Review
Introduction
DC dysfunction and thrombosis
DC dysfunction
Materials of the catheter
Tunneled DCs
DC lumens
Distal ports of DCs, positioning and length of the catheter
Insertion site
DC-related thrombosis
Intraluminal DC thrombosis
DC-associated vascular thrombosis
Guidewire exchange
Catheter management
Choice of the dialysis catheters | |
---|---|
Materials | Silicone or polyurethane catheter |
Heparin coated catheters are not recommended | |
Diameters | 12- to 16-French (4–5 mm) |
Length | For the upper sites: at least 15 cm to obtain right atrium placement for soft DC, superior vena cava for rigid DC |
For the lower sites: probably at least 24 cm | |
Lumens | Dual lumen catheter |
Two single-lumen catheters less easy to place but at
least as accurate as dual lumen catheters | |
Tunnelization | Lower rate of DC dysfunctions but placement more
difficult |
Choice of the insertion site
| |
Femoral and right jugular sites better than left jugular
site | |
Right internal jugular site should be preferred in
intermittent hemodialysis if Q
B has to be higher than
200 ml/min | |
Subclavian sites to be avoided | |
Ultrasound guidance especially for jugular sites | |
Preserve vascular network | |
Positioning of the catheter
| |
Upper sites | Tips of the catheter placed next to the right atrium in the superior vena cava |
Check chest radiography | |
Lower sites | Tips of the catheter placed in the inferior vena cava |
During renal replacement therapy (RRT)
| |
Flush | Use saline solution flushes before and after every RRT session |
Pressure | Check pressure greater than −250 mmHg on the inflow site |
Check pressure <250 mmHg on the outflow site | |
Lock | Anticoagulant lock, i.e., heparin after every RRT |
Clamp | Careful clamp closing after every RRT |
In case of dysfunction
| |
Patient | Try to change patient position |
Flush | Try to flush catheter lumens with saline solutions |
Catheter | Try to rotate the catheter |
Lumens | Try to reverse catheter lumens. Prolonged port reversal not recommended due to recirculation which compromises efficacy |
Locks | Fibrinolytic locks are not evaluated and are not yet recommended |
Dose of RRT | Check previous KT/V in case of intermittent hemodialysis session and consider catheter replacement |
Education of the team
|
DC-related infections
Author | Date | Study design | No. of
patients | Catheters
number | Site of insertion | Catheter tip
culture | Catheter-related
infection definition | Colonization
(/1,000 c.d.) | Catheter-related
infection (/1,000
c.d.) | TC (days,
mean ±
SD) |
---|---|---|---|---|---|---|---|---|---|---|
Souweinea
| 1995-1996 | Prospective, open, monocentric | 170 | 151 | Femoral and jugular | Simplified Brun Buisson |
CRBSI: catheter colonization and blood culture positive for the same organism; site infection: presence of pus at the insertion site. | 24.2 | 1.5 | 6.8 ± 6 |
Westera
| 1997-1998 | Prospective, open, monocentric, CAVHDF, ICU | 43 | 139 | Axillary arteries, femoral veins and arteries, subclavian veins | Semiquantitative culture: >15 CFU; quantitative culture: >10^3 CFU |
Exit site infection: erythema, tenderness, induration, or purulence within 2 cm of the skin at the exit site of the catheter; CRBSI: Same organism isolated from a culture of the catheter and from the blood with clinical symptoms of infection; in the absence of laboratory confirmation, defervescence after removal of a catheter may be considered indirect evidence of CRBSI. | 46.8% vs. 39.1% | 2.2% | 4.2 ± 2 vs. 7.3 ± 4.5 |
Harba
| 1998-1999 | prospective, open, monocentric, ICU | 47 | 79 | Femoral, subclavian, and jugular | Simplified Brun Buisson |
Infected catheter: positive catheter tip culture with clinical signs of sepsis resolving within 48 hours after catheter removal; CRBSI: same microorganism isolated from the catheter tip culture and from cultured peripheral blood culture drawn during catheter placement or within the 24 hours following removal of the catheter. Differential time of positivity >2 hours. | 5.4 (3.7%) | 1.8 (1.2%) | 6.9 ± 5.5 |
Chatzinikalaoub
| 2000-2002 | prospective, randomized, monocentric, antibiotic coated dialysis catheters, 82% ICU | 130 | 130: 66 antibiotic coated vs. 64 non-coated catheters | Femoral | Sherertz | fever (>38°C), chills, hypotension, skin organisms cultured from at least one blood cultures from a peripheral vein that was not related to infection of another site, and antimicrobial therapy; same organism isolated from peripheral blood culture and from DC tip culture (>1,000 CFU); presence of a positive quantitative catheter culture in a patient with clinical signs of sepsis that disappeared within 48 hours after catheter removal. | 22% of all catheters (20% of antibiotics coated catheters vs. 25% of uncoated catheters) | 14.3 (11% of uncoated catheter) | 8 ± 6 |
Souweinea
| 2001-2004 | prospective, open, monocentric | 99 | 130 | Femoral and jugular | Simplified Brun Buisson |
CRBSI: isolation of the same phenotypic microorganism from both peripheral-blood culture and catheter-tip culture growing greater than 10^3 CFU/mL when there was no other source for bacteremia. | 9.1 | 0 | 6.7 ± 4 |
Schönenberga
| 2003-2007 | prospective, open, monocentric | 173 | 173 | Subclavian, jugular, and femoral | NR |
