Maintaining the Patency of Double-Lumen Silastic Jugular Catheters for Haemodialysis

A system has been developed for maintaining the patency of double lumen silastic jugular catheters in patients with refractory vascular access problems. Most patients receive a small daily dose of aspirin. Selected patients also receive warfarin to maintain a prothrombin time (PT) of 15, 20, or 30 seconds. Inadequate blood flow due to thrombus obstruction can be overcome by the intravenous administration of urokinase, 250.000 units. This can be administered safely to outpatients provided that heparin is not given simultaneously. Occasionally a second dose may be required. By adopting this policy all catheter obstructions have been overcome. The danger of iatrogenic bleeding cannot be discounted. Warfarin therapy must be very closely monitored.

Salvage Insertion of Tunneled Central Venous Catheters in the Internal Jugular Vein after Accidental Catheter Removal

Purpose

Tunneled catheters are widely used for intermediate to long-term hemodialysis (HD) access, but are prone to several complications that can require catheter replacement. Replacing malfunctioning catheters with a new line, placed in a different access site, can lead to problems with multiple vein occlusions. This has led many nephrologists to continue using the same vein as long as possible by guidewire catheter exchanges, to preserve other veins for future use. We describe a guidewire exchange technique for the Ash-Split catheter in the internal jugular vein.

Methods

In three patients, the exchange was performed because of partial catheter removal, as evidenced by the outward dislocation of the Dacron cuff. In these patients, the guidewire was inserted through the catheter. In two additional patients, the catheter had been completely removed by accident: the replacement of the dislodged tunneled venous catheters was attempted 5 hr and 1 day after accidental removal. In these patients, the guidewire was inserted through the previous tunnel. After guidewire placement, a skin incision was made in the supraclavicular region. The metal guidewire was easily located inside the fibrous structure that had previously surrounded the catheter. The guidewire was then extracted from the subcutaneous tunnel and used to insert a new catheter safely and easily after creating a new tunnel. Patients were routinely given antibiotic prophylaxis (1 g of cefazolin) immediately before the procedure. A strict aseptic technique was used, including several sterile glove changes.

Results

No infections developed following this procedure, which has the potential for bacterial contamination. All procedures were successful. Only in one patient did we have to convert to a different catheter: it was not possible to replace the old Ash-Split catheter with the same dual-lumen catheter because of difficulties in inserting the peel away introducer-catheter complex. In this patient, rather than forcing it with larger dilators or trying to disrupt the fibrin sheath with balloon dilatation, a single lumen Tesio catheter was successfully placed. In both patients who completely lost the previous catheter, the guidewire was readily reinserted through the subcutaneous tunnel into the vein. Catheter function was excellent in all patients, with a test blood flow rate on the 1st catheter use >350 ml/min.

Conclusions

We described a new method for catheter exchange, which allows the easy insertion of a new catheter and the creation of a new and safer subcutaneous tunnel. In addition, we demonstrated that in cases of complete catheter removal, it is possible to reinsert a catheter in the same vein through a guidewire, even when reinsertion was attempted up to 1 day later.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Sepsis syndrome, bloodstream infections, and device-related infections

The diagnosis of sepsis is challenging given the lack of appropriate diagnostic methods and the inaccuracy of diagnostic criteria. Early resuscitation, intravenous antibiotics, and source control are crucial in the management of septic patients. The treatment of catheter-related bloodstream infection (CRBSI) often comprises 1 to 2 weeks of intravenous antibiotics plus catheter removal. Infections related to surgical devices are more difficult to manage because they require longer duration of therapy and possibly multiple surgical procedures. This review represents an update on the diagnosis and management of sepsis, catheter-related blood stream infections and some clinically important device-related infections.

Insertion of tunneled hemodialysis catheters without fluoroscopy

BACKGROUND

The tunneled cuffed catheter (TCC) is used as a bridge access for hemodialysis. Few prospective studies have been designed to evaluate conversion from non-tunneled to TCC without the use of fluoroscopy when performed by nephrologists.

METHODS

We performed an observational prospective cohort in incident patients receiving hemodialysis through a non-tunneled right jugular vein catheter.

RESULTS

130 procedures were performed in 122 patients (51+/-18 years). The success rate was 100%. There was a total of 26,546 catheter days. Ninety-one of the 130 catheters were removed during the study period. Life table analysis revealed primary patency rates of 92%, 82%, and 68% at 30, 60, and 120 days, respectively. Infection requiring catheter removal occurred at a frequency of 0.09 per 100 catheter days. Catheter malfunction requiring intervention occurred at a rate of 0.03 per 100 catheter days. Hypertension and duration of existing non-tunneled catheter of less than 2 weeks were independently associated with better TCC survival.

