Prevention of Infection in Kidney Patients

Renal patients are particularly vulnerable to infection in part because they are relatively, or significantly, immunocompromised, undergo numerous invasive procedures and typically have frequent contact with healthcare institutions putting them at much higher risk of nosocomial infections. In addition, they are typically exposed to multiple antibiotics, which may select out resistant organisms or damage protective microbiomes. The Covid-19 pandemic has brought the life and death importance of infection control to every renal unit and forced a, perhaps overdue, appreciation of the issues and responsibilities associated with nosocomial infections. In addition, our patients are disproportionately impacted by the growing emergence of antimicrobial resistance. This chapter reviews the key aspects of nosocomial infections in renal patients and the important elements of infection control and antibiotic stewardship that can protect our patients. © Springer Nature Switzerland AG 2014, 2022.

Analysis of Survival in Patients with End-End Chronic Kidney Disease Switching from Peritoneal Dialysis to Hemodialysis Due to Refractory Peritonitis

Introduction: Peritonitis associated with peritoneal dialysis (PD) has complications such as transfer from PD to HD and increased morbidity and mortality. In our environment, there is little information regarding survival in this population. Method(s): Retrospective cohort, 147 PD patients, 18 years, with PD catheter removal between 2018-2021. Clinical, biochemical and technique-related variables were measured. Patients who died of cancer and other unrelated causes were excluded. Descriptive statistics, Kaplan-Mayer analysis and Cox regression analysis were used Results: Age 42 +- 17 years, 65% men, 65% unknown cause of CKD. The time between peritonitis diagnosis and catheter removal was 37 (25-61) days. Nine patients (6%) returned to PD, the rest (94%) remained on HD due to unfit abdomen (55%), patient decision (9%), unknown (17%), others (19%). Mortality was 31% and the causes of death were: sepsis (33%), COVID-19 (29%), pneumonia (19%), pulmonary edema (5%), hyperkalemia (5%), CVD (5%), others (4%). Survival after the refractory peritonitis event was 25 (95% CI 22-28) months. Survival at 3, 12, 24, and 36 months was 87%, 71%, 61%, and 35%. In the bivariate analysis, age, DM, time on dialysis, and serum albumin were associated with a higher risk of death. However, in the multivariate analysis, only time on dialysis was significant (OR 1.014, 95% CI 1.002-1.027). [Formula presented] Conclusion(s): Mortality was 31% and the most frequent cause of death was sepsis. Patient survival was 25 (95% CI 22-28) months. Time on dialysis was associated with a higher probability of death. It is necessary to compare these results with a group of patients who do not present failure of the technique. No conflict of interestCopyright © 2023

Central Venous Catheter Placement in a Prone Positioned Patient: Posterior Lateral Approach

INTRODUCTION: A significant number of patients with ARDS secondary to Covid-19 pneumonia require prone positioning. Common practice is to return patients to a supine position prior to performing invasive bedside procedures such as central venous access. This may present prohibitive risk in patients with refractory hypoxemia. DESCRIPTION: We present the case of a 46 year old male, admitted to the ICU with Covid-19 pneumonia complicated by ARDS. Intermittent prone positioning was initiated. The patient remained with refractory hypoxemia despite prone positioning, optimal ventilator settings and inhaled epoprostenol. The length of time the patient could be supine progressively decreased. The patient developed AKI necessitating hemodialysis (HD) catheter placement. Attempts to supine patient to perform HD catheter placement resulted in near cardiorespiratory arrest. It was decided to attempt HD catheter placement in the RIJ vein via a posterior lateral approach with the patient prone. Patient was brought to the head of the bed allowing the chin to rest on the edge of the bed with head turned laterally and endotracheal tube supported by the respiratory therapist. The patient was placed in an oblique "swimming position" by aid of a pillow under the center torso and right shoulder girdle. An optimal insertion site was selected via real time ultrasound guidance. Utilizing a micropuncture needle, guidewire, and dilator, a 15cm 12 Fr BARD hemodialysis catheter was placed using a standard Seldinger technique. DISCUSSION: Our experience indicates that a posterior lateral approach for CVC placement is a viable option. Given the complexity of this procedure and the paucity of case reports describing it, we felt it prudent to share our approach. Structures of interest to avoid in posterior approach to the RIJ include the phrenic nerve traveling along the scalenus anterior muscle tissue posterior to the internal jugular vein. Accessing the vein below the omohyoid muscle offers the best opportunity to avoid the phrenic nerve and the scalenus. A steep 90 degree angle to access the RIJ was intentionally attempted to minimize the amount of soft tissue to dilate. Utilizing this approach allowed us to safely and effectively place the line without immediate complications.