CRBSI: criteria for laboratory diagnosis of infection and clinical signs of sepsis. Laboratory diagnosis of infection is defined as a positive blood culture with a strain not descending from a different site of infection. | NR | 3.8 | 9.2 |
Kloucheb
| 2004-2005 | prospective, monocentric, randomized, ICU | 30 | 30: 15 tunneled vs. 15 non- tunneled catheters | Femoral | NR | Association of fever or chills or an overtly purulent exit site with a positive catheter clot or catheter culture result | NR | 6.7% | 13.5 ± 9.2 (tunneled) vs. 5.6 ± 3.4 (non-tunneled) |
Parientib
| 2004-2007 | prospective, multicentric, randomized, few coated catheter (21%), ICU | 637 | 637: 366 jugular vs. 370 femoral catheters | Femoral and jugular | Simplified Brun Buisson | catheter tip colonization plus at least one peripheral blood culture yielding the same species with the same antimicrobial susceptibility as the catheter tip within 48 hours of catheter removal, with no other apparent source of sepsis | 40.8 (25.9%, femoral catheter) vs. 35.7 (24.9%, jugular catheter) | 1.5 (0.5%, femoral catheter) vs. 2.3 (0.5%, jugular catheter) | 4.9 ± 2 |
Parientib
| 2004-2007 | prospective, multicentric, randomized, few coated catheter (21%), ICU | 637 | 637: 470 intermittent RRT vs. 266 continuous RRT | Femoral and jugular | Simplified Brun Buisson | catheter tip colonization plus at least one peripheral blood culture yielding the same species with the same antimicrobial susceptibility as the catheter tip within 48 hours of catheter removal, with no other apparent source of sepsis | 38.9 (25.4%) [42.7 (intermittent hemodialysis) vs. 27.7 (continuous renal replacement therapy)] | 1.9 (1.3%) [2.6 (intermittent hemodialysis) vs. 1.2 (continuous renal replacement therapy)] | 6.3 (6.2) vs. 6.6 (6) |
Duguéb
| 2004-2007 | prospective, multicentric, randomized, few coated catheter (21%), ICU | 134 | 268: 57 femoral then jugular vs. 77 jugular then femoral catheter | femoral and jugular | simplified Brun Buisson | NR | 25,4% (femoral catheter) vs. 26,9%(jugular catheter) | NR | 7.9 (5.6) |
Skofica
| 2004-2008 | retrospective, monocentric, prospectively data collection | 290 | 534 | femoral, subclavian, and jugular | NR |
exit site infection: local inflammation with purulent discharge and positive exit site culture; suspected CRBSI: proven systemic infection without any other recognized source of infection; confirmed CRBSI: at least one positive blood culture from a peripheral vein along with at least one positive blood culture from the catheter or positive catheter tip culture with an identical microorganism; possible CRBSI: at least one positive microbiological culture, good clinical response to catheter removal and antibiotic therapy, but lacking all criteria for confirmed CRBSI. | NR | 4.6 (5.2%) | 11 |
Hermiteb
| 2009-2010 | prospective, monocentric, randomized, ICU | 78 | 135: 77 saline vs. 58 citrate lock | femoral and jugular | NR |
CRBSI: fever (>38°C) with concordant positive blood cultures drawn from the catheter and a peripheral vein or a peripheral blood culture and a concordant exit site culture; probable CRBSI: fever with one positive blood culture, in the absence of any other clinically identifiable source of infection other than the catheter. | NR | 30 (saline lock) vs. 24 (citrate lock) |
Mechanisms and incidence of DC-related infections
Measures for preventing DC infections
Choice of the dialysis catheter | |
---|---|
Lumens | No difference between dual lumen catheter and two single lumen catheters placed side by side in terms of infection |
Tunnelization | Not recommended for initiating RRT |
Antimicrobial-coated catheters | Use not currently recommended and should be limited to units with high rates of DC infections despite implementation of adequate preventive strategies |
Choice of the insertion site
| |
No difference between femoral or jugular sites in term of infection. | |
Physicians should be vigilant with femoral site in case of high body mass index, and with internal jugular site in case of low body mass index | |
Insertion procedures
| |
Hygiene procedure | Surgical hand disinfection |
Depilation | Wear a long-sleeved sterile gown, sterile gloves, and cap |
Use a large sterile drape | |
If hairs disturb vascular puncture or dressing occlusion | |
Skin preparation | >0.5% alcoholic chlorhexidine or alcoholic povidone iodine |
Antibiotic prophylaxis Ultrasound guidance | Not recommended. May be proposed for internal jugular DC placement |
During RRT
| |
Hygiene procedure | Use strict aseptic conditions for every DC manipulation |
Dressing | Limit manipulation |
Avoid use of dialysis catheter for perfusion or blood samples, except in case of life threatening emergency | |
Semipermeable transparent polyurethane dressing, sterile gauze | |
Antimicrobial lock solutions | Before applying a new dressing, clean skin with antiseptic solution, 0.5% alcoholic chlorhexidine or alcoholic povidone iodine |
Change in case of disruption or soiled dressing | |
Change dressings at every dialysis | |
Not recommended for prevention | |
Local ointments | Not recommended for ICU dialysis catheter |
Catheter | Catheter replacement not scheduled |
Limit indwelling time and remove as soon as unnecessary |