Central venous access for haemodialysis using the Hickman catheter

One hundred and seven Hickman catheters for haemodialysis were inserted in 90 end-stage chronic renal failure patients, and were used for 1-448 days (median 45 days). Sixty-nine per cent of the patients were treated without any problem for 1-165 days (median 34 days). Clinically evident complications occurred in 44 catheters inserted in 28 patients, and included outflow obstruction (16.8% of the catheters) and thrombosis (13.1% of the catheters). However, many episodes of clotting or insufficient flow could be corrected by simple manoeuvres. Other less frequent complications were recorded: sepsis, mainly in patients with increased risk factors (4.1% of the catheters), laceration of the catheter (3.7%) and occasional cases of jugular-vein phlebitis, transient palsy of a vocal cord, haematoma of the wound, and bleeding of the cutaneous orifice. No clinical sign of subclavian or innominate-vein thrombosis was observed. Nevertheless, a prospective study conducted in 50 asymptomatic patients demonstrated a 12% rate of anomalies of the venous system, although two-thirds of these alterations were mild and had no consequence. When the present series is compared to the results obtained with currently available percutaneous haemodialysis catheters, it is concluded that the Hickman catheter is a safe, comfortable and efficient vascular access device.     

Ambulatory blood pressure monitoring in paediatric patients treated by regular haemodialysis and peritoneal dialysis

Ambulatory blood pressure monitoring (ABPM) has been shown to be more representive of blood pressure (BP) levels than casual BP measurements in adult patients treated by haemodialysis (HD). In this study we compared ABPM using the oscillometric SpaceLabs 90207 monitor with casual BP measurements in 35 paediatric patients [17 treated by peritoneal dialysis (PD) and 18 by DH]. Heart rate and plasma concentrations of atrial natriuretic peptide were also measured. No correlations were found between ABPM and casual BP measurements, except for systolic day-time BP in PD patients (r=0.63). Seventy percent of PD and 33% of HD patients were regarded as hypertensive when evaluated by ABPM, while casual BP measurements demonstrated hypertension in 47% (P<0.05) of PD patients and in 44% (NS) of HD patients. One-third of patients were reclassified by ABPM either from normotensive to hypertensive (7/19) or from hypertensive to normotensive (5/16). BP assessed by ABPM was higher in PD than in HD patients. The physiological decline of BP at night was significant and more prouounced in PD than in HD patients. In HD patients day-time BP did not differ between the 1st and the 2nd interdialytic day, but increased in the night hours before the following dialysis session. A positive correlation was found between day-time BP and pre-dialysis plasma atrial natriuretic peptide in both treatment groups. In conclusion this study demonstrates that casual BP recordings are not representative of average BP in dialysed paediatric patients. ABPM is useful in the diagnosis and treatment of hypertension in children with endstage renal disease.     

Right atrial thrombosis complicating Hickman catheter placement: A case report and literature review

We describe a case of right atrial thrombosis complicating Hickman catheter placement in a patient with necrotising pancreatitis. Heparin therapy resulted in the further complication of peripancreatic haemorrhage. Literature on thrombo‐embolic complications after Hickman or Broviac catheter insertion is reviewed, and the optimum position for catheter placement is discussed.      

大网膜部分切除在腹腔镜腹膜透析管置入术的应用价值

目的探讨大网膜部分切除术在慢性肾脏病5期患者腹膜透析管置入术中的应用价值。方法选择郑州大学第一附属医院腹腔镜外科于2017-01—2019-08间收治的268例慢性肾脏病5期患者,其中190例行常规腹腔镜下腹膜透析管植入术(常规腹腔镜组)、78例行腹腔镜下腹膜透析管置入并大网膜部分切除术(大网膜切除组)。对2组患者的临床资料进行比较分析。结果2组患者的年龄、性别、术前血红蛋白、术前肌酐值等一般资料差异无统计学意义(P>0.05)。268例手术均获成功,大网膜切除组手术时间长于常规腹腔镜组,手术费用多于常规腹腔镜组;常规腹腔镜组堵管10例,大网膜切除组无堵管病例。差异均有统计学意义(P<0.05)。结论腹腔镜下腹膜透析管置入并大网膜部分切除术,对预防术后大网膜包裹腹膜透析管效果良好,具有临床应用价值。     