A Retrospective Data Analysis in a General Icu Population: Acute Dialysis Catheter Type and Dialysis Efficiency

Introduction: Acute kidney injury in intensive care units (ICUs) is often treated with Continuous Renal Replacement Therapy (CRRT). Longer and uninterrupted CRRT sessions benefit patients, providers, and institutions. The impact of acute dialysis catheters on CRRT efficiency has only been evaluated in limited, single-centered Australian studies. This multicenter retrospective analysis examines associations between catheter type and multiple CRRT efficiency-related outcomes in a general ICU population. Method(s): CRRT session data from April 2018-July 2020 in two US ICUs were analyzed. Both units replaced three different acute dialysis catheters with a single new catheter in May 2019. Study intervals were divided into pre-/postchange periods, excluding a transition period (April-June 2019). To evaluate the pandemic's effects, the post-change period was further divided into pre-COVID/COVID periods. Outcome measures included treatment stoppage type (elective/non-elective), circuit life, blood flow rate, and frequency of all/vascular access (VA)-related alarm interruptions. Result(s): In total, 1,1037 CRRT sessions were analyzed. Compared to pre-change sessions (n=530), post-change period (n=507) had a reduced proportion of unintended stoppages (adjusted OR=0.42, 95% CI 0.28-0.62, p<0.001), longer circuit life (adjusted OR=1.31, 95% CI 1.14-1.49, p<0.001), increased blood flow rate (adjusted OR=1.03, 95% CI 1.01-1.05, p<0.01), and fewer VA-related interruptions (adjusted OR=0.80, 95% CI 0.66-0.96, p=0.014) and all interruptions (adjusted OR=0.95, 95% CI 0.87-1.05, p=0.31). Sessions during (n=340) and before (n=167) the pandemic were statistically similar except for a decreased proportion of unintended stoppages (adjusted OR=0.39, 95% CI 0.22-0.70, p<0.01). Discussion and conclusion: Adopting a different dialysis catheter was associated with longer CRRT sessions with fewer interruptions in the critically ill. Although the efficiency metrics were largely similar before and during the COVID19 pandemic, a notable increase in session volume was observed during the pandemic months. Future studies are warranted to evaluate the clinical impacts of CRRT efficiency and different catheter designs on patients and providers.

Use of a Wireless Ultrasound Probe for Venous Line Insertion in Covid-19 Patients

Purpose: To report single centre experience with use of wireless ultrasound probe for bedside venous line placement in COVID-19 patients. Material(s) and Method(s): From October 2020 to September 2021, we performed venous catheter insertions in 209 patients with COVID-19. The procedure was done at the angiographic suite or bedside. One hundred seventy-six patients with COVID-1 9 underwent bedside venous line placement. There were 115 males and 61 females with average age 74,9 years (from 16 to 96 years). We used two types wireless linear US probes with frequency 4-13 MHz (Clarius) or 7.5-10 MHz (LeapMed). Large 12-inch tablets were used to display the ultrasound image. Result(s): The venous line was successfully inserted in 172 (98,9%) patients at the first attempt. Four patients underwent second procedure because of vein dissection in 2 patients and hematoma and vein spasm in 2 patients. All repeated procedures were successful. The most common venous lines we used were midline in 143 patients. The PICC was inserted in 26 patients and central venous catheter (including dialysis catheter) was placed in 7 patients. The ECG was used bedside to verify the tip position of central inserted central venous catheter and PICCs. Conclusion(s): The use of wireless US probes is convenient for bedside venous line placement. The main advantage is simple manipulation, preservation of anti-epidemic conditions (even during non-pandemic COVID-19) and easier probe's dressing with sterile cover, because there is not cable between US probe and tablet (display). The use of wireless US probes makes the insertion of IV catheters in DIVA patients much more accessible and safer.

