Selection of type of vascular access

Selection of type of vascular access

What type of vascular access should be employed?

Guidelines recommend that for acute hemodialysis, access should be obtained by percutaneous placement using the ultrasound guidance of a double lumen catheter in the (order of preferences):

  • 1. Right internal jugular
  • 2. Femoral
  • 3. Left internal jugular
  • 4. Subclavian vein

If RRT is expected to extend beyond several days (>7 days), consideration should be given to early placement of a tunneled catheter in the internal jugular vein. Tunneled catheters have a larger diameter than do non-tunneled catheters, providing higher blood flows, and have a lower incidence of catheter-related bloodstream infections.

Catheter malfunction has a significant impact on the delivered dialysis dose as observed by the investigators of the ATN study; interestingly, one study showed that twin-tunneled catheters in the femoral vein provide better function than a conventional femoral vein catheter. The femoral vein is technically the easiest access to place; nevertheless, concern for infection by this type of access has limited its use. One randomized controlled trial showed that femoral catheters were not associated with an increased risk of infections compared with jugular catheters, except in patients with high body mass indexes. Jugular catheters could be used for prolonged periods of time (usually 3 weeks), with a low risk of bacteremia; on the other hand, femoral catheters—especially in obese and bed-bound patients—should not be used for more than 1 week. Thoracic catheters have the advantage of lower recirculation. However, it should be kept in mind that subclavian vein cannulation is associated with higher rates of both short-term and long-term complications, such as pneumothorax and hemorrhage, and central venous stenosis. Subclavian catheters should be placed only if all the other options are not viable. The use of portable ultrasound machines has improved the success rate of cannulation and decreased the rate of complications, and they should be used if available.

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