During a recent shift, Dr. Waters asked me “can I use a the 15cm trialysis line in the femoral vein?” To which I replied “I don’t see why not.” That got me thinking, is there a reason why not? We do have two length catheters after all (15cm and 24cm). Low and behold there is a reason why not to use the shorter length trialysis catheter there. The reason is that the catheter will not make it past the lumen of the common iliac vein and into the IVC where it is recommended the end of the catheter sit. CVCs pose certain risks such as CRBSIs, DVTs, and vessel stenosis. There are even case reports of vessel erosion happening when a catheter sits in the iliac and not in the IVC.
Bottom line; use the right size kit for the appropriate vessel, like Dr. Waters eventually did! The rest of this post is an overview on trialysis catheter placement.
Trialysis catheter placement in the emergent setting is a procedure undertaken to quickly establish vascular access for hemodialysis in critically ill patients with acute kidney injury or end-stage renal disease. This intervention becomes necessary when traditional vascular access methods, such as peripheral intravenous catheters or arteriovenous fistulas, are not feasible or fail to provide adequate blood flow for dialysis.
Indications:
Urgent Hemodialysis: In cases of severe acute kidney injury or end-stage renal disease, where immediate initiation of hemodialysis is required. “AEIOU” acidosis, refractory hyperkalemia, ingestion of certain substances (methanol, ethylene glycol, lithium, salicylates), overload of volume refractory to medical management, and uremia.
Contraindications:
Vascular Anomalies or Injuries: Presence of significant vascular anomalies or injuries at the potential catheter insertion site.
Local Infections: Infection at the proposed catheter insertion site.
Severe Coagulopathy: Placement may be contraindicated in patients with uncontrolled bleeding disorders. (Relative contraindication – should use more compressible sites like the femoral vein)
Equipment Needed:
Trialysis Catheter Kit: Includes the catheter, guidewires, dilators, and sheaths.
Ultrasound Machine: To assist in locating suitable veins and ensuring proper catheter placement.
Sterile Drapes and Gloves: To maintain aseptic conditions during the procedure.
Local Anesthetic Agents: For numbing the catheter insertion site.
Syringes and Needles: For administration of local anesthetic agents and other medications as needed.
Suture and Dressing Materials: For securing the catheter in place and maintaining a sterile environment post-placement.
Procedure:
Patient Assessment: Evaluate the patient's clinical status, coagulation profile, and vascular anatomy to determine the most appropriate site for catheter placement.
Informed Consent: Obtain informed consent from the patient or their legal representative, explaining the risks and benefits of the procedure.
Preparation: Position the patient appropriately, and ensure sterile conditions using drapes and gloves.
Local Anesthesia: Administer local anesthesia at the proposed catheter insertion site.
Ultrasound Guidance: Use ultrasound to locate a suitable vein and guide the catheter insertion, ensuring proper placement.
Needle placement: With a needle attached to a syringe, insert the needle and begin withdrawing on the syringe while progressing, both to see when blood returns, and to ensure no introduction of air bubbles. Needles should be at a 45 degree angle when inserted. Preferably there is ultrasound visualization of the needle inside the lumen of the vessel.
Guidewire insertion: Remove the syringe from the needle and progress the guidewire. This should be able to occur smoothly. If it is not progressing smoothly, you may need to drop the angle of the needle, as the guidewire may be getting forced against the backwall of the vessel. The wire should only go in about 20cm.
Confirmation of guidewire: Ultrasound visualization should be done to confirm the guidewire. Never assume the guidewire is in the right spot. Know it is, by seeing it is. This should be done in both short plane and longitudinal plane.
Incision: Incise at the site of the guidewire to be able to dilate and place catheter.
Dilate (twice): The trialysis catheter requires double dilation given how large the catheter is. Place the dilator over the guidewire (without letting go of the wire). Go approximately halfway down the dilator, remove the dilator, and then repeat with the next dilator. (Be mentally prepared for a fair amount of blood).
Catheter Insertion: Introduce the catheter through the dilated tract, securing it in place using sutures.
Confirmation: Confirm proper catheter placement using imaging techniques such as fluoroscopy or ultrasound.
Post-Procedure Care: Apply a sterile dressing, monitor for any complications, and secure the catheter to prevent accidental dislodgement.
Sources:
National Kidney Foundation. (2006). "Clinical Practice Guidelines for Vascular Access." Retrieved from https://www.kidney.org/sites/default/files/docs/12-50-0210_jag_dcp_guidelines-va_oct06_sectiona_ofc.pdf
American Society of Nephrology. (2006). "Clinical Practice Guidelines for Hemodialysis Adequacy, Update 2006." Retrieved from https://www.kidney.org/sites/default/files/docs/12-50-0900_anemiaworkbook_upd-0926.pdf