CONCLUSION

The conversion from non-tunneled to TCC performed by nephrologists and without fluoroscopy may be safe by using the internal right jugular vein. The ideal time to do this procedure is within less than 2 weeks of existing non-tunneled catheter.

Novel approach using antimicrobial catheters to improve the management of central line-associated bloodstream infections in cancer patients

BACKGROUND

Central venous catheter (CVC) removal has often been recommended for the treatment of central line-associated bloodstream infections (CLABSIs). However, CVC removal is not always practical in patients with cancer, and changing CVCs with noncoated CVCs over guidewire may result in cross-infection of the new CVC. Therefore, the current matched retrospective cohort study was conducted to evaluate the effectiveness of exchanging infected CVCs for minocycline- and rifampin (MR)-coated CVCs in cancer patients with CLABSIs.

METHODS

The authors identified all cancer patients with CLABSIs who had undergone either CVC exchange with MR-coated CVCs or CVC removal at the study institution. All patients were treated with appropriate systemic antibiotics. The exchange group was matched in a 1:2 ratio with the removal group by organism, underlying disease, and neutropenia. The demographics, clinical characteristics, and outcome were compared. Overall response was defined as the resolution of clinical signs and symptoms and eradication of bacteremia within 72 hours after CVC exchange or removal, without disease recurrence or infection-related death.

RESULTS

A total of 120 cancer patients were included (40 in the exchange group and 80 in the removal group). Overall response rates were 95% in the exchange group and 76% in the removal group (P = .011). No disease recurrences or infection-related deaths occurred in the exchange group; 8 disease recurrences or deaths (11%) occurred in the removal group (P = .05). Patients in the exchange group also experienced lower rates of mechanical failure (3% vs 15%; P = .049).

CONCLUSIONS

Exchanging CVCs for MR-coated CVCs in cancer patients with CLABSIs may improve the overall response rate and decrease the risk of mechanical failure, disease recurrence, and infection-related mortality.

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Avoiding trouble down the line: the management and prevention of hemodialysis catheter-related infections

Over the last 2 decades, hemodialysis catheter use has increased. Annually, approximately 30% of patients using a central venous catheter (CVC) experience a septic or bacteremic episode and are subsequently at risk of its associated long-term complications and mortality. Because of the serious clinical and financial impact of hemodialysis catheter-related bacteremias (HCRIs), standardized, validated definitions based on the hemodialysis patient population are necessary in order to better diagnose, monitor, and report HCRI for patient quality assurance and research purposes. The pathophysiology of HCRI involves a complex interaction between a triad that consists of the host patient, the infecting microorganism, and the vehicle catheter. Although the microorganism contribution in the pathogenesis of HCRI is likely most important, certain patient and catheter-related characteristics may be more amenable to manipulation. The key to managing HCRI is on prophylaxis against the initial microorganism catheter adherence and subsequent biofilm development. General and specific prophylactic maneuvers directed at both an intravascular and extraluminal route of microorganism entry are discussed including antibiotic- and silver-impregnated catheters and dressings, subcutaneous access devices, and topical prophylaxis at the exit site. In addition to systemic antibiotic use, the 3 methods of HRCI treatment using catheter salvage, guidewire exchange, and concurrent antibiotic lock are compared. The outcome and complications of HCRI may be serious and highlight the importance of careful, continual infection surveillance. Although the use of a multidisciplinary hemodialysis infection control team is desirable, staffing education and physician feedback have been shown to improve adherence to infection control guidelines and reduce HCRI.

Vascular access

Vascular access is the cornerstone of medical therapy in the pediatric population and presents unique challenges. The vessels are small, often exceedingly so, and gaining access may require considerable patience and skill. Peripheral IVs are difficult to place in children, both because of lack of patient cooperation and because of the very small size of many veins. In addition, repeated venipuncture has been identified as one of the greatest stresses in hospitalized children. In the recent past, all forms of central venous access were the preserve of surgeons and were placed in the operating room under general anesthesia. In recent years, pediatric interventional radiologists have described placing peripherally inserted central catheters (PICCs), subcutaneous venous access ports, hemodialysis catheters, and a variety of temporary and permanent central lines even in the smallest children. This has been achieved safely, reliably, and, by dispensing with general anesthesia and operating room time in most cases, at considerable cost savings to the entire health care system. In addition, new forms of reliable, stable access such as the PICC line have made possible outpatient treatment of a wide variety of conditions, particularly infectious, which previously necessitated hospital admission. This has resulted not only in considerable cost saving for the health care system but also improved quality of life for the patient and their family. In this section, I review the current state of pediatric vascular access with emphasis on those areas where pediatric differs from adult practice.

