- Email: [email protected]
An innovative approach to temporary hemodialysis vascular access
An Innovative Approach to Temporary Hemodialysis Vascular Access Jamie L. Ross, MD, Catherine Staffeld, MD, Jill S. Lindberg, MD, and Mary Lee, RN ● The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) has set down explicit and extensive guidelines for temporary and permanent hemodialysis vascular access. It is now incumbent on the nephrologist to ensure compliance to these standards. Two of our interventional nephrologists performed 402 central venous access procedures over a 12-month period (November 1996 to October 1997) to test the hypothesis that increased control over insertion technique would improve outcome. All but eight of the procedures were successfully completed, resulting in a failure rate of 2%. The expected serious procedural complication rate outlined in the NKF-DOQI standards is 2%. Our complication rate was 0.7% if all procedures were accounted for and 0.89% for just internal jugular and subclavian catheters. We conclude that the use of interventionally trained nephrologists and strict control of technique can improve outcome in temporary vascular access procedures. 娀 1999 by the National Kidney Foundation, Inc. INDEX WORDS: Hemodialysis; temporary vascular access; central venous catheters.
V
ASCULAR ACCESS for hemodialysis is one of the most difficult and frustrating areas for patients, dialysis staff, and nephrologists. In addition to the high cost in terms of patient morbidity and mortality, the fiscal cost to Medicare is $1 billion annually. In response to this, dialysis caregivers have targeted vascular access as one of the four major areas for continuous quality improvement in end-stage renal disease (ESRD) care through the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI).1 It is a comprehensive statement that covers a continuum from pre-ESRD planning for vascular access to managing access problems. The NKF-DOQI recommendations were designed to improve overall outcomes, increase surgical placement of arteriovenous fistulas, and intervene before thrombotic events. The goals of this aggressive initiative are to increase access survival and reduce overall patient morbidity and mortality. In a teaching institution such as Ochsner Clinic (New Orleans, LA), the task of placing central venous catheters frequently belongs to the least experienced house staff. The supervising attending staff also have varying degrees of expertise with this procedure. It is clear that the more
From the Sections on Nephrology and Kidney Transplantation, and the New Orleans Chronic Dialysis, Ochsner Clinic, New Orleans, LA. Received March 23, 1998; accepted in revised form October 9, 1998. Address reprint requests to Jamie L. Ross, MD, Section on Nephrology, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121. E-mail: [email protected]
娀 1999 by the National Kidney Foundation, Inc. 0272-6386/99/3304-0013$3.00/0 718
experienced the operator, the less likely complications will ensue from any procedure, including central catheter placement for dialysis.2,3 Failure rates of catheter placement clearly vary with experience and technique of insertion. A surgically based central venous catheter team has recently reported a failure rate of 4%, whereas even with ultrasound support, the optimal resident failure rate was 10% with ultrasound and approximately 50% without this device.2,3 Complications can also vary significantly with the experience and skill of the person performing the procedure.4,5 Certainly any damage to a single great vessel can result in the loss of a future access site and limits the patient’s options for future dialytic intervention. In addition, strict adherence to the Centers for Disease Control and Prevention and NKF-DOQI standards for sterile technique is recommended to decrease the number of catheterrelated infections. It was these issues that motivated us to increase the nephrologists’ role in the placement of temporary access catheters. By forming a vascular access team, we limited the placement of temporary central catheters to two interventional nephrologists. We maintain strict control with regard to the type of room used and sterile technique applied to this procedure. We used ultrasound guidance in approximately 30% of our cases; those with a complicated access history and/or a coagulopathy. Femoral catheter placement was used preferentially for patients requiring a temporary dialysis catheter for less than 2 to 3 days. For temporary catheters needed for up to 3 weeks, we used the internal jugular (IJ) location. The subclavian (SC) site was used as a last choice for temporary hemodialysis access placement.6,7
