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PERMCATH

(PERMANENT CATHETER)

OR SUBCLAVIAN CATHETER

I. BACKGROUND

History

One day in the early 1940s, Dr. Alwall from Lund entered his living room

and asked his wife whether in her opinion blood could be washed. She

answered that theoritically everything could be washed and this probably

started the adventure of clinical dialysis. Nevertheless, very little credit is given

to Dr. Alwall; however, without his important contribution dialysis would

probably have died in its early stages since experiments of Scribner and Kolff

were not encouraging at the beginning. Dialysis, used as a substitute therapy

for patients suffering from chronic renal failure, was introduced in early 1960s

in Seattle, Wash. when Scribber and his collaborators worked out a technique

for long-term vascular access and designed a complete device for preparing the

dialysis solution. Again, the important contribution of Dr. Alwall should be

acknowledged. Long-term vascular access was obtained by inserting a rigid

Teflon tube into both the radial artery and one of the forearm veins. The

dialysate was prepared in a container and refrigerated to avoid bacterial

contamination. A pump forced the dialysate into the filter in the opposite

direction of the bloodstream. The Kiil Kidney was used as a dialyzer. It was

composed of two sheets of plastic material cut into thin tubes which were

covered with sheets made of Cuprophan. During each dialysis session these

sheets formed two separate bags into which the blood was pumped by the

patient’s blood pressure. The same pressure permitted the blood to return into

the patient’s bloodstream, prior to heating through the venous line immersed in

a receptacle containing heated water.

Fig. 1. First generation of Scribner arteriovenous shunts

(Ronco, C., 2004: 2)

Vascular access is currently one of the biggest problems of chronic

dialysis. In 1972 Kopp et al. proposed a single-needle dialysis with a peristaltic

pump which alternatively aspirated and forced in order to achieve the

traumatism of a double puncture. The technique was proposed not just for

chronic dialysis patients but also for acute patients utilizing a jugular or a

femoral catheter as a vascular access. In 1973 for the same reason Van

Waeleghem et al. proposed a blood pump with a double head which allowed a

better blood flow and less recirculation of the vascular access. In 1980 Uldall et

al. designed a double-lumen catheter to place in the subclavia for short- and

medium-term treatments. With this type of access the patient undergoes just

one puncture of the vessels and the pump with a single head could achieve a

good blood flow with reduced recirculation of the vascular access. Since the

mid 1980s dialysis machines had blood pumps for single-needle treatments and

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systems for detecting blood flows and pressures in the blood circuit. At the

same time double-lumen catheters with different internal configurations were

developed (paralel flux or coaxial flux). In fact, to faciliate insertion, it is

possible to find catheter which are rigid at room temperature and soften once

they are inserted. Also different biomaterials are utilized including processes of

coating to prevent biofilm formation and infection/ thrombosis.

Fig. 2. Single-needle dialysis made it possible to treat patients with

difficult vascular access. For this, double-headed blood pumps

should be utilized. (Ronco C., 2004: 7)

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Fig. 3. Different double-lumen venous catheter. (Ronco C., 2004: 8)

Vascular access continues to be a significant economic, surgical, and logistic

problem for patients and their health care providers. In general, vascular access

success is directly related to the frequency of use of hemodialysis catheters, the

patency of the arteriovenous (AV) access (AVF versus AVG), and the prevalence

of subsequent catheter and access complications (i.e., infection, malfunction, and

thrombosis). The most cost-effective and lasting vascular access for hemodialysis

id the native (AVF) fistula, but an increasing number of patients have exhausted

their autogenous veins are required to have AVG or permanent cuffed dialysis

catheters.

But, in one study only 36,5% of ESRD (End-Stage Renal Disease) patients

were instructed to protect their forearm veins for subsequent AVFs and subclavian

catheters continue to be used for initial access (leading to continued problems

with outflow stenosis and thrombosis). Because approximately 40% of ESRD

patients have had less than 3 months of nephrology care, only 45% of patients

starting dialysis and 60% of patients after 30 days of dialysis had a permanent

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access (i.e., AVF or AVG) and subclavian catheters were used in 80% patients.

