Safety of Bedside Placement of Tunneled Hemodialysis Catheters in the Intensive Care Unit: Translating from the COVID-19 Experience

Abstract

Background: Critically ill patients with coronavirus disease 2019 (COVID-19) and kidney dysfunction often require tunneled hemodialysis catheter (TDC) placement for kidney replacement therapy, typically under fluoroscopic guidance to minimize catheter-related complications. This entails transportation of patients outside the intensive care unit to a fluoroscopy suite, which may potentially expose many healthcare providers to COVID-19. One potential strategy to mitigate the risk of viral transmission is to insert TDCs at the bedside, using ultrasound and anatomic landmarks only, without fluoroscopic guidance. Methods: We reviewed all COVID-19 patients in the intensive care unit who underwent right internal jugular TDC insertion at the bedside between April and December 2020. Outcomes included catheter placement-related complications such as post-procedural bleeding, air embolism, dysrhythmias, pneumothorax/hemothorax, and catheter tip malposition. TDC insertion was considered successful if the catheter was able to achieve blood flow sufficient to perform either a single intermittent or 24 h of continuous hemodialysis treatment. Results: We report a retrospective, single-center case series of 25 patients with COVID-19 who had right internal jugular TDCs placed at the bedside, 10 of whom underwent simultaneous insertion of small-bore right internal jugular tunneled central venous catheters for infusion. Continuous veno-venous hemodialysis was utilized for kidney replacement therapy in all patients, and a median catheter blood flow rate of 200 mL/min (IQR: 200–200) was achieved without any deviation from the dialysis prescription. No catheter insertion-related complications were observed, and none of the catheter tips were malpositioned. Conclusions: Bedside right internal jugular TDC placement in COVID-19 patients, using ultrasound and anatomic landmarks without fluoroscopic guidance, may potentially reduce the risk of COVID-19 transmission among healthcare workers without compromising patient safety or catheter function. Concomitant insertion of tunneled central venous catheters in the right internal jugular vein for infusion may also be safely accomplished and further help limit personnel exposure to COVID-19.

Comparison of feasibility and effectiveness of catheter placement with or without DSA guidance: a propensity score-matched cohort study

“…Aurshina et al [13] reported on 1065 patients who underwent surgery under ultrasound guidance, among whom there were no cases of severe complications such as hemothorax or pneumothorax, with only 2 cases of arterial injury and 3 cases requiring post-operative revision due to incorrect catheter placement. Sohail et al [14] reported on 25 cases during the COVID-19 pandemic where institutions that routinely used DSA for placement changed their approach to ultrasound guidance, achieving a 100% success rate with post-operative blood ow and ultra ltration meeting the requirements of dialysis prescriptions.However, there is currently a lack of studies comparing the placement of hemodialysis catheters under DSA and ultrasound guidance. The references for DSA and ultrasound guidance for TDC placement surgery in KDIGO 2019 are sourced from an article published by Yevzlin et al [15] in 2007, which only reported higher surgical success rates and lower costs under DSA guidance.…”

Safety and durable patency of tunneled hemodialysis catheter inserted without fluoroscopy

“…In such a scenario, initially in the former cases (about 30 to 40 cases), the appropriate catheter length site was estimated based on the patient's height, as well as measurements on the patient's recent chest X-ray. In the later 50 to 60 cases, we used the manubrial-sternal angle (angle of Louis) as a topographical landmark for the carina [1,5]. The estimated insertion depth was selected by adding the distance between the puncture site and a point 5 cm below the manubrial-sternal angle.…”

“…Ultrasound and fluoroscopy-guided punctures are recommended for safe procedures when performing catheter insertion including hemodialysis (HD) catheters. However, for unstable patients, such as those on a ventilator in an intensive care unit (ICU), transferring the patient to the fluoroscopy is subject to constraints, sometimes worsening the patient's condition in the process [1]. ICU patients Safety and durable patency of tunneled hemodialysis catheter inserted without fluoroscopy receiving critical care often require renal replacement therapy (RRT).…”

Feasibility Analysis of Ultrasound-Guided Placement of Tunneled Hemodialysis Catheters

“… 7 , 8 During COVID era, successful and safe bedside placement of tunneled CVC using anatomic landmarks has been reported. 9 Recently, for tunneled dialysis CVC, a technique using agitated saline for localization of the catheter tip near the atrium has been described. 10 , 11 …”