American Journal of Kidney Diseases, Vol 33, No 4 (April), 1999: pp 718-721
TEMPORARY HEMODIALYSIS VASCULAR ACCESS
According to the NKF-DOQI, the expected rate of serious complications with catheter placement requiring intervention in dialysis patients should be 2% or less. These include pneumothorax requiring a chest tube, symptomatic air embolism, hemothorax, hemomediastinum, and/or a neck hematoma requiring evacuation.1 Specifically, a pneumothorax is primarily operator dependent, and the incidence can range from 1% to 10% with the SC approach and 0.1% with IJ placement.4,5 It was our expectation that with the use of consistent technique and skilled operators, we could improve overall outcomes for our patients by decreasing the incidence of complications secondary to temporary vascular access placement. MATERIALS AND METHODS Each patient was assessed with a prothrombin time, partial prothrombin time, and platelet count before choosing the site for central venous access. Any patient who had undergone prior central venous cannulations or had laboratory evidence of abnormal coagulation parameters underwent central venous access cannulation with ultrasound guidance using a SiteRite device (Dymax Corp, Pittsburgh, PA).8 The insertion location was chosen by the physician placing the catheter. The patient was prepared with Betadine solution (Purdue Fredrick, Norwalk, CT) in the neck, shoulder, or femoral area. The femoral Betadine scrub was followed by a rinse with Betadine solution. In patients allergic to Betadine, Hibiclens solution (Stuart Pharmaceuticals, Wilmington, DE) was substituted. The patient was draped with sterile towels, and the operator placing the access device was attired in a sterile surgical gown, hat, mask, goggles, and sterile surgical gloves. The catheters were inserted through a modified Seldinger technique. The dialysis and plasmapheresis catheters were Mahurkatur type, manufactured by Quinton Instrument Co (Bothell, WA), and a Vitacuff (Arrow International, Inc, Reading, PA) was placed at the hub of all these catheters to minimize infection.9,10 If the catheter was in a femoral location and was to be removed after one dialysis treatment, then a Vitacuff was not placed. The catheter size depended on the patients’ body habitus and the central venous location chosen. In the femoral location, only an 11.5 Fr and a 16-cm or 19.5-cm length was used. In the IJ or SC location, an 11.5 Fr and a 13.5-cm, 16-cm, or 19.5-cm length was used, depending on the patients’ needs. A minority of these (13 patients) required simultaneous infusion and hemodialysis or plasmapheresis. In those patients, a triple-lumen, 12 Fr hemodialysis catheter with a 16-cm length was used. This particular catheter was manufactured by Arrow International Inc and was impregnated with antiseptic/antibiotic material.11,12 Patients requiring access for medication infusion only received a triple-lumen catheter (Arrow International Inc) impregnated with an antiseptic/antibiotic material.11,12 These catheters were 8 Fr and varied in length from 16 to 20 cm.
719
RESULTS
From November 1996 through October 1997, the Line Service performed 402 central catheter placements. The number of catheters unsuccessfully attempted was eight, a 2.0% failure rate. The total significant complication rate was 0.7% (three patients). If only the successful SC and IJ catheter placements are considered, then our complication rate was 0.89%. One patient developed a pneumothorax that was less than 10% volume and required no intervention. There were two significant hematomas requiring intervention and/or evacuation. Because the type of patient and reason for catheter insertion may alter the complication and failure rates, we reviewed the reasons for catheter placement (Table 1) and documented their inpatient or outpatient status. Of those procedures, there were 306 hemodialysis catheters (76%) and 87 central catheters placed for central venous infusion (22%). Table 1 shows that hemodialysis was the primary reason for catheter insertion. Clotted permanent or temporary vascular access, malfunctioning semipermanent catheters were also a common diagnosis for temporary central catheter placement. Temporary dialysis catheters had to be replaced 13% of the time because of thrombosis of a previously placed temporary central catheter. There were 269 inpatients (67%) and 133 outpatients (33%). The inpatients were in the intensive care unit or general medical or surgical services. The outpatients were mostly chronic hemodialysis patients with vascular access malfunction. Ten of the outpatients were plasmapheresis patients. Thirteen patients (3%) showed eviTable 1. Reasons for Central Catheter Placement Reason
No.