COVID-19 Pandemic Impact on Dialysis Access Procedures for End Stage Renal Disease Patients

Introduction: The COVID-19 pandemic has affected the health services globally. The impact on the provision of vascular access services for patients with chronic kidney disease is not known. One can speculate that reduced hospital bed capacity, limited elective theatre lists, and the shielding requirement for vulnerable patients in this particular group will have an adverse effect. This study was conducted to evaluate the effect of the COVID-19 pandemic on dialysis access procedures performed at a tertiary care centre. Methods: This was a single centre, retrospective, observational study of all dialysis access procedures performed between January 2019 and December 2020. Patient data were collected from electronic patient records, operation theatre databases, and clinical case records. Vascular access procedures were categorised according to the site and type of dialysis access (autogenous/non-autogenous fistulas) and secondary access procedures. Secondary access procedures were those that dealt with complications of vascular access. Peritoneal access procedures were also included in the data. Placement of acute and long term dialysis catheter lines were excluded. Pre-COVID data from 2019 were compared with the 2020 data. Statistical methods for data analysis were performed using SPSS version 23.0 by applying Pearson’s chi square test for variables to measure the significance of outcome. Results: A total of 271 dialysis access related procedures were performed in 2019 versus 212 in 2020. There was a significant drop of 21.7% in the total number of dialysis access procedures during the COVID-19 pandemic in the year 2020 (p <.05). In the pre-COVID era, 162 (59.8%) procedures were the formation of autogenous arteriovenous fistulas. The case mix consisted of 69 (25.5%) radiocephalic fistulas, 70 (25.8%) brachiocephalic fistulas, 13 (4.8%) first stage basilic vein transpositions, and 10 (3.7%) second stage basilic vein transpositions. In comparison, during the year 2020, 118 (55.7%) procedures were autogenous arteriovenous fistulas. The case mix included 54 (25.5%) radiocephalic fistulas and a similar proportion of brachiocephalic fistulas (n = 54 [25.5%]), six (2.8%) first stage basilic vein transpositions, and four (1.9%) second stage basilic vein transpositions. There were 14 (5.2%) non-autogenous arteriovenous graft formations in 2019 versus 21 (9.9%) in 2020 (p <.05). There were 53 (19.5%) secondary vascular access procedures in 2019 versus 30 (14.1%) in 2020 (p <.05). The proportion of peritoneal dialysis catheter placements, repositioning, and catheter exchanges increased slightly. Forty-two (15.5%) procedures were done in 2019 versus 43 (20.3%) in 2020. The proportion of new peritoneal catheters was significantly higher in the year 2020 (p <.05). There were 35 (12.9%) new peritoneal dialysis catheter placements (nine laparoscopic/26 open insertions) in 2019, whereas in 2020 there were 38 (17.9%) n (one laparoscopic, 31 open and five percutaneous). There were no laparoscopic peritoneal dialysis catheter placements after the start of the pandemic. Conclusion: During the COVID-19 pandemic, there was a significant reduction in the total number of vascular access procedures performed and also secondary surgical interventions, but an increase in the use of arteriovenous grafts. The number of new peritoneal dialysis access increased despite overall reduction in the total number of procedures. Percutaneous peritoneal tube insertion technique was introduced during the pandemic to reduce hospital admissions while laparoscopic techniques were abandoned.