Diagnosis and Management of Long-term Central Venous Catheter Infections

The pathogenesis, diagnosis, and management of central venous catheter infections differ between short-term and long-term catheters. This review summarizes available data regarding the diagnosis and management of catheter-related bloodstream infections (CRBSIs) associated with long-term catheters. A review of various diagnostic modalities is provided, including methods of CRBSI diagnosis for catheters that are retained. Management of CRBSIs for long-term catheters is also addressed, with an emphasis on differentiating infections that require catheter removal from those that may allow catheter salvage. Data regarding catheter salvage with use of antibiotic lock therapy are also reviewed.

Outcomes and performance of the Tesio twin catheter system placed for hemodialysis access

PURPOSE

To assess the effectiveness of and outcomes with a twin catheter system.

MATERIALS AND METHODS

The authors retrospectively reviewed the medical records, hemodialysis records, and clinical information system data from 132 consecutive patients who were referred for placement of a tunneled catheter for hemodialysis access. A commercially available twin catheter system was placed in all patients. Outcomes evaluated included infection rate, complication rate, and catheter malfunction and failure rates. Performance parameters evaluated included blood flow rates, urea reduction percentages, and recirculation percentages.

RESULTS

One hundred eighty-four twin catheter systems were placed in 132 patients from January 11, 1996, to October 23, 1997. The initial technical success rate was 100%. There were four immediate procedural complications: Air emboli occurred in two patients, and prolonged bleeding necessitating intervention occurred in two. The total number of days a catheter was in place was 13,200 (mean, 74.6 days). Thirty-one infections occurred in 20 patients (total infection rate, 0.23 episodes per 100 catheter days). Sixty-five catheters malfunctioned during the study period, 19 of which necessitated removal, for a rate of 0.14 episodes per 100 catheter days. The average blood flow rate was 281.4 mL/min (range, 117.1-405.6 mL/min; median, 295.2 mL/min). Mean and median urea reductions were both 61%. Mean and median recirculation was 6.1% and 3.5%, respectively (range, 0%-31%).

CONCLUSION

Percutaneous placement of the tunneled twin catheter system can be performed with excellent technical success and safety and acceptable catheter performance and outcomes for effective intermediate- to long-term hemodialysis.

Central venous dialysis catheters: catheter-associated infection

Tunneled dialysis catheters (TDC) are extensively used for long-term venous hemodialysis access and their use is frequently associated with infectious complications. Catheter-related bacteremia (CRB) is the most common and important infection associated with TDC use and may be caused by a wide variety of Gram-positive or Gram-negative organisms. Prevention of CRB can be difficult despite use of rigorous infection-control techniques for catheter insertion and access. A number of antibacterial catheter-packing solutions hold promise for reduction of CRB. Treatment of CRB with antibiotics alone yields poor results and may increase the risk for other infectious complications, especially endocarditis. In selected cases where initial infection control can be achieved with antibiotics, guidewire exchange of the TDC results in cure rates equivalent to those of TDC removal and subsequent replacement. Dialysis programs should monitor TDC infections with attention to incidence, bacteriology, and outcomes.

Guidelines for the management of intravascular catheter-related infections

These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications.

Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci,Staphylococcus aureus, aerobic gram-negative bacilli, andCandida albicansmost commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical iv antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patient's acute illness, underlying disease, and the potential pathogen (s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed.

