncture, CVCs do offer needle-free dialysis. The benefits must be balanced against the increased risks of catheter malfunction with poor blood flows, catheterrelated infection episodes, as well as restrictions on bathing and swimming [6,7]. CVCs might also contribute to increased inflammation independent of infection [8].…”

The Upfront Risks of Vascular Access Complications

“…13 The increased rates of early noninfectious catheter complications have also been described. 14 Xue et al reported use of tissue plasminogen activator and rate of catheter replacement use of 6.38 and 1.05, respectively, per 1000 accessdays over 1 year, with a higher rate of intervention in the first 90 days. 9 Strengths of this investigation include the ascertainment of longitudinal data and a large cohort (n57140) of randomly selected incident patients starting hemodialysis for the first time from the DOPPS.…”

Post-operative intracranial hemorrhage related to using t-PA for declotting an occluded hemodialysis catheter: A cautionary tale

“…They also found that by precisely measuring the volume of the catheter with saline (which was on average <2 mL) prior to dalteparin administration, they could reduce both the aPTT and risk of bleeding [12]. This finding has been supported in both in vitro [13,14] and in vivo studies [11,[15][16][17][18]. Proposed mechanisms for systemic spillage included variable catheter volume, catheter design with side holes, and laminar flow [11].…”