The use of wireless ultrasound probes for bedside venous line placement in COVID-19 patients

Aim: To report single centre experience with use of wireless ultrasound probe for bedside venous line placement in COVID-19 patients. Method: From October 2020 to September 2021, we performed venous catheter inser-tions in 209 patients with COVID-19. The procedure was done at the angiographic suite or bedside. One hundred seventy-six patients with COVID-19 underwent bedside venous line placement. There were 115 males and 61 fema-les with average age 74.9 years (from 16 to 96 years). We used two types wireless linear US probes: Clarius Scanner L7 HD (Clarius Mobile Health Corp, Vancouver, Kanada) or 4Echo LeapMed (Guide Imaging, Oostende, Belgie). Large 12.9-inch tablets (iPad Pro, Apple Inc, Cupertino, USA) were used to display the ultrasound image. The ECG was used to verify the tip position of central inserted central venous catheter and PICCs. Results: The venous line was successfully inserted in 172 (97.7 %) patients at the first attempt. Four patients underwent second procedure because of vein dissection in 2 patients and hematoma and vein spasm in 2 patients. All repeated procedures were successful. The most common venous lines we used were midline in 143 patients. The PICC was inserted in 26 patients and central venous catheter (including dialysis catheter) was placed in 7 patients. Conclusion: The use of wireless US probes is convenient for bedside venous line placement. The main advantage is simple manipulation, preservation of anti-epidemic conditions and easier probe’s dressing with sterile cover, because there is not cable between US probe and tablet.

SHORT-TERM CATHETER TYPE AND DIALYSIS EFFICIENCY: A RETROSPECTIVE DATA ANALYSIS IN A GENERAL ICU POPULATION

Background: Continuous Renal Replacement Therapy (CRRT) is commonly used in intensive care units (ICUs) to treat patients that develop acute kidney injury. Efficient CRRT can minimize differences between prescribed and delivered hemodialytic doses and reduce alarm fatigue. The role of acute dialysis catheters in CRRT efficiency has been assessed in single-center Australian studies focusing on circuit life. This multi-center retrospective analysis examines associations between catheter type and a comprehensive set of CRRT efficiency-related measures in the ICUs of two hospitals caring for patients with medical, surgical, and other critical illnesses. Methods: CRRT session data from two US ICUs between April 2018 and July 2020 were analyzed. Both units transitioned to a single new acute dialysis catheter from three different catheters in May 2019. The transition period (April 2019-June 2019) was excluded, and study intervals were divided into pre-and post-change periods. The post-change period was further divided into pre-COVID and COVID management periods to assess the pandemic's impacts. Outcome measures included frequency of alarm interruptions (all/vascular access [VA]-related alarms), circuit life, blood flow rate, and treatment stoppage type (elective/non-elective). Results: The final dataset included 1,1037 dialysis sessions. Relative to the pre-change period (n=530), post-change sessions (n=507) had fewer VA-related interruptions (adjusted OR=0.80, 95% CI 0.66-0.96, p=0.014), and all interruptions (adjusted OR=0.95, 95% CI 0.87-1.05, p=0.31), lower proportion of non-electively terminated sessions (adjusted OR=0.42, 95% CI 0.28-0.62, p<0.001), increased blood flow rate (adjusted OR=1.03, 95% CI 1.01-1.05, p<0.01), and longer circuit life (adjusted OR=1.31, 95% CI 1.14-1.49, p<0.001). Dialysis sessions before (n=167) and during COVID-19 (n=340) were comparable, excepting a lower proportion of unexpected stoppages (adjusted OR=0.39, 95% CI 0.22-0.70, p<0.01). Conclusion: Changing the acute dialysis catheter type was associated with longer CRRT sessions and fewer interruptions among a mixed population of critical patients in two US community hospitals. Pre-COVID CRRT sessions were similar in measures of efficiency to management during COVID-19;however, there was a striking increase in the volume of sessions during the pandemic months. The impacts of dialysis efficiency on patients and healthcare teams should be studied further, as should the influence of dialysis catheters and their design.