Antibiotic-heparin lock: in vitro antibiotic stability combined with heparin in a central venous catheter

Long-term hemodialysis frequently requires vascular access through central venous catheters (CVCs). Infection related to these catheters is a significant complication. The use of an antibiotic-heparin lock could decrease the risks associated with infected permanent catheters. As an initial step in developing an antibiotic-heparin lock, we investigated the in vitro stability of antibiotic-heparin combinations in CVCs. Initially, cefazolin, vancomycin, ceftazidime, ciprofloxacin 10 mg/ml each, and gentamicin 5 mg/ml were incubated separately in glass test tubes in the dark at 37 degrees C for 72 hours. Samples were analyzed spectrophotometrically for stability at 24-hour intervals. The procedure was repeated with the addition of heparin (final concentration 5000 U/ml in glass test tubes), and the combination was also examined in CVCs. High-performance liquid chromatography analysis was conducted on the antibiotic-heparin combinations at 72 hours to confirm the spectrophotometric results. Ciprofloxacin produced an immediate precipitate with the addition of heparin and was not analyzed further. Absorbance values decreased for all antibiotics, with the greatest decreases at 72 hours for cefazolin (27.4%), vancomycin (29.7%), ceftazidime (40.2%), and gentamicin (8%) when combined with heparin. These decreases were postulated to be secondary to adsorption of the antibiotics to the luminal surface of the catheters because submitting the catheters to ultrasound with 1% sodium bicarbonate and analyzing the resulting solution for absorbance revealed that some of the drug was recovered. Although free antibiotic in CVC solution was reduced, the concentration should be sufficient (approximately 5 mg/ml) to decrease the frequency of infections associated with CVCs. We conclude that the concentrations of vancomycin, ceftazidime, cefazolin, or gentamicin used in our study should be sufficient for an antibiotic-heparin lock.

The hemodialysis catheter conundrum: hate living with them, but can't live without them

BACKGROUND

Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice.

METHODS

We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters.

RESULTS

This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions.

CONCLUSION

Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.

Management of bacteremia associated with tunneled-cuffed hemodialysis catheters

The dominant problem associated with the use of tunneled-cuffed catheters is infection. When this occurs, two issues must be addressed: treatment of the infection and management of the catheter. The purpose of this 2-yr study was to report the results of a prospective observational series in which catheter management was based on the clinical picture presented by the patient. Data were collected on patients with catheter-related bacteremia (CRB) dealt with in one of three ways: (1) minimal symptoms with a normal-appearing tunnel and exit site (exchange over guidewire within 48 h of antibiotic initiation [Xchng group], 49 cases); (2) minimal symptoms but with tunnel or exit site infection (exchange over a guidewire with creation of a new tunnel [Nutunl group], 28 cases); and (3) severe clinical symptoms (catheter removal with delayed replacement after defervescence [Delay group], 37 cases). All cases were treated immediately with empiric antibiotics followed by 3 wk of antibiotic therapy based on culture sensitivities. A cure was defined as a 45-d symptom-free interval after antibiotic therapy was complete. A cure rate total of 87.8% for the Xchng group, 75% for the Nutunl group, and 86.5% for the Delay group was seen for the 114 episodes of CRB. It is concluded that in selected patients, catheter exchange over a guidewire within 48 h of antibiotic initiation followed by 3 wk of specific antibiotic therapy is a viable treatment option. Additionally, replacing the catheter in patients presenting with severe symptoms of sepsis as soon as they have defervesced is a reasonable approach to therapy.

Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange

Cuffed venous access catheters have become commonplace for hemodialysis access. The major complications of these catheters are catheter thrombosis, catheter fibrin sheathing and infection. When catheter associated bacteremia occurs treatment with antimicrobial therapy alone has been unsuccessful in providing acceptable cure rates. Failed antimicrobial therapy exposes the patient to the risks of prolonged bacteremia, while the alternative, catheter replacement at a new site can lead to central venous stenosis and compromise future long-term upper extremity access. Catheter guidewire exchange when the tunnel tract is clinically not infected theoretically allows the preservation of future access sites and yields a higher treatment success rate while avoiding temporary non-cuffed access placement. We report a series of 23 cases of hemodialysis patients with tunneled cuffed catheters and bacteremia related to the catheter who were treated with the exchange of a new catheter over a guidewire combined with three weeks of systemic antibiotics. Patients eligible for the study required no evidence of tunnel tract infection and defervescence within 48 hours of antimicrobial therapy. Technique failure was defined as repeat infection from any organism within 90 days of catheter exchange. Four patients (18%) redeveloped bacteremia within 90 days of the exchange. The bacteremias developed at 4, 19, 63 and at 74 days days after the exchange. Guidewire exchange in combination with intravenous antibiotics in cases of catheter related bacteremia has an acceptable rate of treatment success and is a viable treatment option in a carefully selected patient population.

Replacement of failing tunneled hemodialysis catheters through pre-existing subcutaneous tunnels: a comparison of catheter function and infection rates for de novo placements and over-the-wire exchanges

PURPOSE

Tunneled hemodialysis catheter dysfunction often occurs from fibrin sheath formation. As a way to preserve existing catheter venous access sites, the authors evaluated over-the-wire exchange of catheters through pre-existing subcutaneous tunnels as an alternative to catheter removal and de novo catheter replacement.

