Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis.

To find out whether internal jugular vein cannulation with a soft silastic hemodialysis access catheter causes jugular vein thrombosis, the authors carried out Doppler ultrasound examinations on 96 patients receiving hemodialysis who had undergone 144 separate catheter insertion episodes in 116 veins. Two internal jugular vein thromboses were found in 101 veins that had been the site of percutaneous insertions only. In addition, 5 internal jugular vein thromboses were identified in 15 veins that had been cannulated surgically with the Quinton PermCath. The authors conclude that percutaneous internal jugular vein cannulation for hemodialysis access causes an acceptably low incidence of jugular vein damage. This strengthens the case for preferential use of the internal jugular vein for vascular access in patients with end-stage renal failure, and suggests that percutaneous cannulation is less damaging than surgical insertion.

A new vascular access catheter for hemodialysis.

A new vascular access catheter has been developed (Cook Critical Care, Bloomington, IN) that is suitable for both short-term and long-term hemodialysis. Designed primarily for the internal jugular vein, it emerges through a subcutaneous tunnel on the anterior chest wall. With parallel cylindrical lumens to provide blood flows of 400 mL/min, it is compressible during insertion and can be placed percutaneously in the vein through a 13-French peel-away sheath. This allows repeated insertions at different times in the same patient. In 80 catheter insertions, we have found one case of jugular vein thrombosis attributable to the catheter and no subclavian vein thrombosis. After 15 months of use, the bloodstream infection rate was one per 19.7 patient-months. Using this device, it should be possible to stop the subclavian vein damage and perforating injuries that have been the most important complications of semistiff, tapered, subclavian catheters.

Superior vena cava stenosis associated with hemodialysis catheters.

The cases are described of four patients on long-term hemodialysis who developed stenosis of the superior vena cava (SVC) that interfered with the functioning or placement of jugular catheters for hemodialysis. All four patients had previously received multiple subclavian and/or jugular catheters inserted for hemodialysis access. In three patients, the SVC stenosis was successfully dilated by balloon angioplasty, and in one of these a stent was inserted to prevent restenosis. These three patients have subsequently been successfully dialyzed with jugular catheters. Stenosis of the SVC should be suspected when jugular catheters in the SVC give inadequate flows in the absence of thrombotic obstruction. Balloon dilatation with or without vascular stenting may allow satisfactory vascular access to be reestablished.

Maintaining the patency of double-lumen silastic jugular catheters for haemodialysis.

A system has been developed for maintaining the patency of double lumen silastic jugular catheters in patients with refractory vascular access problems. Most patients receive a small daily dose of aspirin. Selected patients also receive warfarin to maintain a prothrombin time (PT) of 15, 20, or 30 seconds. Inadequate blood flow due to thrombus obstruction can be overcome by the intravenous administration of urokinase, 250.000 units. This can be administered safely to outpatients provided that heparin is not given simultaneously. Occasionally a second dose may be required. By adopting this policy all catheter obstructions have been overcome. The danger of iatrogenic bleeding cannot be discounted. Warfarin therapy must be very closely monitored.

Control of oral anticoagulation in patients using long-term internal jugular catheters for haemodialysis access.

Patients using long-term double-lumen silastic jugular catheters for haemodialysis access frequently require oral anticoagulants to maintain patency of the catheter. It may be difficult or impossible to obtain peripheral vein blood samples for PT measurements to regulate the oral anticoagulant dose. Our studies have shown that removal of 3 mls of blood from the catheter limb containing the heparin (to be discarded) followed by 10 mls as a heparin wash-out (to be returned to the patient) allows blood to be taken from the arterial limb of the catheter for PT measurement. The PT measurement obtained from the arterial limb after a 10 ml wash-out is nearly always identical with the PT measurement on blood obtained from a peripheral vein. If the simultaneously measured aPTT is normal the PT is predictably and consistently accurate. If the aPTT is raised due to traces of residual heparin then the PT may be inaccurate and should be repeated. This method is easy and reliable and can be recommended as an aid to regulation of the oral anticoagulant dose.

Continuous veno-venous hemodialysis (CVVHD) in the management of complicated renal failure.

CVVHD is an effective treatment of choice applicable to all critically ill unstable patients with CARF. It is a technique that offers clinical advantages. It is easily initiated. It offers good clearance. Its closed dialysate circuit offers accurate control of UF that is adaptable to the patient's needs. The use of a blood pump reduces the risks of heparin-induced bleeding and arterial cannulation. In all patients, the blood flow rate was maintained at 100 ml/min. or more regardless of systemic BP. The UF removed per hour was between 100-200 mls/hour. Fluid removal on overloaded patients was easily accomplished with stable hemodynamic status. Adequate parenteral nutrition was able to be maintained to meet the requirement of the patients. The accuracy of the UF pump, no large volume fluid replacement and the safeguard of a closed system facilitates the work of the ICU nurses who have few or no adjustments to perform. Experience with CVVHD has proven that nurses working in the ICU are willing to be trained to take responsibility for this mode of treatment.