Interventional radiology workflow and hospital occupancy in the pandemic era: areas for improvement

Purpose: Throughout the COVID-19 pandemic, an increasing hospital occupancy rate has been an ongoing issue, with several hospitals operating at or near full capacity. Emphasis has been placed to improve discharge strategies to maintain bed space and decrease hospital occupancy rate. The interventional radiology (IR) department can play a pivotal role in the discharge process by providing timely interventions that are essential prior to a patient’s discharge. This project aims to define the time intervals between the date of priority request for an IR procedure (in preparation to discharge), date of IR procedure, and date of patient’s actual discharge. Materials and Methods: Between April–September of 2021, a retrospective review of hospitalized patients in a tertiary medical center for whom an IR procedure labeled as “Priority Discharge” was requested by primary teams was performed. Multiple procedure-related variables, including time intervals between the placement of the order, and the patient’s actual discharge were recorded. Results: During the study period, a total of 75 IR procedure requests (42 male, 33 female, mean age of 60y, range 21-98y) were labeled as “Priority Discharge.” Overall 74 of 75 (99%) procedures were completed on the same day of request. Performed procedures were: peripherally inserted catheter (51%) midline (24%), tunneled hemodialysis catheter (16%), and other (9%). The average time interval that patients stayed in the hospital after the IR procedure was 3 days (SD: 4, Range of 0-20 days). Of the total 75 patients, 23 (31%) patients were discharged on the same day as the procedure, 33 (44%) patients were discharged within 1-4 days after the procedure, 12 (16%) patients were discharged within 5-9 days after the procedure, and 7 (9%) patients were discharged 10 or more days after the procedure. The average admission duration for the study population was 10 d (range 2-33 d). Conclusion: Due to the inherent complexity of the hospital operations, strategies aiming to prioritize IR procedures for patients pending discharge could help to improve hospitals’ occupancy rates. Nevertheless as shown in our study a considerable percent of these patients stay in hospital for several days after the procedure is complete. Inefficient application of this system could disrupt the triage of the requested procedures, which may eventually lead to an unnecessary delay for other patients and prolong their hospitalization. Accordingly, tools should be incorporated into these strategies that could improve IR workflow and decrease susceptibility of these strategies to miscommunication and errors.

A FOUR-YEAR ANALYSIS ON HOME DIALYSIS AT THE NORTH BRISTOL NHS TRUST-WHAT TO DO NEXT?

BACKGROUND AND AIMS: Home dialysis, including peritoneal dialysis (PD) and home hemodialysis (HHD), has been associated with improved patient autonomy, quality of life and overall cost effectiveness (Weinhandl et al. Propensity matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010;21: 499-506). The 2021 Get It Right First Time (GIRFT) Renal report revealed that home dialysis patients were at a lower risk of contracting and dying of coronavirus disease 2019 (COVID-19), compared to those who received in-center hemodialysis (ICHD) (2). Despite these advantages, uptake of home dialysis is still lower than that of ICHD. The aim of our study was to analyse the numbers and reasons for home dialysis withdrawal at the North Bristol NHS Trust between 2018 and 2021. METHOD: All patients on PD and HHD between 2018 and 2021 were included. Analysis of the episodes that led to home dialysis cessation was carried out. As some patients required withdrawal more than once during the 4-year period, each episode of dropout was considered separately. The prevalence rate of patients on home dialysis was calculated. RESULTS: The total number of patients on home dialysis increased from 74 in 2018 to 98 in 2021. The male: female ratio of patients was 3:2 with an average age of 58.3. The number of patients on PD increased from 58 at the end of 2018 to 82 in 2021. The number of patients on HHD remained stable over the years, with an average of 16. The prevalence rate of home dialysis was 17.1% at the end of 2021. Figure 1 shows the total number of patients who started and dropped out of home dialysis every year. The number of patients initiating PD was 58 in 2018, 55 in 2019, 37 in 2020 and 59 in 2021. The number of dropouts was 57 in 2018, 41 in 2019, 29 in 2020 and 43 in 2021. The dip in number of patients initiated on PD in 2020 can be attributed to the start of the COVID-19 pandemic, when elective procedures were temporarily withheld. On the other hand, a lower number dropped out during 2020. This may be explained by the emphasis given to self-isolation rules and persistence with home dialysis during the outbreak. The overall increase in PD uptake in 2021 may be explained by the establishment of a new specialist clinic that promotes the uptake of home dialysis. The initiation of a new peer support service group in 2021 may also have contributed. The number of patients initiating and withdrawing from HHD followed the same pattern, with a significant dip in 2020. Figure 2 demonstrates the reasons for withdrawal from PD over the study period. The most prevalent reasons were PD-related infections and transplantation. The observed figures for transplantation reflect the continuous efforts involved in the maintenance of a successful transplant programme. The figure also shows that termination of PD due to failure was highest in 2021. The authors postulate that this surge might be due to the previous year's low PD dropout rate. The leading reason for stopping HHD was transplantation. Other reasons included recovery of renal function and switching to conservative management. Death led to one dropout/year in 2018-20, but none in 2021. CONCLUSION: Around 17% of the NBT's total dialysis population is currently on home dialysis. The commonest reasons for termination of home dialysis were transplantation and PD-related infections. The GIRFT report recommends that all adult renal units in the UK should reach a minimum prevalence rate of 20% of their dialysis population on home dialysis by the end of 2024 (Lipkin et al. Renal medicine: Get It Right First Time (GIRFT) Programme National Specialty Report. March 2021. NHS England and NHS Improvement). Whereas our statistic falls slightly short of this, we aim to reach this target through various strategies. These include continued audit, home dialysis campaign, continued psychological services and a reduction in waiting time for PD catheter insertion.