Percent
New ESRD Clotted access Medical infusion Clotted central catheter Infected central catheter Plasmapheresis Malfunctioning semipermanent catheter Malfunctioning peritoneal catheter Transplant rejection Infected semipermanent catheter Infected graft Infected peritoneal catheter
135 60 83 53 20 10 11 8 7 6 5 4
33.6 15.0 20.6 13.2 5.0 2.5 2.7 2.0 1.7 1.5 1.2 1.0
720
ROSS ET AL Table 2. Site of Central Catheter Placement Site
No.
Percent
Internal jugular Femoral Subclavian
288 58 48
73 15 12
dence of severe coagulopathy and required emergency catheter placement. Significantly, neither of the two patients who developed significant neck hematomas had laboratory evidence of a coagulopathy at the time of the procedure. The location of the site chosen to place the catheter may influence the complication rate and/or the success of the catheter placement. The denominator here was 394 because the central catheters not successfully placed cannot be included in this analysis. Table 2 lists the location of the central catheters placed. These numbers reflect the policy of this group to preferentially use the IJ site. DISCUSSION
Ochsner Clinic is a tertiary care facility. The majority of patients in this retrospective review were inpatients with multisystem organ failure. By using two operators and strictly controlling the conditions of catheter insertion, our complication rate was less than the NKF-DOQI expected complication rate of 2% (Fig 1). We also reduced the failure rate to 2%, not just by using ultrasound on difficult cases, but by knowing our patient population well. Figure 2 compares our failure rate favorably with a surgical-based service and resident-placed central venous catheters.4,5 The results of these efforts have improved patient service and satisfaction and reduced hos-
Fig 2. Insertion failure rates. Abbreviations: Neph, nephrologist; Surg, surgeon.
pital cost. Certainly our decreased complication rate supports this fact. At this institution, an estimated cost of approximately $10,000 has been calculated for hospital and professional fees for a 2-day intensive care unit stay in 1997 to monitor and support the patient with a severe hematoma not involving surgical intervention. Our data show a decrease of 1.1% over an expected rate of 2.0%, or four to five cases, and has thereby decreased our institutional costs by approximately $50,000. The main goal of the NKF-DOQI is to improve dialysis outcomes in a way that maintains or improves quality of care for dialysis patients. Improved outcomes frequently reduce the cost of health care delivery as described. Nephrologists must take seriously this call to monitor and ultimately improve outcomes in all aspects of dialytic care. Nephrologists in the era of the NKF-DOQI are being asked to assume responsibility for improvement over areas in which they have had little actual involvement in the past. One of these is vascular access. It is evident from our initial work that the role of interventional nephrology can be to ensure that the goals outlined in the NKF-DOQI vascular access statement are met with regard to temporary catheters. REFERENCES
Fig 1.
Complication rates.
1. NKF-DOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 30:S54-S78, 1997 (suppl 3) 2. Walters G, Kahn A, Jescovitch A Jr, Astor R Jr, Jones CE: Efficacy of a central venous access service. South Med J 90:37-39, 1997 3. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR: Subclavian catheterization greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 23:692-697, 1995
TEMPORARY HEMODIALYSIS VASCULAR ACCESS
4. Fon PY: Acute vascular access. Adv Ren Replace Ther 1:90-98, 1994 5. Fon PY, Schub SJ: Vascular access: Concepts for the 1990s. J Am Soc Nephrol 3:1-11, 1992 6. Cimochowski GC, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H: Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 54:154-161, 1990 7. Schwab S, Quarles D, Middleton JP, Cohan RH, Saeed M, Dennis VW: Hemodialysis-associated subclavian vein stenosis. Kidney Int 33:1156-1159, 1988 8. Troianos CA, Jobes DR, Ellison N: Ultrasound-guided cannulation of the internal jugular vein. Anesth Analg 72:823826, 1991 9. Maki DG, Cobb L, Gartman JK, Shapiro JM, Ringer
721
