General:
· Non-tunneled catheters and Tunneled cuffed catheters
o Non-tunneled: IJ, subclavian, femoral vein
o Tunneled: Cuffed catheters are inserted under fluoroscopic guidance into subclavian vein
· Catheters placed through the IJ or subclavian optimal tip location is at the junction of the superior vena cava and right atrium roughly around 15cm in length is appropriate.
· Subclavian vein less commonly used in acute emergency setting because as flow rates may be more reduced, the site carries associations with subsequent subclavian vein stenosis, making placement of a tunneled cuffed catheter or surgical AV fistula more difficult in the future.
· Femoral vein catheters should be >20cm in length so that the tip of the catheter can pass through the common iliac vein and reach the IVC
· Wikem Lengths:
o Right IJ: 12-15cm – less complications like kinking, obstruction, stenosis
o Left IJ: 15-20cm – more tortuous leading to reduced flows
o Femoral: 19-24cm – reduces patient mobility. If the RRT Circuit is constantly shutting down, or having low flows, check the HD catheter length. If the catheter tip is not long enough to reach the distal IVC, the RRT pump will often shut down secondary to inadequate flows.
Contraindications:
· Local infection over insertion site
· Thrombosis or stenosis within the target vein
· Distorted anatomy
· Local vascular injury
Complications:
· Similar complications to central lines
· Thrombosis
· Infection
· Pneumothorax
· Stenosis of central veins
· Dialysis catheter kinking or poor position of tip
Interesting Article from 2015:
· Two RCTs independently demonstrated no significant difference in major infection (sepsis) rates between the three sites.
· Similarly, a Cochrane review and systematic review/meta-analysis reported no significant difference in complications (CRBI or DVT) between the femoral and subclavian or IJ sites.
· Femoral line colonization, however, was intuitively noted to be increased in morbidly obese patients.
References
https://www.statpearls.com/ArticleLibrary/viewarticle/37044
https://emcrit.org/emcrit/femoral-central-lines/
https://wikem.org/wiki/Dialysis_catheter_placement