THE LONGITUDINAL EVOLUTION OF COVID-19 OUTCOMES AMONG HEMODIALYSIS PATIENTS: A NATIONWIDE MULTICENTRE CONTROLLED STUDY

BACKGROUND AND AIMS: Haemodialysis (HD) patients are at increased risk for adverse short-term consequences of COVID-19. In this study, we investigated the characteristics of chronic HD patients in the post-COVID-19 period and compared them with the control group. METHOD: We conducted a national multicentre observational study involving adult chronic HD patients recovering from COVID-19. The control HD group was selected from patients with similar characteristics who did not have COVID-19 in the same center. SARS-CoV-2 RT-PCR negative patients and patients in the active period of COVID-19 were not included. RESULTS: A total of 1223 patients (635 COVID-19 groups, 588 control groups) were included in the study from the data collected from 47 centres between 21 April 2021 and 11 June 2021. The patients' baseline demographics, comorbidities, medications, HD characteristics and basic laboratory tests were quite similar between the groups (Table 1). 28th-day mortality and between 28th day and 90th day mortality were higher in the COVID-19 group than in the control group [19 (3.0%) patients and 0 (0%) patients;15 (2.4%) patients and 4 (0.7%) patients, respectively]. Presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection and A-V fistula thrombosis were significantly higher in the COVID-19 group in the first 28 days of illness and between 28 and 90 days. Mortality was significantly associated with preexisting COVID-19, age, current smoking, use of tunneled HD catheter, persistence of respiratory symptoms, rehospitalization, need for home oxygen support, presence of lower respiratory tract infection within 28 days and persistence of respiratory symptoms. CONCLUSION: In the post-COVID-19 period, mortality, rehospitalization, respiratory problems and vascular access problems are higher in maintenance HD patients who have had COVID-19 compared to control HD patients. (Table Presented).

POS-677 COMPARISON BETWEEN SINGLE AND DOUBLE CUFFED TENCKHOFF CATHETER IN EARLY ONSET EXIT SITE INFECTION AND PERITONITIS - SINGLE CENTER EXPERIENCE