Effective use of streptokinase for peritoneal catheter failure

The fibrinolytic enzyme streptokinase (streptase) was infused into the peritoneal catheter in 19 episodes of catheter failure in 16 patients. Intraabdominal bleeding prior to infusion was seen in seven of these episodes. Fibrin strands and clots were present in four additional successful cases. Streptokinase successfully relieved the obstruction in 13 episodes in 11 patients. The procedure failed in two cases of omental ingrowth and in another with catheter malposition. Streptokinase infusion also failed in two patients with Pseudomonas aeruginosa and one patient with Staphylococcus epidermidis peritonitis. Intraperitoneal streptokinase infusion is simple and free of side effects. Its use should be considered in peritoneal catheter failure, particularly in cases where bleeding or fibrin accumulation may play a role.     

Peritoneal dialysis catheter embedment: surgical considerations,expectations, and complications

Background

Peritoneal dialysis catheter embedment consists of implanting the catheter far in advance of anticipated need, with the external tubing buried under the skin. The catheter is externalized when initiation of dialysis is required. Details of the surgical procedure and management of associated complications are generally lacking.

Methods

A total of 84 catheters including conventional and extended catheters were embedded and externalized during the study period. Factors influencing duration of embedment, functionality upon externalization, and long-term outcomes were analyzed.

Results

Mean duration of embedment was 13.9 months (median 9.4; range .5 to 68.5). Immediate function was exhibited in 85.7% of catheters. Employing laparoscopic revision, 98.8% of embedded catheters were successfully used for peritoneal dialysis. Extended catheters and duration of embedment were important determinants of catheter functionality.

Conclusions

Catheters can be embedded for prolonged periods and still result in functional dialysis access when needed. Complications are few and easily managed.     

Laparoscopic-assisted peritoneal dialysis catheter placement: a microinvasive technique

Background Peritoneal dialysis is an alternate form of dialysis for patients with end-stage renal disease (ESRD). Although not as widely used as hemodialysis, peritoneal dialysis (PD) has clear advantages, especially those related to patient satisfaction and simplicity. The purpose of our study was to describe and look at the results of a microinvasive technique for placement of peritoneal dialysis catheters under laparoscopy. Methods From August 2003 to January 2006, 12 patients with ESRD underwent laparoscopic-assisted peritoneal dialysis (LAPD) catheter placement with the microinvasive technique at our institution. Data collected included age, gender, underlying renal disease, and length of operation. Followup was completed for all patients (at least 6 months) and catheter-related morbidity and mortality were also analyzed. Results There were 13 procedures performed (one patient had LAPD catheter placement twice). The average age was 45 years and the most common cause of ESRD was uncontrolled arterial hypertension. Procedural time averaged 33.6 min (range = 24–50 min). Peritoneal dialysis was introduced two weeks after the procedure and no dialysate leaks were observed. There were two catheter-related morbidities; both were catheter exit-site abscesses, one managed surgically with removal of the PD catheter and the other managed conservately with culture-sensitive antimicrobials. Patient satisfaction was beyond acceptable in 92% of the patients (12 of 13). Average longevity of the catheter was 61 weeks (427 days). There were no mortalities. Conclusion LAPD catheter placement is an easy technique with acceptable catheter longevity and minimal morbidity. The microinvasive technique leads to better patient satisfaction and cosmetic outcome without affecting its function. Therefore, we believe that by promoting microinvasive LAPD catheter placement, PD will gain more acceptance among doctors and patients.     

Peritoneal dialysis catheter insertion strategies and maintenance of catheter function

It has been more than 40 years since permanent peritoneal dialysis (PD) access with the Tenckhoff catheter was first described, and despite much experimentation with catheter design and insertion techniques, access to timely and skilled PD catheter insertion remains a barrier to more widespread PD use in many centers. This article reviews different insertion techniques with a focus on both mechanical outcomes as well as logistic advantages associated with the embedded catheter and percutaneous techniques. Maintenance of catheter function is discussed with a focus on an organized and evidence-based approach to preventing and treating mechanical catheter problems.     

