Hemodialysis: Chapter 11, Venous Catheter - Basics, Insertion, Use and Care - Dr.Gawad

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1. Mohammed Abdel Gawad MD/PhD Neph, ESENeph
Nephrology Unit, School of Medicine, NewGiza University
Nephrology Consultant, Alexandria
Founder of NephroTube.com
Chair of AFRAN Web/Media Committee
ISN Education SoMe Team Member
Chapter 11
Venous Catheter:
Basics, Insertion, Use and
Care
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4. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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5. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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6. Indications for venous catheter insertion and
use
•AKI requiring dialysis.
•Intoxication or overdose requiring dialysis.
•Plasmapheresis.
•ESKD patients with one of the following:
oESKD patients needing urgent hemodialysis but without available mature access.
oESKD patients with limited life expectancy.
oESKD patients with AV access-related issues.
oPeritoneal dialysis patients with complications that require time-limited peritoneal
rest or resolution of complication.
oTransplant recipients needing temporary hemodialysis due to acute transplant
rejection or other complications.
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7. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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8. Venous catheters versus AVF and AVG in ESKD
•KDOQI suggests AVF or AVG in preference to CVC in most incident and
prevalent ESKD patients.
•KDOQI suggests that CVC should convert to either an AVF or AVG, if
possible.
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AVF or AVG lower vascular access–related events (e.g.,
infection, thrombotic, and non-thrombotic complications).

9. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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10. Venous Catheter types:
Tunneled (cuffed) versus non-tunneled (uncuffed)
catheters
•KDOQI Vascular Access Guideline (2019 Update) considerations for
ESKD patients:
•Tunneled CVC is preferred over non-tunneled CVC.
•Use non-tunneled internal jugular CVC only temporarily for a
limited period (<2 weeks or per individual facility policy).
•KDIGO Acute Kidney Injury Guideline (2012) considerations for AKI:
Initiate dialysis in patients with AKI via an uncuffed non-tunneled
dialysis catheter rather than a tunneled catheter.
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11. Venous Catheter types:
Tunneled (cuffed) versus non-tunneled (uncuffed)
catheters
•KDOQI Vascular Access Guideline (2019 Update) considerations for
ESKD patients:
•Tunneled CVC is preferred over non-tunneled CVC.
•Use non-tunneled internal jugular CVC only temporarily for a
limited period (<2 weeks or per individual facility policy).
•KDIGO Acute Kidney Injury Guideline (2012) considerations for AKI:
Initiate dialysis in patients with AKI via an uncuffed non-tunneled
dialysis catheter rather than a tunneled catheter.
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Tunneled CVC is preferred over non-tunneled CVC due to the
lower infection risk.

12. Venous Catheter types:
Tunneled (cuffed) versus non-tunneled (uncuffed)
catheters
•KDOQI Vascular Access Guideline (2019 Update) considerations for
ESKD patients:
•Tunneled CVC is preferred over non-tunneled CVC.
•Use non-tunneled internal jugular CVC only temporarily for a
limited period (<2 weeks or per individual facility policy).
•KDIGO Acute Kidney Injury Guideline (2012) considerations for AKI:
Initiate dialysis in patients with AKI via an uncuffed non-tunneled
dialysis catheter rather than a tunneled catheter.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Tunneled CVC is preferred over non-tunneled CVC due to the
lower infection risk.

13. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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14. Kidney Int Rep. 2021 Oct 11;6(12):2958-2968.

15. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Transverse section
“Double-D” configuration
Side holes for blood
entry into the catheter
Tip holes to return blood
to the patient’s veins
Longitudinal section
Side-by-side configuration
Figure 11.1. Symmetric tip venous catheters with side holes

16. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
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17. I. Tunneled cuffed venous catheters for ESKD
patients
•Upper extremity before lower extremity, only if choices are equivalent.
•Right versus left upper extremity.
•If the duration of use is expected to be <3 months, use upper extremity tunneled CVC.
•Some experts support if the duration of use is expected to be <1 month and transplant is not an
option, use femoral tunneled cuffed CVC.
•If the duration of use is expected to be >3 months, without anticipated use of AV access, tunneled
cuffed CVC may be placed in the following locations in order of preference:
oInternal jugular.
oExternal jugular.
oFemoral.
oSubclavian.
oLumbar.
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18. I. Tunneled cuffed venous catheters for ESKD
patients
•Upper extremity before lower extremity, only if choices are equivalent.
•Right versus left upper extremity.
•If the duration of use is expected to be <3 months, use upper extremity tunneled CVC.
•Some experts support if the duration of use is expected to be <1 month and transplant is not an
option, use femoral tunneled cuffed CVC.
•If the duration of use is expected to be >3 months, without anticipated use of AV access, tunneled
cuffed CVC may be placed in the following locations in order of preference:
oInternal jugular.
oExternal jugular.
oFemoral.
oSubclavian.
oLumbar.
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19. II. Non-tunneled uncuffed venous catheters for
AKI patients
•Right internal jugular: It is the first preferred site.
•Femoral.
•Left internal jugular.
•Subclavian (right side insertion location to be used preferentially):
oIt has a high incidence of insertion-related complications.
oIt has a high incidence (up to 40%) of central venous stenosis.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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20. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

21. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

22. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

23. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

24. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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25. I. Complications related to all catheters
(internal jugular, subclavian, and femoral):
•Arterial puncture.
•Accidental arterial insertion of a dialysis catheter
•Air embolism: More common with internal jugular and subclavian
catheters than femoral catheters.
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26. II. Complications related to internal jugular and
subclavian catheter insertion:
•Pneumothorax, hemothorax, arrhythmias, pericardial tamponade.
•Perforation of superior vena cava or cardiac chamber.
•Injury to adjacent structures, such as: Brachial plexus or recurrent
laryngeal nerve.
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27. III. Complications related to femoral catheter
insertion:
Retroperitoneal hemorrhage:
•Suspected if there is abdominal pain and rapidly decreasing
hemoglobin.
•Diagnosis is by CT abdomen.
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28. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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30. Catheter lock manipulation
I. After each hemodialysis session.
II. Before each dialysis:
•The lock solution in each lumen is aspirated.
•The catheter is flushed with heparinized saline (100 units/mL) or
pure saline.
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31. Types of catheter lock solutions
I. Heparin and citrate lock:
The choice based on the clinician’s discretion and best clinical
judgment, as there is inadequate evidence to demonstrate a difference
in CVC survival or complications between these locking solutions.
II. Tissue plasminogen activator (TPA) lock:
•In general, once per week to help reduce CVC dysfunction.
•Once weekly in patients in need of long-term CVC who are at high risk
of CRBSI, especially in facilities with high rates of CRBSI (>3.5/1,000
days).
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32. Types of catheter lock solutions
III. Antibiotic or antimicrobial-containing lock:
Indications:
•Prophylactic in patients in need of long-term CVC who are at high
risk of CRSBI, especially in facilities with high rates of CRBSI (e.g.,
>3.5/1,000 days).
•Management of CRBSI.
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33. Types of catheter lock solutions
III. Antibiotic or antimicrobial-containing lock:
Which antibiotic or antimicrobial-containing lock should be used for
prophylaxis?
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34. Types of catheter lock solutions
III. Antibiotic or antimicrobial-containing lock:
Which antibiotic or antimicrobial-containing lock should be used for
prophylaxis?
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35. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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36. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

37. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
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38. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
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•Cleanse the skin surrounding the catheter exit
site with a chlorhexidine-based solution.
•If chlorhexidine is contraindicated, povidone-
iodine solution (preferably with alcohol) is a
reasonable substitute.

39. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
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•Apply antibiotic ointment or povidone-iodine
ointment to catheter exit sites during dressing
at each hemodialysis session.
•There is a high concern about the emergence
of resistant organisms with the continuous use
of antibiotic ointment:
oUse only until the insertion site has
healed.
oUse can be limited to patients with
repeated episodes of infection.
•Interaction with the catheter.

40. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•Sterile dry dressing
•Nonbreathable or nonporous dressings should
be avoided
•Transparent versus nontransparent dressing:
Inadequate evidence to demonstrate a
difference

41. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Minimum once weekly

42. Instructions for venous catheter dressing
I- Catheter exit site care:
1. Skin cleansing
2. Skin ointment for exit site
II- Dressing type
III- Dressing frequency
IV- Dressing and wet environment
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•Protect against wet and dirty
environments.
•If the patient insists on showering, some
experts suggest that:
oShowering should be done only after
the exit-site sinus tract has become
established
oShowering should be done before
coming to the dialysis unit, where a
new dressing and antibacterial
ointment will be promptly applied.

43. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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44. Tunneled cuffed catheter duration of use
•KDOQI Vascular Access Guideline (2019 Update): There is no
maximum time limit to CVC use.
•The overall survival of tunneled catheters is highly variable according
to the available studies.
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45. Non-tunneled catheter duration of use
•KDOQI Vascular Access Guideline (2019 Update): maximum 2 weeks.
•KDOQI Vascular Access Work Group (2006):
o Non-tunneled venous catheters should be used only in the
inpatient setting for the patient’s safety.
o Non-tunneled internal jugular catheters: no more than 1 week.
o Non-tunneled femoral catheters: no more than 5 days
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46. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

47. Because of this risk, specific protocols should be in place for removing
venous catheters from the neck. The recommended protocol is as follows:
•No heparin on the day of planned removal.
•Put the patient in a head-down position during catheter removal.
•Patient instructed not to cough or inhale deeply during removal.
•Air-occlusive dressing with a generous amount of inert ointment to provide an
instantaneous air seal.
•Observer the patient for 30 minutes before leaving the dialysis facility.
•Air-occlusive dressing left in place for at least 24 hours.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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48. Talk Outline: Chapter 11: Venous Catheter:
Basics, Insertion, Use and Care
•Indications for venous catheter insertion and use
•Venous catheters versus AVF and AVG in ESKD
•Venous Catheter types
•Venous catheter tip design
•Insertion location
•Catheter length
•Catheter tip position after placement
•Insertion related complications
•Catheter Lock
•Instructions for venous catheter dressing
•Duration of venous catheter use
•Risk of air embolism on removal of dialysis catheters from the neck
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

49. Thank You