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| Journal of Vascular Access 2002; 3: 174 - 176 |
| Central Venous Catheters in hemodialysis: an actual conundrum without solutions |
B. Di Iorio1
1Nephrology and Dialysis Unit, “A. Landolfi” Hospital, Solofra (AV) - Italy
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ABSTRACT
Vascular access maintenance is a major problem for adequate care of End Stage Renal Disease. An ideal access delivers an adequate flow rate for the HD prescription, remains usable for an indefinitely long period of time, and has a low complication rate. The native arteriovenous fistula (AVF) remains the best access, but this option may be impraticable in many conditions. This paper describes why to use CVC, where CVC can be positioned and how CVC infections can be prevented. Also today, vascular access in hemodialysis remains the conundrum without solution, but it is often necessary and remains the only possible venous access in a particular category of patients. (The Journal of Vascular Access 2002; 3: 174-6)
Key Words. Central venous catheters, Hemodialysis, Conundrum
INTRODUCTION
Adequate care of patients with End Stage Renal Disease (ESRD) requires constant attention to maintain vascular access for hemodialysis (HD), and vascular access maintenance is a major problem. In fact, vascular access complications contribute to patient morbidity and mortality. Indeed, access complications either directly or secondarily determine frequent hospitalisation of patients. The cost of maintaining dialysis vascular access exceeded in USA $ 1 billion in 2001 (1).
An ideal access delivers a flow rate adequate for the HD prescription, remains usable for an indefinitly long period of time, and has a low complication rate (2). The native arteriovenous fistula (AVF) remains the best access to meet all these criteria.
This option may however be impossible to adopt for many conditions (acute illness, inadequate or exhausted vessels, reduced life expectancy, difficult venipuncture).
Why you can position CVC
The recent NKF-K/DOQI for Vascular access declares, in point C of Guideline 3, that “Cuffed tunnelled central venous catheters should be discouraged as permanent vascular access” (3). The same Guidelines indicate the rationale of disadvantages (Guideline 5) in high morbidity due to thrombosis and infections, risk of permanent central venous stenosis or occlusion, shorter expected use-life than other access types, lower blood flow rates. Other Authors show the same data: a recent paper by Pastan et al (4) shows that the proportion of patients who died was higher among those who were dialysed with a non cuffed (16.8 %) or cuffed (15.2 %) catheter compared to those dialysed with a graft (1.2 %) or a AVF (0.8 %; p<0.001). The adjusted odds ratio (95% CI) for all-cause and infection-related death among patients dialyzed with a catheter was 1.4 (1.1, 1.9) and 3.0 (1.4, 6.6), respectively, compared to those with an arteriovenous (AV) fistula. However, the analysis of Pastan’s data shows that patients with cuffed or non cuffed catheters had a higher prevalence of comorbidities: in fact, these patients were older than the patients with graft or AVF (the patients over 71 years old are 31.4 and 23.3 versus 26.5 and 17.2 %, respectively), had lower albumin levels (<3.5 g/dl in 29.2 and 29.2 versus 20.2 and 15.8 %, respectively), lower hematocrit (<30% in 28.1 and 35 versus 20.6 and 19.1 %, respectively), higher prevalence of previous myocardial infarction (9.7 and 6.6 versus 2.2 and 7.1 %, respectively), higher number of severely compromised functional status (27.4 and 16.8 versus 14.3 and 8.3 %, respectively) (5).
Then, I ask if the use of CVC is the reason for reduced life expectancy or if CVC is inserted in older patient and with higher number of comorbidities and reduced life expectancy (5). It is true that Pastan et al gave adjusted odds ratio for all-cause and infection-related death among patients, but it is very difficult to interpret their finding that the gross mortality for infection-related events is higher in patients with cuffed catheter compared with those with non-cuffed catheters (5).
The problem of infection is very important. A recent review by Mickley (6) examines several papers that show frequency of catheter-associated bacteremia for different types and locations of central venous access: the internal jugular access vein shows a range of 0.8-2.9 episodes per 1000 CVC days compared with 2.4-15.3 of femoral access.
Our study in Lucania (2) shows only 10 episodes of catheter related sepsis (1 case in every 305 month/patient): all episodes were resolved by antibiotic therapy without catheter removal. In our study 30 % of the patients had positive culture from swabs passed on exit site of catheter, but eradicating antibiotic therapy was effective in all cases of positive blood culture, even without infection symptoms. In addition, the CVC survival at 84 months is higher than 85 %. Other papers show one episode in every 162, 12, 48, 52 or 84 months (7-11).