Diagnosis and insertion of Hickman catheter for a patient with persistent left superior vena cava

A vascular access with good function for drug delivery is the basis of chemotherapy. If there is any congenital or acquired vascular abnormality, procedurally related and late complications such as vessel rupture, malposition, and dysfunction of the catheter with ensuing thrombosis may occur, especially when it is undiagnosed or ignored. We describe a case of implantable central venous catheter (CVC) malposition and subsequent insertion of a Hickman catheter for stem cell transplantation after the diagnosis of persistent left superior vena cava (PLSVC) by radiologic image studies. The case is about a 60-year-old male who suffered from mantle cell lymphoma. He complained of discomfort when chemotherapeutic drugs were delivered through an implanted subcutaneous port system. Malposition of the CVC with aberrant path venous catheter, which led to its migration to the right internal jugular vein (RIJV) was noted on the chest X-ray. In addition, results of ultrasound imaging revealed total occlusion of the RIJV, and a subsequent three-dimensional (3D) computed tomography (CT) reconstruction image revealed a PLSVC with an atretic right SVC. Ultrasound-guided venous puncture of the left internal jugular vein and intraoperative fluoroscopy for confirming the correct guide-wire path were used for successful insertion of Hickman catheter without any complication. When unexpected occurrence of migration or malposition of the long-term CVC is detected, early removal of the catheter is vital for preventing further complications. Proper and advanced image studies including ultrasound, contrast-enhanced venography, CT, and magnetic resonance imaging may be necessary for understanding the potential vascular abnormality and guiding the following treatment.     

Risk factors for early peritoneal dialysis catheter failure in children

Background

There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan.

Methods

A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or χ² analysis.

Results

There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 ± 7 years) were younger than patients with a functioning catheter at 2 months (12 ± 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type.

Conclusion

Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.     

腹腔镜在腹膜透析管复位中的临床应用

目的：评价应用腹腔镜手术方法行腹膜透析管复位的治疗效果,并总结相关治疗经验。方法收集2010年3月至2014年5月我院腹透中心收治的33例经常规保守治疗后,腹透液进出仍然不通畅,并确诊为导管持续性移位,须行手术复位腹膜透析导管患者的临床资料,进行回顾性分析,评价腹腔镜下腹透导管复位术的效果。结果33例导管持续性移位的患者均采用全麻下腹腔镜手术复位。术中所见多为单纯导管移位（21/33,63.6%）,腹腔镜直视下将腹膜透析管直接放至膀胱直肠陷窝或子宫直肠陷窝,并加用不可吸收线将导管固定于邻近腹壁,以减少再次移位的可能性;其次为大网膜包裹（12/33,36.4%）,腹腔镜直视下钝性分离包裹于导管上的大网膜,后续操作步骤同单纯导管移位者。全部33例患者均用上述技术成功复位,手术时间维持在30~45 min,平均出血量约5~10 ml;术中患者生命体征平稳,未见明显并发症;术后行腹膜透析,伤口处无渗液、漏液,伤口愈合良好;术后随访3~50个月,33例患者均可正常进行腹膜透析,未再出现导管移位。结论腹腔镜下腹膜透析管复位定位准确,切口小,易于愈合,合理运用可显著提高腹膜透析技术成功率。     

Swan neck presternal catheter for continuous ambulatory peritoneal dialysis in children

Since 15 December 1991 four swan neck presternal catheters (SNPC) have been implanted in four children aged 2–11 years. The observation period ranged from 4 to 10 months. The aim of this study was to evaluate the usefulness of a new peritoneal dialysis catheter implantation method in paediatric patients. The indications for insertion of the SNPC were: young age, use of nappies, obesity and recurrent exit site infection (ESI). The surgical technique of the SNPC implantation was similar to that used for adults. The chest location of the catheter exit site is advantageous for the following reasons: (1) easier care of a small child because of greater distance from nappies, (2) better healing and decreased risk of ESI in the area with less fat thickness and (3) less trauma. A larger number of children with a longer follow-up is necessary for better evaluation of the SNPC, as well as for estimation of frequency of ESI and peritonitis.     

