ABSTRACT
Background: Central venous catheter (CVC) is the preferred vascular access in critically-ill patients needing kidney replacement therapy (KRT). Non-tunneled CVC (NT-CVC) is frequently selected for bedside placement and provider familiarity. With hemodynamic instability, tunneled CVC (T-CVC), despite its known advantages of lower infection risk, lower mechanical complications, better blood flow rates and patient comfort, is infrequently considered due to competing demands for central vein access, and provider inexperience. We report our early experience of building a collaborative training program to improve vascular access approach in the critically-ill patients. Methods: A single center retrospective study of T-CVC placed in an adult medical ICU between March 1, 2020 and December 31, 2020 by a nephrologist or an intensivist. The T-CVCs were placed in hemodynamically unstable patients for KRT and other medical therapies. Statistical analysis was limited to assess feasibility and safety of implementing a collaborative procedural service in an academic medical ICU. Results: A total of 120 CVC related procedures were completed during the study period. 106 were T-CVC placements (68 for KRT, 38 small bore non-KRT), seven T-CVC removals, one difficult NT-CVC for KRT, one T-CVC exchange, one fluoroscopy guided repositioning of NT-CVC, four aborted for suspected central vein occlusion. Twentyseven T-CVC (23 in COVID-19 positive and 4 for other compelling reasons) were placed at bedside with ultrasound guidance and anatomical landmarks without fluoroscopy. A safety pre-procedure checklist was developed for eligibility based on this experience. A minimum of 48-hr sterile blood culture report was essential to proceed. Complex comorbidities included coagulopathic patients. A minimum training competency was established and 2 critical care staff physicians were credentialed during this period. No major complications were encountered. Conclusions: A collaborative care model between nephrology and medical ICU for T-CVC focused strategy is feasible. T-CVC can be placed safely in a carefully selected critically-ill patient population. Training intensivists with basic procedural skills for T-CVC procedure is achievable over a short period.