M, Helgerson RB: An attachable silver-impregnated cuff for prevention of infection with central venous catheters: A prospective randomized multicenter trial. Am J Med 85:307314, 1988 10. Flowers RH, Schwenzer KJ, Kopel RF, Fisch MJ, Tucker SI, Farr BM: Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. JAMA 261:878-883, 1989 11. Kamal GD, Pfaller MA, Rempe LE, Jebson PJ: Reduced intravascular catheter infection by antibiotic bonding. JAMA 265:2364-2368, 1991 12. Maki DG, Stolz SM, Wheeler S, Mermel LA: Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized controlled trial. Ann Intern Med 127:257-265, 1997
V
ASCULAR ACCESS for hemodialysis is one of the most difficult and frustrating areas for patients, dialysis staff, and nephrologists. In addition to the high cost in terms of patient morbidity and mortality, the fiscal cost to Medicare is $1 billion annually. In response to this, dialysis caregivers have targeted vascular access as one of the four major areas for continuous quality improvement in end-stage renal disease (ESRD) care through the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI).1 It is a comprehensive statement that covers a continuum from pre-ESRD planning for vascular access to managing access problems. The NKF-DOQI recommendations were designed to improve overall outcomes, increase surgical placement of arteriovenous fistulas, and intervene before thrombotic events. The goals of this aggressive initiative are to increase access survival and reduce overall patient morbidity and mortality. In a teaching institution such as Ochsner Clinic (New Orleans, LA), the task of placing central venous catheters frequently belongs to the least experienced house staff. The supervising attending staff also have varying degrees of expertise with this procedure. It is clear that the more
From the Sections on Nephrology and Kidney Transplantation, and the New Orleans Chronic Dialysis, Ochsner Clinic, New Orleans, LA. Received March 23, 1998; accepted in revised form October 9, 1998. Address reprint requests to Jamie L. Ross, MD, Section on Nephrology, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121. E-mail: [email protected]
娀 1999 by the National Kidney Foundation, Inc. 0272-6386/99/3304-0013$3.00/0 718
experienced the operator, the less likely complications will ensue from any procedure, including central catheter placement for dialysis.2,3 Failure rates of catheter placement clearly vary with experience and technique of insertion. A surgically based central venous catheter team has recently reported a failure rate of 4%, whereas even with ultrasound support, the optimal resident failure rate was 10% with ultrasound and approximately 50% without this device.2,3 Complications can also vary significantly with the experience and skill of the person performing the procedure.4,5 Certainly any damage to a single great vessel can result in the loss of a future access site and limits the patient’s options for future dialytic intervention. In addition, strict adherence to the Centers for Disease Control and Prevention and NKF-DOQI standards for sterile technique is recommended to decrease the number of catheterrelated infections. It was these issues that motivated us to increase the nephrologists’ role in the placement of temporary access catheters. By forming a vascular access team, we limited the placement of temporary central catheters to two interventional nephrologists. We maintain strict control with regard to the type of room used and sterile technique applied to this procedure. We used ultrasound guidance in approximately 30% of our cases; those with a complicated access history and/or a coagulopathy. Femoral catheter placement was used preferentially for patients requiring a temporary dialysis catheter for less than 2 to 3 days. For temporary catheters needed for up to 3 weeks, we used the internal jugular (IJ) location. The subclavian (SC) site was used as a last choice for temporary hemodialysis access placement.6,7
American Journal of Kidney Diseases, Vol 33, No 4 (April), 1999: pp 718-721
TEMPORARY HEMODIALYSIS VASCULAR ACCESS