双涤纶套鹅颈管与Tenckhoff管在腹膜透析患者中的疗效比较

目的 比较双涤纶套鹅颈管与Tenckhoff管在持续性非卧床腹膜透析（CAPD）患者中的临床疗效。 方法 前瞻性入选首次植管并接受CAPD治疗的终末期肾脏病（ESRD）患者110例，随机分为鹅颈管组（A组）和Tenckhoff管组（B组），各55例。腹透管末端均为直型，以常规手术法植入，随访1年。记录并发症、生存时间、退出透析或死亡等结局。采用Kaplan-Meier法、Log-Rank检验进行生存分析。 结果 随访结束时，110例CAPD患者中17例死亡，3例转为肾移植，8例转为血液透析治疗，3例转至其他医院，79例（71.8％）继续在我院腹透治疗。两组患者共发生腹膜炎26例（35例次），总腹膜炎发生率为0.32次/病人年，A组为0.35次/病人年和B组为0.29次/病人年（P > 0.05）。植管距离首次腹膜炎时间分别为A组（30±29）周和B组（29±24）周（P > 0.05）。12个月时两组发生腹膜炎的风险同为26.97％。两组共发生隧道感染2次，出口感染9次，隧道及出口感染的发生率为0.1次/病人年。与A组比较，B组隧道感染（0.036次/病人年比0）和出口感染（0.11次/病人年比0.06次/病人年）发生率较高，但差异无统计学意义（P > 0.05）。两组间导管机械并发症（导管移位、大网膜包裹、腹透液渗漏、外涤纶套滑出）、腹股沟疝及腹痛的发生率差异均无统计学意义（P > 0.05）。两组各有4例拔管，12个月技术生存率两组同为92.73％。两组共17例死亡（15.45％），其中A组死亡7例，B组死亡10例（P > 0.05），死亡原因主要为心脑血管并发症（47.1％）和感染（23.5％）。患者12个月生存率A组为86.34％，B组为80.68％（P > 0.05）。 结论 鹅颈管与Tenckhoff管应用于CAPD患者，在感染并发症与机械并发症的发生率、12个月技术生存率及患者生存率等方面的差异均无统计学意义，两种腹透管的疗效相近。     

利用导丝经临时静脉导管置入涤纶环导管的临床评价

目的评价利用导丝经右颈内静脉临时导管置入涤纶环导管在维持性血液透析中的应用价值。方法观察22例次利用导丝经右颈内静脉临时导管置入涤纶环导管（A组）和24例次新穿刺右颈内静脉留置涤纶环导管（B组）的临床应用情况。结果A组和B组导管中位使用寿命分别为19、21个月,导管使用寿命生存曲线差异无统计学意义（χ^2=0．05,P=0．82）。A组和B组插管处皮肤感染的发生率分别为（O．13±0．01）、（0．15±0．02）次／100导管日,导管引起的全身感染发生率分别为（O．31±0．03）、（0．32±0．02）次／100导管日,组间比较差异无统计学意义;A组和B组插管时局部出血或血肿发生率[40．91％（9／22）比45．83％（11／24）]、使用导管透析时血流量[（230．53±28．27）ml／min比（238．71±25．94）ml／min]和导管血栓形成率[31．82％（7／22）比33．33％（8／24）]比较,差异无统计学意义（P〉0．05）;两组均无纤维鞘形成和颈内静脉狭窄发生。结论利用导丝经右颈内静脉临时导管置入涤纶环导管可避免再次穿刺颈内静脉,同时不增加导管相关并发症,可作为留置涤纶环导管的一种方法。     

Blood-volume monitoring in paediatric haemodialysis

A correlation between relative blood volume (RBV) reduction and adverse intradialytic events has been reported in children. Our aim was to determine whether the shape of the RBV curve and the RBV thresholds discriminated between haemodialysis treatments where patients developed complications and those where they did not. We retrospectively reviewed blood volume records (n = 74), using the Fresenius module. “Treatment complications“ were defined as hypotension and/or intradialytic symptoms requiring nursing intervention. Treatments with complications were significantly associated with changes in heart rate (P = 0.05) and steeper decline of the RBV curve in the first hour (P = 0.01), but the final RBV measurement was not predictive (P = 0.27). When receiver operator characteristic (ROC) analyses were used, cut-off RBV thresholds of 88% at the end of the first hour, 84% at the end of the second hour, and 82% at the end of the third hour of dialysis, were able to discriminate between treatments with and without complications, but no RBV values at the end of the fourth hour of dialysis were discriminatory. The RBV curve differed in polyuric patients, such that complications occurred at lower RBV thresholds than in oliguric patients. Evolution of tachycardia and a steeper RBV fall in the first hour of dialysis predicted the occurrence of treatment complications. The authors declare that they have no conflict of interest.     

