Vascular access for haemodialysis
Since the earliest days, the ‘Achilles heel’ of haemodialysis.
In acute renal failure, temporary access to the circulation for dialysis is achieved by inserting a wide-bore dual lumen catheter into a major vein, usually the femoral or internal jugular vein. For patients awaiting AV fistula development or with no possibility of fistula formation, soft tunneled central catheters are used.
Risks for all catheter devices:
- Infection, especially by Staphylococci, which may be life-threatening. May be difficult to eradicate without removal of catheter. Severe secondary infections (endocarditis, discitis, osteomyelitis) may occur.
- Thrombosis/ stenosis. Thrombosis within the catheter can often be cleared by instillation of urokinase or tissue plasminogen activator (tPA). Thrombosis around the catheter can alternatively be cleared by ‘stripping’ with a snare, often inserted via the femoral vein. Occlusion of vessels is a major problem in some patients.
Catheter care programmes and recurrent cycles of audit are being increasingly used to minimise these risks.
Temporary (non-tunnelled) and femoral vein catheters are most likely to become infected. However the femoral veins are often favoured for emergency access as there is no risk of pneumothorax, insertion can be undertaken in a semi-erect patient, and it preserves central veins.
- Edren handbook on vascular access
- YouTube videos of fistula cannulation etc;
We need a modern one …
40 years ago – just the same! (not for the squeamish)
- Solving vascular access made haemodialysis possible – History of Nephrology blog