According to the NKF-DOQI, the expected rate of serious complications with catheter placement requiring intervention in dialysis patients should be 2% or less. These include pneumothorax requiring a chest tube, symptomatic air embolism, hemothorax, hemomediastinum, and/or a neck hematoma requiring evacuation.1 Specifically, a pneumothorax is primarily operator dependent, and the incidence can range from 1% to 10% with the SC approach and 0.1% with IJ placement.4,5 It was our expectation that with the use of consistent technique and skilled operators, we could improve overall outcomes for our patients by decreasing the incidence of complications secondary to temporary vascular access placement. MATERIALS AND METHODS Each patient was assessed with a prothrombin time, partial prothrombin time, and platelet count before choosing the site for central venous access. Any patient who had undergone prior central venous cannulations or had laboratory evidence of abnormal coagulation parameters underwent central venous access cannulation with ultrasound guidance using a SiteRite device (Dymax Corp, Pittsburgh, PA).8 The insertion location was chosen by the physician placing the catheter. The patient was prepared with Betadine solution (Purdue Fredrick, Norwalk, CT) in the neck, shoulder, or femoral area. The femoral Betadine scrub was followed by a rinse with Betadine solution. In patients allergic to Betadine, Hibiclens solution (Stuart Pharmaceuticals, Wilmington, DE) was substituted. The patient was draped with sterile towels, and the operator placing the access device was attired in a sterile surgical gown, hat, mask, goggles, and sterile surgical gloves. The catheters were inserted through a modified Seldinger technique. The dialysis and plasmapheresis catheters were Mahurkatur type, manufactured by Quinton Instrument Co (Bothell, WA), and a Vitacuff (Arrow International, Inc, Reading, PA) was placed at the hub of all these catheters to minimize infection.9,10 If the catheter was in a femoral location and was to be removed after one dialysis treatment, then a Vitacuff was not placed. The catheter size depended on the patients’ body habitus and the central venous location chosen. In the femoral location, only an 11.5 Fr and a 16-cm or 19.5-cm length was used. In the IJ or SC location, an 11.5 Fr and a 13.5-cm, 16-cm, or 19.5-cm length was used, depending on the patients’ needs. A minority of these (13 patients) required simultaneous infusion and hemodialysis or plasmapheresis. In those patients, a triple-lumen, 12 Fr hemodialysis catheter with a 16-cm length was used. This particular catheter was manufactured by Arrow International Inc and was impregnated with antiseptic/antibiotic material.11,12 Patients requiring access for medication infusion only received a triple-lumen catheter (Arrow International Inc) impregnated with an antiseptic/antibiotic material.11,12 These catheters were 8 Fr and varied in length from 16 to 20 cm.
719
RESULTS
From November 1996 through October 1997, the Line Service performed 402 central catheter placements. The number of catheters unsuccessfully attempted was eight, a 2.0% failure rate. The total significant complication rate was 0.7% (three patients). If only the successful SC and IJ catheter placements are considered, then our complication rate was 0.89%. One patient developed a pneumothorax that was less than 10% volume and required no intervention. There were two significant hematomas requiring intervention and/or evacuation. Because the type of patient and reason for catheter insertion may alter the complication and failure rates, we reviewed the reasons for catheter placement (Table 1) and documented their inpatient or outpatient status. Of those procedures, there were 306 hemodialysis catheters (76%) and 87 central catheters placed for central venous infusion (22%). Table 1 shows that hemodialysis was the primary reason for catheter insertion. Clotted permanent or temporary vascular access, malfunctioning semipermanent catheters were also a common diagnosis for temporary central catheter placement. Temporary dialysis catheters had to be replaced 13% of the time because of thrombosis of a previously placed temporary central catheter. There were 269 inpatients (67%) and 133 outpatients (33%). The inpatients were in the intensive care unit or general medical or surgical services. The outpatients were mostly chronic hemodialysis patients with vascular access malfunction. Ten of the outpatients were plasmapheresis patients. Thirteen patients (3%) showed eviTable 1. Reasons for Central Catheter Placement Reason
No.
Percent
New ESRD Clotted access Medical infusion Clotted central catheter Infected central catheter Plasmapheresis Malfunctioning semipermanent catheter Malfunctioning peritoneal catheter Transplant rejection Infected semipermanent catheter Infected graft Infected peritoneal catheter
135 60 83 53 20 10 11 8 7 6 5 4
33.6 15.0 20.6 13.2 5.0 2.5 2.7 2.0 1.7 1.5 1.2 1.0
720
ROSS ET AL Table 2. Site of Central Catheter Placement Site
No.
