Salvage of infected tunneled hemodialysis catheters using 70% ethanol lock solution: A brief report.

Tunneled hemodialysis catheters are the lifeline to patients on maintenance hemodialysis with failed arteriovenous fistulas. However, thrombosis and infection are the main causes of reduced longevity of these accesses. According to IDSA guidelines, catheter-related infection with Pseudomonas and fungi are absolute indications for catheter removal. Considering the cost and difficulties in catheter replacement, for those in whom all accesses are exhausted, retaining the same catheter may be lifesaving. We would like to present two patients in whom, 70% ethanol instillation was used to eradicate infection with these organisms as confirmed by repeat cultures post procedure. Hemodialysis is being successfully continued through the same catheter.

Challenges with tunneled dialysis catheter placement with subcutaneous emphysema.

Central vein catheter is a convenient and preferred vascular access for blood purification therapy in intensive care unit. Utilizing ultrasound to access the central vein is considered standard of care. However, critically ill patients can pose challenges while acquiring an optimal ultrasound image. The presence of subcutaneous air pockets, concerns for air embolism, and excessive bleeding from the exit site is one such clinical situation. We describe our experience with a unique situation while placing a tunneled dialysis catheter in a COVID-19 patient with acute respiratory failure and subcutaneous emphysema.

Effect of External Ventricular Drain Tunnel Length on Cerebrospinal Fluid Infection Rates-A Bayesian Network Meta-Analysis.

BACKGROUND: External ventricular drain (EVD)-associated cerebrospinal fluid infection (EACI) remains a major complication associated with EVD. Length of EVD tunnel, an overlooked but modifiable factor, can be associated with increased risk of EACI. The aim of this study is to find the tunnel length associated with least chances of EACI by performing a network meta-analysis. METHODS: A comprehensive search of different databases was performed to retrieve studies that studied the rates of EACI with different EVD tunnel lengths and a Bayesian network meta-analysis was performed. RESULTS: Six studies met the inclusion criteria and were included in the network meta-analysis. With 0 cm tunnel length as reference, the odds ratio (OR) for developing EACI was minimum for tunnel length 5-10 cm (OR, 0.027). It was followed by tunnel length of 5 cm (OR, 0.060) and 10 cm (OR, 0.075). The surface under the cumulative ranking curve plot showed that the probability of the tunnel length 5-10 cm (ranked first), 5 cm (ranked second), and 10 cm (ranked third) for being the best EVD tunnel length was found to be 86%, 64%, and 61%, respectively. CONCLUSIONS: The length for which an EVD is tunneled may have an impact on the rate of EACI. Our network meta-analyses showed that the tunnel length of 5-10 cm was associated with the lowest rates of EACI, with 86% probability of being the best EVD tunnel length. The probability of a patient with 5-10 cm EVD length developing EACI was 2.7% compared with zero tunnel length.

Reduced CVC-related infection rate during the CO VID -19 pandemic

Background: In hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been reinforced. We evaluated their effects on CVC-related infection rates. Materials and Methods: An observational mono-centric retrospective study was conducted in our hemodialysis unit. In the last year, we treated 137 chronic hemodialysis patients, 54 of whom (39%) using either a tunneled-CVC or a not-tunneled-CVC. In the CVC cohort, we compared data on catheter-related infection rates during the COVID-19 pandemic in Italy (February to December 2020) with data from the whole of 2019. Results: In 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 0.94 (95% CI 0.52-1.56)/1000 days and a tunnel and exitsite infection rate of 1.3 (95% CI 0.79-2.01)/1000 days. Infection rates drastically decreased during the COVID-19 pandemic, with just three catheter- related bloodstream infections being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.26 (95% CI 0.06-0.72)/1000 days (p = 0.03) and a non-significant reduction in tunnel and exit-site infections to 0.8 (95% CI 0.45-1.58)/1000 days. Conclusions: The observed 72% reduction in catheter-related bloodstream infections compared to the whole of 2019 (IRR 0.28 (95% CI 0.06-0.92) suggests that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVCrelated infections.

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.