Introduction: In Malaysia, the overall prevalence of Chronic Kidney Disease (CKD) is 15.48%1. The incidence of patients with end-stage renal disease (ESRD) requiring dialysis has been growing rapidly in Malaysia from 18 per million population (PMP) in 1993 to 231 PMP in 20132. From 2007 to 2016, the acceptance rate for both hemodialysis and peritoneal dialysis nearly doubled while the prevalence rate had increased by more than two-fold.3Early observational studies reported lower peritonitis rates with double versus single-cuffed catheters.4However, Eklund B et al. showed that there is no significant difference in terms of catheter survival, exit site infection and peritonitis.5Exit-site infection (ESI) is a common complication of peritoneal dialysis (PD) and is one of the important risk factors in PD-related peritonitis and technical failure.6In addition, exit site infection is an independent risk factor for early onset peritonitis. Early onset peritonitis on the other hand, is identified as an independent risk factor for mortality and technique failure in PD patients.7 Our objective of this study is to identify the incidence of exit site infection and early onset peritonitis among patients whom had their tenckhoff catheter inserted in Hospital Sultanah Bahiyah from January 2021 till June 2021. Methods: This is a single centered, retrospective observational study which examines the incidence of early onset exit site infection in the first 3 months and early onset peritonitis in the first 3 months for patients on newly inserted single or double cuffed tenckhoff catheters. All patients had their tenckhoff catheter inserted from 1stof January 2021 till 31stof June 2021 were recruited. The catheters are inserted by Nephrologists under Y-Tech peritoneoscope guidance in the operation theatre. Coiled Dacron cuffed catheters were used. I-series coiled PD catheter from MEDCOMP USA was used for single cuffed catheter while Argyle Curl Cath Peritoneal Catheters from MEDTRONIC USA was used for double cuffed catheter. Results: A total of 62 patients were included, 35 patients had double cuffed catheter inserted while 27 patients had single cuffed catheter inserted. One patient who had single cuffed catheter inserted was excluded from this study due to malfunctioning of tenckhoff catheter postoperatively. The mean age for single cuffed catheter and double cuffed catheter patients were 50.3 and 55.8 years old respectively. Among the single cuffed catheter patients, 12(44%) were female while 15(56%) were male. Among the double cuffed catheter patients, 19(54%) were female while 16(46%)were male. The incidence of exit site infection for single cuffed catheter was 2(8%) while double cuffed catheter was 6(17%) The incidence of early onset peritonitis for single cuffed catheter and double cuffed catheter were 4(15%) and 11(31%) respectively. Conclusions: There is a higher incidence of early onset exit site infection and early onset peritonitis among patients with double cuffed tenckhoff catheter. Our study has limitation due to small sample size as the study being conducted during the height of COVID19 pandemic. Further study would be needed to recruit more patients over longer duration to ascertain late onset exit site infection, peritonitis and the long term catheter survival among single and double cuffed tenckhoff catheter. No conflict of interest

Safety of Bedside Placement of Tunneled Hemodialysis Catheters in the Intensive Care Unit: Translating from the COVID-19 Experience.

BACKGROUND: Critically ill patients with coronavirus disease 2019 (COVID-19) and kidney dysfunction often require tunneled hemodialysis catheter (TDC) placement for kidney replacement therapy, typically under fluoroscopic guidance to minimize catheter-related complications. This entails transportation of patients outside the intensive care unit to a fluoroscopy suite, which may potentially expose many healthcare providers to COVID-19. One potential strategy to mitigate the risk of viral transmission is to insert TDCs at the bedside, using ultrasound and anatomic landmarks only, without fluoroscopic guidance. METHODS: We reviewed all COVID-19 patients in the intensive care unit who underwent right internal jugular TDC insertion at the bedside between April and December 2020. Outcomes included catheter placement-related complications such as post-procedural bleeding, air embolism, dysrhythmias, pneumothorax/hemothorax, and catheter tip malposition. TDC insertion was considered successful if the catheter was able to achieve blood flow sufficient to perform either a single intermittent or 24 h of continuous hemodialysis treatment. RESULTS: We report a retrospective, single-center case series of 25 patients with COVID-19 who had right internal jugular TDCs placed at the bedside, 10 of whom underwent simultaneous insertion of small-bore right internal jugular tunneled central venous catheters for infusion. Continuous veno-venous hemodialysis was utilized for kidney replacement therapy in all patients, and a median catheter blood flow rate of 200 mL/min (IQR: 200-200) was achieved without any deviation from the dialysis prescription. No catheter insertion-related complications were observed, and none of the catheter tips were malpositioned. CONCLUSIONS: Bedside right internal jugular TDC placement in COVID-19 patients, using ultrasound and anatomic landmarks without fluoroscopic guidance, may potentially reduce the risk of COVID-19 transmission among healthcare workers without compromising patient safety or catheter function. Concomitant insertion of tunneled central venous catheters in the right internal jugular vein for infusion may also be safely accomplished and further help limit personnel exposure to COVID-19.