(Nissenson R. Allen and richard N. Fine, 2008: 49-40)

Vascular Access around the world

The Dialysis Outcomes and Practice Patterns Study (DOPPS) is undoubtedly a

rich international resource of epidemiological data pertaining to practice patterns

related to VA (Vascular Access) outcomes worldwide. A brief overview of the

study design of this major international effort is therefore pertinent. DOPPS phase

I was initiated as an international, prospective observational study of HD practice

patterns in 7 countries (France, Germany, Italy, Japan, Spain, the United

Kingdom, and the Unted States). Phase II began in the spring of 2002, and the

study has now been expanded to include 5 additional countries (Australia,

Belgium, Canada, New Zealand, and Sweeden). Briefly, nationally representative

samples of randomly selected HD facilities were recruited in each country.

Facility selection was stratified to provide proportional sampling by geographic

region and type of dialysis facility within each country. The DOPPS used uniform

data collection instruments translated into the native language of each country to

allow for direct comparison of HD practices across countries and dialysis

facilities.

Among incident HD patients, 65-67% of new ESRD patients in Japan and

Europe initiated HD with an AVF compared with 15% in the US. In contrast, 24%

new HD patients in the US compared wth only 3% in Europe and Japan used

synthetic grafts.

Catheter use is very common among new ESRD patients, with 60% of US

patients and 31% of HD patients in Europe starting dialysis with a catheter.

(Ronco C., 2004: 16)

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II.DEFINITION

Hemodialysis, is the most often used treatment for end-stage renal disease

(ESRD), more commonly known as kidney failure. During a hemodialysis

treatment, a machine pumps blood from the body by way of a flexible plastic

tube, cleans it and then returns it to the body through a separate tube. In order

to perform hemodialysis, an acces must be created. An acces is a site from

which blood can be safely removed and returned to the body. The acces site is

often referred to as the ‘lifeline’.

If the kidney disease has progressed quickly, and there is not enough time

to get a permanent vascular access before starting hemodialysis treatments. A

venous catheter can be used as a temporary access. Which is the insertion of a

tube into a vein in the chest/ subclavian vein (Subclavian Catheter), neck

(Jugular) or leg near the groin (femoral). (US Department of Health and

Human Services, National Institutes of Health, 2008: 2)

Subclavian Catheter is one of central venous catheter for hemodialysis

which has largebore double-lumen catheters that are inserted percutaneously

into subclavian vein. (Black, Joyce M., 2009: 36)

Subclavian catheter is kind of double lumen catheters, these are made of

plastic polymers and are used for temporary dialysis. They are inserted under

strict aseptic techniques percutaneously using a guide wire into a large vein in

subclavian. (Al khader, 2005)

Permanent catheter (subclavian catheter) is one of temporary access

options, which is placed the catheters into the subclavian vein under the

collarbone on the chest. Catheters which are used should be flexible, hollow

tubes which allow blood to flow in and out of the body. They are most

commonly used as a temporary access for up to three weeks. (www.aakp.org

accessed february 17th, 2011 at 11.09 pm)

Although brand names such as Quinton Catheter, VasCath, and PermCath

are commonly used as slang to describe hemodialysis catheters, in actuality

there is a wide assortment of available catheters. Temporary (nontunneled,

uncuffed) catheters are primarily composed of polyurethane, which is stiff at

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room temperature but softens at body temperature to minimize vessel trauma.

Tunneled cuffed catheters (long-term catheters) are primarily composed of

silicone and silicone elastomers that are flexible and require a stylet and/ or

sheat for insertion. (Nissenson R. Allen and richard N. Fine, 2008: 49-40)

III.INDICATION

Actually catheters are not ideal for permanent access. They can clog,

become infected, and cause narrowing of the veins in which they are placed.

But if it needs to start hemodialysis immediately, a catheter will work for

several weeks or months while the permanent access develops.

Therefore, temporary-access catheters are often used when dialysis must

be performed in less than 3 to 4 weeks and there is inadequate time for the

chronic access fistula or graft to mature.

Occasionally, for medical or social reasons, these temporary access

catheters become “permanent temporary access (long-term catheter access).”

This may occur when a patient with a temporary hemodialysis catheter

becomes acutely or chronically ill and is unable to undergo a permanent

access procedure, or when a chronic access procedure cannot be performed or

unsuccesful due to anatomic limitations. Catheters that will be needed for

more than about 3 weeks are designed to be tunneled under the skin to

increase comfort and reduce complications. Even tunneled catheters, however,

are prone to infection.

These can be used in patients requiring urgent hemodialysis. For example:

The ESRD patients whose fistula or graft needs time to mature.

Patients with peritoneal dialysis requiring temporary hemodialysis,

because of peritonitis.

Acute renal failure patients.

Patients undergoing plasmapheresis.

Patients receiving venovenous Continous Renal Replacement Therapy.

