ASDIN 9th Annual Scientific Meeting
Topics
Vascular Access in the
CKD Patient
(and the general public)
1. Pts requiring VA (w/o present access)
2. Pts requiring VA (tunneled cath in situ)
Disclosures
Jack Le Donne MD
Teleflex
3. Acute HD cath
Ethicon
Tunneled cath
SonoSite
4. Retrograde Tunneled HD cath
Nephrolo
gy
Endocrin
e
1.Pts Requiring VA
(w/o present access)
CKD
Neur
o
CKD
VA
Cardiolo
gy
ED
Vascular
Access
ICU
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Coa
g
Where are we going to insert these CVCs?
Onc
What is my objection to
the IJ vein?
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ASDIN 9th Annual Scientific Meeting
IJ Dressing
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TPN...malpractice
60 yo man
transferred to ICU for
hypotension
• Did not look good
• Eyes Rolled back
• CKD Level 2
• INR = 3.6
• Resident with me
• IJ cath
After achieving access, what do you do next? Resp fail
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as I was approaching the pts room...
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ASDIN 9th Annual Scientific Meeting
The Location of Choice
for Non-tunneled CVCs
(in pts w/o CKD) is the
Chest.
2. Pts Requiring VA
(tunneled cath in situ)
Jack LeDonne 2007
Jean-Francois Timsit 2002
Mauro Pittiruti
Andy Bodenham
I believe...infection control
asked this question 1,000
times...
Patient A
Use the HD Cath vs New Access
Patient B
Sunday 7:30 pm phone call from resident
“Pt with DM &CKD. We need emergent VA. BS
Obese pt, ESRD (RIJ HD cath) with chest pain
Hospitalist orders CT Angiogram
is 4.”
Me: “How do they dialyze the pt?”
VA assessment: LIJ
Obtain consent, prepare the room
Res: With a catheter.
Nephrologist on phone with radiology
Me: Please administer dextrose via HD cath.
Radiologist agrees to use HD cath for CTA
Monday. I find a femoral HD cath
What are the lessons?
Pt. A
Nephrologists great job...
When pt has BS 4, don’t be calling consultants
What kind of MDs are we producing...maybe
Significance of a tunneled groin cath
3. Acute HD Cath
Tunneled Cath
Preserve the RIJ
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Use Left Side (JR...malpractice)
Pt. B
Are these caths pressure rated?
When should the ED or ICU use an HD cath vs
inserting a second line?
A.L.A.R.A.
Put the smallest cath into the largest vein
definitely a place for...
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ASDIN 9th Annual Scientific Meeting
11/1/12
Rt SCV
22 yo man drove into parked car (6 wks ago)
2 weeks ago was moving furniture, injured back
Brachiocep
h
Rx: Percocet, Flexeril, Ibuprofen
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Presents to ED
with severe back pain, anuria
Creatinine 24, Potassium 9, pH 7.1, CK 10,000
Acute HD cath
SVC
11/8/12, asked to insert tunneled cath
3 Choices:
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Wire exchange
LIJ and Brachiocephalic
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Remove temp, same vein
New site
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Acute CR-DVT
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Who will anticoagulate?
4. Tunneled HD Cath
Is the choice of HD cath evidencebased?
Retrograde Tunnel
Tip is positioned before the 2nd incision
–Adjustment is possible
Length of exit site = diameter of catheter
What are the factors?
Flow ( Diameter = Flow)
Cost
Cuff, which is larger than catheter,
never sees the 2nd incision
External securement unnecessary
Nursing care and maintenance is simplified
Exit Site
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ASDIN 9th Annual Scientific Meeting
Retrograde Tunnel
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Beyond the Jugular Vein
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Jack LeDonne MD
ridiculous
Summary
There is a rationale for AXV/SCV/Ceph
We have to find a way to make it known when
the extremities are done.
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Ditto, the pts with difficult/impossible access.
H.264
decompressor
QuickTime™
and
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and
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DV/DVCPRO
-decompressor
NTSC decompressor
are needed
see this
are needed
totosee
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picture.
Consider getting out of bed for these pts
Beware US guided PIV
Anticoagulation for acute CR-DVT?
Retrograde Tunnel HD Catheters
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