Percent
Internal jugular Femoral Subclavian
288 58 48
73 15 12
dence of severe coagulopathy and required emergency catheter placement. Significantly, neither of the two patients who developed significant neck hematomas had laboratory evidence of a coagulopathy at the time of the procedure. The location of the site chosen to place the catheter may influence the complication rate and/or the success of the catheter placement. The denominator here was 394 because the central catheters not successfully placed cannot be included in this analysis. Table 2 lists the location of the central catheters placed. These numbers reflect the policy of this group to preferentially use the IJ site. DISCUSSION
Ochsner Clinic is a tertiary care facility. The majority of patients in this retrospective review were inpatients with multisystem organ failure. By using two operators and strictly controlling the conditions of catheter insertion, our complication rate was less than the NKF-DOQI expected complication rate of 2% (Fig 1). We also reduced the failure rate to 2%, not just by using ultrasound on difficult cases, but by knowing our patient population well. Figure 2 compares our failure rate favorably with a surgical-based service and resident-placed central venous catheters.4,5 The results of these efforts have improved patient service and satisfaction and reduced hos-
Fig 2. Insertion failure rates. Abbreviations: Neph, nephrologist; Surg, surgeon.
pital cost. Certainly our decreased complication rate supports this fact. At this institution, an estimated cost of approximately $10,000 has been calculated for hospital and professional fees for a 2-day intensive care unit stay in 1997 to monitor and support the patient with a severe hematoma not involving surgical intervention. Our data show a decrease of 1.1% over an expected rate of 2.0%, or four to five cases, and has thereby decreased our institutional costs by approximately $50,000. The main goal of the NKF-DOQI is to improve dialysis outcomes in a way that maintains or improves quality of care for dialysis patients. Improved outcomes frequently reduce the cost of health care delivery as described. Nephrologists must take seriously this call to monitor and ultimately improve outcomes in all aspects of dialytic care. Nephrologists in the era of the NKF-DOQI are being asked to assume responsibility for improvement over areas in which they have had little actual involvement in the past. One of these is vascular access. It is evident from our initial work that the role of interventional nephrology can be to ensure that the goals outlined in the NKF-DOQI vascular access statement are met with regard to temporary catheters. REFERENCES
Fig 1.
Complication rates.
1. NKF-DOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 30:S54-S78, 1997 (suppl 3) 2. Walters G, Kahn A, Jescovitch A Jr, Astor R Jr, Jones CE: Efficacy of a central venous access service. South Med J 90:37-39, 1997 3. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR: Subclavian catheterization greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 23:692-697, 1995
TEMPORARY HEMODIALYSIS VASCULAR ACCESS
4. Fon PY: Acute vascular access. Adv Ren Replace Ther 1:90-98, 1994 5. Fon PY, Schub SJ: Vascular access: Concepts for the 1990s. J Am Soc Nephrol 3:1-11, 1992 6. Cimochowski GC, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H: Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 54:154-161, 1990 7. Schwab S, Quarles D, Middleton JP, Cohan RH, Saeed M, Dennis VW: Hemodialysis-associated subclavian vein stenosis. Kidney Int 33:1156-1159, 1988 8. Troianos CA, Jobes DR, Ellison N: Ultrasound-guided cannulation of the internal jugular vein. Anesth Analg 72:823826, 1991 9. Maki DG, Cobb L, Gartman JK, Shapiro JM, Ringer
721
M, Helgerson RB: An attachable silver-impregnated cuff for prevention of infection with central venous catheters: A prospective randomized multicenter trial. Am J Med 85:307314, 1988 10. Flowers RH, Schwenzer KJ, Kopel RF, Fisch MJ, Tucker SI, Farr BM: Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. JAMA 261:878-883, 1989 11. Kamal GD, Pfaller MA, Rempe LE, Jebson PJ: Reduced intravascular catheter infection by antibiotic bonding. JAMA 265:2364-2368, 1991 12. Maki DG, Stolz SM, Wheeler S, Mermel LA: Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized controlled trial. Ann Intern Med 127:257-265, 1997