(C.F Gutch, 1999:108)

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IV. INSERTION OF SUBCLAVIAN CATHETER

A. Untunneled/ uncuffed Catheter

1. The patient lies supine with their head down and turned away from

the operator.

2. The infraclavicular approach is most commonly used, but in

difficult patients an experienced operator can use the supraclavicular

approach.

3. The skin is cleaned and prepared with antiseptic solution (such as

iodine) and a local anesthetic is applied to the area.

4. A thin (22-gauge) needle on a syringe filled with heparinized

saline is inserted into the cleaned and anesthetized area under the clavicle

(where its medial third joins the lateral two thirds at the lateral aspect of

the deltopectoral groove). The needle first touches the inferior margin of

the clavicle and is then advanced deeper into the subclavian vein. (The

use of a thin-gauge needle prevents the formation of a large hole if the

needle enters the artery)

5. Gentle suction should be applied to the syringe while advancing

the needle.

6. As soon as venous blood can be easily withdrawn, the needle’s

position and direction are noted and it is withdrawn. A large bore (18-

gauge) needle is then advanced to the vein, the syringe removed, and a

guide wire inserted through the needle into the vein.

7. If the 22-gauge needle fails to reach the vein, a longer and a larger

bore needle can be used.

8. The guide wire should pass easily to the superior vena cava about

10-15 cm in an average sized adult. If it is difficult to advance the guide

wire, it should not be forced but must be withdrawn.

9. Once the guide wire is in place, the needle is withdrawn and the

wire is held in place to prevent its withdrawal.

10. The entry site is then enlarged with a size 11 blade.

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11. For a larger, dual-lumen catheter, a dilator is then advanced over the

guide wire into the vein through skin, subcutaneous tissue, and venous

wall.

12. The dilator is withdrawn, and if a semi-rigid catheter is used, the

catheter is then threaded gently over the guide wire into the vein and

positioned at the appropriate level.

13. Use of a softer catheter (which is preferable) requires insertion of a

peel-away sheath over the introducer.

14. The introducer (with sheath) is threaded over the guide wire and then

withdrawn, leaving the sheath in the vein.

15. The catheter can then be introduced through the sheath, positioned at

the appropriate level, the blood flow checked, and the sheath peeled off

slowly and withdrawn.

16. Every precaution should be taken to ensure that the catheter does not

move out while the sheath is peeled off.

17. The catheter can be fixed to the skin close to the exit point with a suture

and filled with heparinized saline to prevent clotting.

18. It is important that the instruction sheet accompanying the catheter is

read carefully prior to starting the procedure.

19. After the subclavian insertion, a chest X-ray must be taken to ensure the

location is correct and that no trauma has occured. Dialysis should not

be initiated before this X-ray has been reviewed. The technique differs

for different catheters and is discussed extensively in the brochures

accompanying the catheters.

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B. Tunneled/ Cuffed Catheter

Fig. 4. Dual-lumen catheter (Cuffed)

(Suhail Ahmad, 2009: 46)

V. PREPARATION OF THE PATIENT

A. Initiating

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VI. CONTRAINDICATION

Subclavian catheters should not be used on the following patients:

Patients with acute respiratory distress who cannot be positioned either

supine or in the Trendelenburg position.

Patients with known subcalavian vein stenosis.

(C.F. Gutch, 1999)

VII. COMPLICATION

A. Complications of Tunneled-Cuffed Catheters:

1. Limited ability to provide sufficient blood flow

2. Complications of initial placement

a. Pneumothorax

b. Bleeding

c. Hematoma formation

d. Arterial puncture

e. Hemothorax

f. Air embolism

g. Hemomediastinum

h. Recurrent laryngeal nerve palsy

3. Thrombosis

4. Infectious complications

a. Bacteremia, sepsis

b. Tunnel infection

c. Exit side infection

5. Central vein stenosis

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B. Noncuffed Catheters

Noncuffed, double-lumen catheters are frequently used by nephrologist

as a temporary vascular access. These catheters are suitable for bedside

insertion and provide marginally acceptable blood flow rates (250 mL/ min)

for short-term dialysis. When compared to TCCs, these catheters have a

higher incidence of infection, higher incidence of loss of function, higher

incidence of dislodgement. It is recommended that their use be limited no

more than 3 weeks. When everything is taken into account, the only

advantage that the noncuffed temporary catheter posseses is that it can be

inserted at the bedside.

VIII. CONCLUSION AND SUGGESTIONS

IX. REFFERENCES

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