PROCEDURE: Ultrasound and fluoroscopy guided tunneled hemodialysis catheter placement        Â
INDICATION:Â Â Â Â
DATE:Â Â Â Â
OPERATORS: , MD (Attending)/ Â , MD (Fellow)
ACCESS SITE: Right internal jugular vein with ultrasound
MEDICATIONS: Versed   mg IV, fentanyl   mcg IV, and   Â
CONTRAST: NoneÂ
FLUOROSCOPY TIME: Â Â minutes
CATHETER: 15.5 French, Â Â cm tip to cuff catheter
COMPLICATIONS:Â NoneÂ
TECHNIQUE:
The risks, benefits, and alternatives to the procedure and sedation were explained. Written informed consent was obtained. A timeout was performed.
The right neck and upper chest were prepped and draped in sterile fashion. Using local anesthetic and ultrasound guidance, the right internal jugular vein was punctured with a 21 gauge needle. An image was saved and stored to PACS.Â
A 0.018-inch wire was passed centrally and the needle exchanged for a 5 French transitional dilator. A 0.035-inch wire was advanced through the dilator and negotiated into the IVC. The skin tract was dilated and a 16 French dilator peel-away combination placed over the wire.
The soft tissues caudal and lateral to the sheath entry site were anesthetized with lidocaine with epinephrine. A dermatotomy was made and a tunneling tool brought from the dermatotomy to the venotomy. The catheter was brought through the tunnel.
During suspended respiration, the catheter was advanced through the peel-away and positioned centrally using fluoroscopy. The peel-away was removed and hemostasis achieved with manual compression.
The venotomy was closed with Dermabond and Steri-Strips applied. The catheter was secured with 2-0 Ethilon. An antimicrobial disc and sterile dressing were applied.
The catheter was aspirated, flushed, and heparinized per protocol. The procedure was well tolerated, and the patient was discharged in satisfactory condition.
FINDINGS:
- The right internal jugular vein is ultrasonographically patent. Needle entry was documented.
- The newly placed catheter has a smooth course with the tips terminating in the right atrium.
- There is excellent function with 20 ml syringes.
IMPRESSION:Â
Uneventful image guided placement of a right internal jugular tunneled hemodialysis catheter as described.
Frequently Asked Questions
What is a tunneled hemodialysis catheter?
A tunneled hemodialysis catheter, also known as a permacath, is a type of long-term vascular access device used for hemodialysis. It consists of a flexible tube inserted into a large vein, often the internal jugular vein, and 'tunneled' under the skin to reduce infection risk. The catheter's tip is placed in a large central vein, such as the superior vena cava, allowing for efficient blood flow during dialysis.
How is a tunneled hemodialysis catheter placed?
The placement of a tunneled hemodialysis catheter involves using ultrasound and fluoroscopy for guidance. After obtaining consent and prepping the site, a small puncture is made in the vein using a needle. A guidewire is inserted, followed by a series of dilators to make space for the catheter. The catheter is tunneled under the skin to an exit site, then advanced into the vein, ensuring proper positioning with imaging.
What are the risks of a tunneled hemodialysis catheter placement?
Risks associated with tunneled hemodialysis catheter placement include infection, bleeding, and damage to nearby structures like arteries or nerves. Though rare, complications can also include catheter malposition or clotting. Careful technique and sterile conditions help minimize these risks, and the procedure is generally safe when performed by experienced clinicians.
Why is ultrasound used during catheter placement?
Ultrasound is used during catheter placement to visualize the internal jugular vein and surrounding structures in real-time. This allows the clinician to accurately puncture the vein while avoiding nearby arteries and nerves, reducing the risk of complications. Ultrasound guidance increases the success rate and safety of the procedure.
What is the purpose of heparinizing a catheter?
Heparinizing a catheter involves flushing it with a heparin solution to prevent clot formation within the catheter. Heparin is an anticoagulant that helps maintain catheter patency between dialysis sessions, reducing the risk of blockage and ensuring effective dialysis treatment.
What is the role of sedation in catheter placement?
Sedation is used during tunneled hemodialysis catheter placement to ensure patient comfort and cooperation. Medications like Versed and fentanyl may be administered to alleviate anxiety and pain, making the procedure more tolerable. The level of sedation is carefully monitored to maintain patient safety.
How is the catheter secured after placement?
After placement, the catheter is secured with sutures to prevent movement and potential dislodgement. The venotomy site is closed with skin adhesive and Steri-Strips, and an antimicrobial disc is applied to reduce infection risk. A sterile dressing covers the site to maintain cleanliness and support healing.
What follow-up care is needed after catheter placement?
Following catheter placement, patients should keep the site clean and dry, monitor for signs of infection, and attend regular follow-up appointments. Dialysis staff will manage catheter care, including regular flushing and dressing changes. Patients should report any unusual symptoms like redness, swelling, or fever to their healthcare provider immediately.