Comparing outcomes of tunnelled dialysis catheter insertions and exchanges with or without fluoroscopy.

BACKGROUND/OBJECTIVE: To study the safety and outcome profiles of tunnelled dialysis catheter (TDC) insertions and exchanges with fluoroscopy versus without fluoroscopy. METHODS: This was a retrospective cohort study of all TDC insertions or exchanges performed at our centre, between January 2017 and December 2017. Patient demographics, laboratory results and catheter placement information were obtained from electronic records. Immediate technical success, early and late catheter associated complications were collected. Outcomes for TDC inserted with or without fluoroscopy were statistically analysed. RESULTS: A total of 351 TDC insertions and 253 TDC exchanges were performed. Out of 351 TDC insertions, 261 were done with fluoroscopy while 90 were done without. Out of 253 TDC exchanges, 219 were done with fluoroscopy while 34 were done without. For both TDC insertions and exchanges, there were no significant differences in complication rates when done with or without fluoroscopy. Mean duration of catheter patency was longer for TDC inserted without fluoroscopy, after adjusting for site of insertion and presence of previous TDC. CONCLUSIONS: The technique of inserting TDC in the right internal jugular vein (IJV) without fluoroscopy is a safe and effective method in selected patients. This supports the practice of performing the procedure without fluoroscopy, especially in institutions where fluoroscopy facilities are not readily available. This potentially translates into reduced healthcare resources and hospitalisation days, which is particularly valuable in times of limited resources such as the current Coronavirus Disease 2019 (COVID-19) pandemic.

Malfunctioning temporary hemodialysis catheters in patients with novel coronavirus disease 2019.

OBJECTIVE: The hypercoagulability seen in patients with novel coronavirus disease 2019 (COVID-19) likely contributes to the high temporary hemodialysis catheter (THDC) malfunction rate. We aim to evaluate prophylactic measures and their association with THDC patency. METHODS: A retrospective chart review of our institutions COVID-19 positive patients who required placement of a THDC between February 1 to April 30, 2020, was performed. The association between heparin locking, increased dosing of venous thromboembolism (VTE) prophylaxis and systemic anticoagulation on THDC patency was assessed. Proportional hazards modeling was used to perform a survival analysis to estimate the likelihood and timing of THDC malfunction with the three different prophylactic measures. We also determined the mortality, rate of THDC malfunction and its association with d-dimer levels. RESULTS: A total of 48 patients with a mortality rate of 71% were identified. THDC malfunction occurred in 31.3% of patients. Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation, and 38 (79.1%) received VTE prophylaxis. Overall, the rate of THDC malfunction was lower at a trend level of significance, with heparin vs saline locking (24.3% vs 54.6%; P = .058). The likelihood of THDC malfunction in the heparin locked group is lower than all other groups (hazard ratio [HR], 0.07; 95% confidence interval [CI], 0.01-0.45]; P = .005). The rate of malfunction in patients with subcutaneous heparin (SQH) 7500 U three times daily is significantly lower than of the rate for patients receiving none (HR, 0.03; 95% CI, 0.001-0.74; P = .032). A trend level significant association was found for SQH 5000 U vs none (P = .417) and SQH 7500 vs 5000 U (P = .059). Systemic anticoagulation did not affect the THDC malfunction rate (P = .240). Higher d-dimer levels were related to greater mortality (HR, 3.28; 95% CI, 1.16-9.28; P = .025), but were not significantly associated with THDC malfunction (HR, 1.79; 95% CI, 0.42, 7.71; P = .434). CONCLUSIONS: Locking THDCs with heparin is associated with a lower malfunction rate. Prospective randomized studies will be needed to confirm these findings to recommend locking THDC with heparin in patients with COVID-19. Increased VTE prophylaxis suggested a possible association with improved THDC patency, although the comparison lacked sufficient statistical power.