Residual renal function in children on haemodialysis and peritoneal dialysis therapy

Residual renal function was studied in 28 haemodialysis (HD) and 31 peritoneal dialysis (PD) patients aged 1–20 years observed over 6–43 (median 19) months. After the start of dialysis urine volume (UV) decreased to 57%, 46% and 26% of initial mean values in HD patients after 6, 12 and 24 months, respectively. In PD patients the corresponding figures were 57%, 69% and 62%. Mean UV calculated from all individual mean UV measurements observed was higher in PD than HD patients (954 vs. 537 ml/m² per 24 h,P<0.01). A better conservation of diuresis in PD patients was also suggested by a significantly longer persistence of a UV greater than 500 ml/m² per 24 h compared with HD patients. Cox proportional hazard analysis identified dialysis modality and pre-dialysis UV of less than 1,000 ml/m² per 24 h as the only significant risk factors for UV survival. However, the decline of UV per time was similar in both modes of treatment. No significant changes of glomerular filtration rate were observed during both HD and PD treatment.     

Modified minimally invasive laparoscopic peritoneal dialysis catheter insertion with internal fixation

BackgroundLaparoscopic technique is widely used in peritoneal dialysis (PD) catheter placement. We developed a modified minimally invasive laparoscopic PD catheter (PDC) insertion with internal fixation and evaluated the early results by observing the intraoperative and postoperative conditions of the novel technique with those of conventional open surgery.MethodsRetrospective research was performed on 59 patients who underwent PDC insertion from June 2019 to January 2022, including 23 patients who received open surgery and 36 patients who received modified minimally invasive laparoscopic surgery. Information such as preoperative conditions, operation time, incision length, incidence of intraoperative complications, time from operation to starting PD, time from operation to discharge, and incidence of catheter-related complications were collected and analyzed.ResultsThe incision length, intraoperative blood loss, catheter migration rates and the total incidence of complications 6 months after operation in the laparoscopic group were lower than those in the conventional group. There were no statistically significant differences between the two groups in operation time, time from operation to starting PD, time from operation to discharge and the incidence of catheter blockage, leakage, exit-site infection, peritoneal dialysis associated peritonitis and hernia.ConclusionsModified minimally invasive laparoscopic PDC insertion and internal fixation method achieved direct vision and reliable fixation of the catheter, significantly reduced incision length and blood loss. The incidence of catheter migration was significantly lower than that of open surgery. Our primary findings reveal that modified minimally invasive laparoscopic PDC insertion with internal fixation is safe, effective and beneficial for PD patients.     

Mini-laparoscopic placement of a peritoneal dialysis catheter

Background: The laparoscopic placement of continuous ambulatory peritoneal dialysis (CAPD) catheters is now an accepted technique. We evaluated a new technique for CAPD catheter placement that requires only a single 2-mm port. Methods: A pilot study was conducted at an academic minimally invasive surgery center. Seven consecutive patients in whom a CAPD catheter was required underwent placement of a 2-mm Veress port and a laparoscope. A carbon dioxide pneumoperitoneum was induced up to 14 mmHg. Under direct visualization with a 2-mm scope, a CAPD catheter was advanced over the right lower quadrant toward the pelvis using a modified Seldinger technique. Results: Seven patients (four women and three men) with end-stage renal disease underwent mini-laparoscopic placement of a CAPD catheter. Mean patient age was 35.3 ± 11.3 years (range, 17–50). Mean operative time was 20.7 ± 5.0 min (range, 14–29). Patients were dialyzed in the immediate postoperative period. No leaks were identified, and there were no intraoperative or postoperative complications. Conclusion: A mini-laparoscopic technique using a single 2-mm port and a modified Seldinger technique is feasible, safe, and effective for peritoneal dialysis catheter placements.     

Acute airway obstruction following placement of a subclavian Hickman catheter

The purpose of this case report is to describe the events, intervention, and aetiology which led to acute airway obstruction in an adult patient after the placement of a Hickman catheter. Airway obstruction secondary to superior vena cava obstruction occurred after placement of a subclavian vein Hickman catheter. This was felt to occur, in part, to a narrowed superior vena cava as evident by subclavian venography. It resulted in emergency oral tracheal intubation to relieve airway obstruction. Shortly after removal of the Hickman catheter, the signs of superior vena cava obstruction syndrome resolved and the patient was extubated without incidence. It is concluded that, although rare, the serious complication of acute airway obstruction can occur after placement of a Hickman catheter.