PATIENTS AND METHODS

One hundred nineteen catheters were placed in 68 patients. Seventy-seven catheters were placed de novo and 42 catheters were placed through the pre-existing subcutaneous tunnels of failing catheters. Technical success, short-term complications, infection rates, and functional catheter longevity were evaluated.

RESULTS

Technical success for catheter exchange was 93%. Infection rates were comparable to those of de novo catheter placement: 0.15 and 0.11 infections per 100 catheter days for de novo and exchanged catheters, respectively. Catheter duration of function was not significantly different for de novo versus exchanged catheters: 63% and 51% at 3 months, 51% and 37% at 6 months, and 35% and 30% at 12 months, respectively.

CONCLUSIONS

Over-the-wire exchange of tunneled hemodialysis catheters is safe and easily performed. It causes no increase in infectious complications and provides similar catheter longevity to de novo catheter placement. The procedure is an important option for prolonging tunneled hemodialysis catheter access sites.

Image-guided insertion of the Uldall tunneled hemodialysis catheter: technical success and clinical follow-up

PURPOSE

To evaluate the technical success, complication rates, and survival time of the Uldall double-lumen catheter placed by interventional radiologists in patients presenting to a hemodialysis clinic.

MATERIALS AND METHODS

Patients eligible for this study included those with end-stage renal disease (ESRD) who had failed peripheral vascular access or who were awaiting access at a hemodialysis unit between June 1993 and March 1996. All catheters were placed under fluoroscopic and ultrasound guidance in the angiography suite.

RESULTS

Attempts were made to insert 130 catheters into jugular veins in a consecutive series of 61 patients with ESRD. The accumulated catheter experience in this cohort was 15,380 days and the median survival time was 141 days (95% confidence interval [CI]; 116 days-166 days). One hundred twenty-one catheters (93%) were successfully inserted, mainly (94%) into the internal jugular vein. Excellent dialysis blood flow rate was obtained-on average 365 mL/min (95% CI; 350-379 mL/min). The overall infection rate, including exit site (n = 13), sepsis (n = 19), and clavicular osteomyelitis (n = 1), was 2.1 episodes per 1,000 catheter days.

CONCLUSIONS

This catheter is recommended for acute and longer term hemodialysis for patients without peripheral vascular access. It can be inserted percutaneously, the same internal jugular vein can be used repeatedly with few complications and good blood flow, and the technique can be easily learned by any experienced angiographer.

Central venous catheters for maintenance hemodialysis: a cautionary approach

There is an increasing trend toward the use of indwelling central venous catheters (CVC) for maintenance hemodialysis. Although such devices are necessary in some problematic cases, the general use of CVC is worrisome. Not only may CVC prejudice the ultimate success of future permanent vascular access, but CVC also may be associated with reduced dialysis delivery and with several important complications. This review summarizes recent developments in catheter design, placement techniques, maintenance of the indwelling catheter, and complications of CVC use. Based on cumulated experience, a judicious position is taken that recognizes the place of CVC among the various access options but that favors permanent vascular access whenever feasible.

Clinical considerations in hemodialysis access infection

Hemoaccess infections remain a substantial cause of morbidity in patients on hemodialysis, especially with the increasing reliance on prosthetic devices as the average age of the hemodialysis population increases. Access manipulation, either through needle puncture or secondary surgical procedures, is the primary etiology of infection. Other conditions such as access location, patient hygiene, and intravenous drug use can cause contamination. Local evidence of inflammation or infection, especially pain and purulence, are the most reliable signs of infection; however, the access can be infected and there may be minimal systemic symptoms. Medical therapy must be directed primarily against Staphylococcus aureus, with vancomycin being used most frequently. There are distinct conditions in which infection with gram-negative bacilli is also common. A coordinated effort between medical management and surgical intervention is essential to optimize therapy. Several situations, such as loss of vascular integrity or infection at anastomosis sites, mandate full excision of the graft. However, the access or at least the access site, can be preserved through creative surgical intervention along with aggressive medical treatment. Approaches to the diagnosis and treatment of infection in autologous arteriovenous fistulae, polytetrafluoroethylene arteriovenous conduits, and cuffed dual-lumen venous hemodialysis catheters are discussed.