Our excellent results may be due to the fact that CVC were treated with the same care and asepsis required in the management of peritoneal catheters. The CVC was the last available vascular access for these patients, but we stress that it is an open door for the entry of micro-organisms into the bloodstream. Our protocol requires that a nurse wears sterile gloves and mask to disinfect the skin at the beginning and at the end of the dialysis session. Gauze soaked with disinfectant is also maintained around the catheter caps for 5 minutes, the caps are opened with meticolous asepsis, and 2 to 3 ml of blood are withdrawn and discarded. During dialysis the connection points between the two lumens of the catheter and arterial and venous lines are bound in gauze soaked with disinfectant. The catheter is always closed with two new sterile caps (12).
Canaud correctly pointed out that in order to reduce infections related to the use of hemodialysis catheters, it is important to identify risk factors, to make specific recommendations and to look at new technical solutions (13).
Another problem raised in the literature is the reduced flow performance and dialysis dose when compared with AVF. Our data (2) show that blood flow was 273 ± 39 ml/min with a mean Kt/V of 1.32 ± 0.18, similar to values obtained in the same 53 patients, when they had a well-functioning AVF (1.3 ± 0.15 ml/min).
The recent paper of Canaud on this issue (14) demonstrates that mean effective blood flow rates achieved were 316 ± 3.5 ml/min with CVC versus 340 ± 3.3 ml/min with AVF (about – 7%); Kt/V were 1.37 ± 0.03 and 1.45 ± 0.02 (p=0.0012), respectively; recirculation rates evaluated with the “slow blood flow” method were 8.6 ± 0.6 and 12.1 ± 0.8, respectively; and duration of dialysis were 214 ± 2 and 220 ± 2 min, respectively. Canaud concludes that CVC use is associated with a 6% reduction in the dialysis dose; such a loss of dialysis efficacy has no deleterious consequences when an efficient treatment programme is applied; lengthening dialysis time may represent a simple and efficient way to compensate for reduced flow performances with CVC use (14). Mickley (6) reports the same results in blood recirculation.
CVC thrombosis can be treated with urokinase (3, 15), but recombinant tissue plasminogen activator may also be used (16, 17).
Where can CVC be positioned
The preferred insertion site for CVC is the right internal jugular vein. Subclavian access should be used only when jugular options are not available (Evidence). CVC are not placed on the same side as a maturing AVF (Evidence). Fluoroscopy is mandatory for insertion of CVC and real-time ultrasound-guided insertion is recommended to reduce insertion-related complications (Evidence/opinion). These are the recommendation of recent Guidelines (3).
Indeed, CVC placement in the left internal jugular and in subclavian vein is associated with poor blood flow rates and higher rates of stenosis or thrombosis (18-20). Chronic obstruction of the subclavian vein, of course, will complicate later construction of a peripheral arteriovenous access on that arm. After occlusion of both subclvian veins, major reconstructive surgery or a thigh access will be necessary (6).
Subclavian-vein cannulation is burdened with a 10% rate of severe acute complications such as arterial puncture with haemotorax and pneumotorax (6, 21). The right internal jugular vein is therefore seen as the ideal vein for central catheter vascular access.
How can CVC infection be prevented
Strategies should be aimed at preventing colonization of the external surface of the catheter and of the catheter lumen (22). All catheter manipulations should be done by specifically trained personnel, catheter exit side should be examined and dressing renewed at each dialysis session, during all procedures that include catheter cap or catheter dressing removal the patient should wear surgical mask or face shield and personnel should wear surgical mask or face shield and sterile gloves (22).
Our strategies are similar to those described by Blankestijn. In our experience CVC infection can be prevented by treating venous catheters with the same attention required in the management of peritoneal catheters (5, 12).
In conclusion, since its introduction more than 15 years ago, the CVC continues to have an important role as a reusable access to the circulation. In the past decade, an increasing number of CVC became available. In fact, in 1993 a tunnelled catheter was present in 9.7 % of the patients 30 days after the start of dialysis. However, in 1996, according to the US Renal Data System annual report, 18.9 % of all patients started hemodialysis using a cuffed tunnelled catheter; sixty days later, 12.9 % of these patients were still using the catheter as their dialysis access (23).
Predominant complications are catheter infection, thrombosis, catheter displacement and subcutaneous bleeding (2), but other rare complications are reported (24).
The conundrum of Schwab and Beathard (25) remains without solution, but the central venous catheter is still necessary and remains the only possibility of vascular access in a substantial number of patients.
Reprint requests to:
Biagio Di Iorio, MD
C.so L. Cadorna, 129
I-83030 Venticano (AV)
Italy
e-mail: bidiior@tin.it
REFERENCES
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21. Macdonald S, Watt AJB, McNally D, et al. Comparison of technical success of outcome of tunnelled catheters inserted via jugular and subclavian approaches. J Vasc Intervent Radiol 2000: 11; 225-31.
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B. Di Iorio
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