Ok, lets review the indications for emergent dialysis and the process of placing a dialysis catheter. Indications: -severe acidosis secondary to renal failure or unresponsive to medical therapy -toxic ingestion that is small not protein bound, such as alcohols salicylate, lithium, theophylline, valproate - symptomatic hyperkalemia - symptomatic hypernatremia -fluid overload with oliguria causing respiratory failure -uremia causing encephalopathy, pericarditis, or hemorrhage
placement:
**review your own kit to make sure you have everything you will need and to be mindful of possible extra steps for the following
give anxiolysis if needed
position patient and ultrasound for best place for your catheter
sterilize skin
prep your kit, gown, hat, mask, gloves, sterile cover for ultrasound
flush lumens of your cathetern and apply lumen valves to each lumen but do not place one on the most distal luman through which your wire will pass
have sterile heparin drawn up
drape patient
anesthetize skin
find view use ultrasound guidance and advance needle into vein be sure to be drawing the syringe plunger back to aspirate for blood
once in the lumen advance the needle slightly more in the middle of the lumen to prevent loosing your placement
with non-dominant hand flatten need while making sure to not pull out of the vein
remove syringe from the needle and advance your wire *if there is resistance ultrasound to recheck your placement
advance wire while holding it securely (be sure to always have at least one hand holding the wire)
remove needle
load smaller dilator onto wire
cut the dermis at wire insertion be sure to cutaway from wire
advance dilator and push through skin with twisting motion and inline with trajectory of the wire
remove dilator
load second larger dilator and repeat steps 17 & 18
remove dilator there will be lots of blood good job
advance catheter holding close to the skin with a firm but gentle twisting motion
remove wire
check that all lumens draw back blood with ease
flush each lumen with 1cc of heparin to prevent clotting of the catheter
secure the catheter with sutures
apply sterile dressing
if in internal jugular of subclavian veins confirm placement with xray