Bacteremia in a pediatric hemodialysis unit secondary to Enterococcus fecalis

Bacteremia is often a serious and recurring problem in children with hemodialysis catheters. We report an outbreak of Enterococcus bacteremia in a pediatric hemodialysis unit occurring from June 1992 to June 1993. During this period, 18 episodes of bacteremia occurred in eight children; 11 infections were polymicrobial. Enterococcus fecalis was associated with 13 infections in five patients (8 polymicrobial). Other pathogens included Enterobacter cloacae (5 infections), Staphylococcus (3), Staphylococcus epidermidis (2), and Klebsiella pneumoniae (2). All Enterococcus infections occurred in patients with dual-lumen subclavian venous catheters. Skin and catheter sites were culture negative, except in one patient. Rectal swabs were positive for Enterococcus in five patients. Enterococcus was not isolated from any source within the unit. Serotypes of all Enterococcus isolates were different, except for 2 isolates in the same patient. Starting in June 1993, catheters were flushed after dialysis with vancomycin or ampicillin. Since initiating this procedure, further episodes of Enterococcus bacteremia have not occurred. A questionnaire sent to other pediatric hemodialysis units failed to identify Enterococcus among 26 cases of bacteremia.

IN CONCLUSION

(1) Enterococcus is an unusual pathogen for hemodialysis-related bacteremia in children; (2) patients with dialysis catheters were predisposed to this infection; (3) a common source for Enterococcus could not be identified by either culture or by serotyping; (4) flushing catheters with antibiotics after dialysis was effective prevention.

Percutaneous translumbar inferior vena cava cannulation for hemodialysis

The purpose of this study was to evaluate the percutaneous translumbar approach for long-term hemodialysis catheter access. Seventeen double-lumen hemodialysis catheters were placed percutaneously from the right flank to the inferior vena cava in 12 patients. Catheter placement was successful in all patients. Adequate flow rates were obtained. Seven episodes of thrombosis-related access failure occurred (0.33 episodes/100 days at risk). Two catheters were removed and five catheters were managed with urokinase infusion. Six episodes of infection occurred (0.28 episodes/100 days at risk). Four required catheter removal. Two catheters were removed after defects developed in the catheter. Five catheters were removed electively because catheter hemodialysis was discontinued. Four catheters remained in place. Cumulative patency was 52% at 6 months and 17% at 12 months. Translumbar inferior vena cava hemodialysis catheters represent a valuable alternative in cases in which traditional catheter sites have failed.

Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: management by guidewire exchange

Standard therapy of catheter-related sepsis of long-term, tunnelled, silicone dialysis catheters is catheter removal, parenteral antibiotics, and catheter replacement in a new venous site after documented clearing of bacteremia. This leads to loss of future venous access sites. Thirteen consecutive cases of dialysis catheter-related sepsis in 10 patients successfully managed by guidewire exchange with preservation of the same central venous access site are reported. Although the most common cause of catheter sepsis in this series was coagulase-negative staphylococcus, guidewire exchange also was successful in cases due to gram-negative rods and yeast. To preserve future venous access sites in the chronic hemodialysis population, long-term, tunnelled dialysis catheter-related sepsis should be managed by a short course of parenteral antibiotics and by changing the catheter over a guidewire using the same venous insertion site.

Acute vascular access: new advances

Dual lumen central venous hemodialysis catheters have become the preferred form of acute of acute vascular access. Although they provide rapid angioaccess, these catheters are associated with a number of serious insertion complications. Furthermore, prolonged use can lead to late complications including infection and central venous stenosis. Recent advances in catheter construction as well as new techniques for line placement should reduce the incidence and severity of catheter-related problems.

A new vascular access catheter for hemodialysis

A new vascular access catheter has been developed (Cook Critical Care, Bloomington, IN) that is suitable for both short-term and long-term hemodialysis. Designed primarily for the internal jugular vein, it emerges through a subcutaneous tunnel on the anterior chest wall. With parallel cylindrical lumens to provide blood flows of 400 mL/min, it is compressible during insertion and can be placed percutaneously in the vein through a 13-French peel-away sheath. This allows repeated insertions at different times in the same patient. In 80 catheter insertions, we have found one case of jugular vein thrombosis attributable to the catheter and no subclavian vein thrombosis. After 15 months of use, the bloodstream infection rate was one per 19.7 patient-months. Using this device, it should be possible to stop the subclavian vein damage and perforating injuries that have been the most important complications of semistiff, tapered, subclavian catheters.