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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 patients blood pressure. The same pressure permitted the blood to return into the patients 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

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)

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

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)

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

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:
y y

The ESRD patients whose fistula or graft needs time to mature. Patients with peritoneal dialysis requiring temporary hemodialysis, because of peritonitis.

y y y

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 needles 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.

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.

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:
y

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 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

A. Complications of Tunneled-Cuffed Catheters:

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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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