Perceptions of Home Dialysis Training and Experience Among US Nephrology Fellows

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A Central Venous (W-B-W) Catheter for Multipurpose Vascular Access in Children

A central venous (W-B-W) catheter has been developed for vascular access in children of all ages and sizes. The catheter design and implantation technique permit nonsurgical bedside adjustment of catheter position and ease of removal. Multiple possible uses include intravenous fluid administration, blood sampling, central venous pressure monitoring, and plasma exchange therapy in addition to hemodialysis. Twenty-seven W-B-W catheters were placed in 24 patients in a 12-month period. The catheter provided adequate blood flow for hemodialysis. Seven catheters were removed nonelectively in five patients. One episode of catheter-associated sepsis occurred after renal transplantation in a patient on immunosuppressive therapy. It is concluded that the W-B-W catheter is a relatively safe, multipurpose, pain-free acute vascular access for children, which may also suffice for chronic hemodialysis.     

Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners

Recent data indicate that the incidence of end-stage renal disease (ESRD) in pediatric patients (age 0–19 years) has increased over the past two decades. Similarly, the prevalence of ESRD has increased threefold over the same period. Hemodialysis (HD) continues to be the most frequently utilized modality for renal replacement therapy in incident pediatric ESRD patients. The number of children on HD exceeded the sum total of those on peritoneal dialysis and those undergoing pre-emptive renal transplantation. Choosing the best vascular access option for pediatric HD patients remains challenging. Despite a national initiative for fistula first in the adult hemodialysis population, the pediatric nephrology community in the United States of America utilizes central venous catheters as the primary dialysis access for most patients. Vascular access management requires proper advance planning to assure that the best permanent access is placed, seamless communication involving a multidisciplinary team of nephrologists, nurses, surgeons, and interventional radiologists, and ongoing monitoring to ensure a long life of use. It is imperative that practitioners have a long-term vision to decrease morbidity in this unique patient population. This article reviews the various types of pediatric vascular accesses used worldwide and the benefits and disadvantages of these various forms of access.     

Bacterial Colonization in Hemodialysis Temporary Dual Lumen Catheters: A Prospective Study

Aims. The use of hemodialysis temporary dual-lumen catheters is often complicated by infections, which may be a significant cause of death among patients with end stage renal disease (ESRD). The aim of this study was to assess the incidence of bacteremia and bacterial colonization related to non-tunneled, non-cuffed, dual-lumen temporary catheters in patients with ESRD submitted to hemodialysis. Methods. This study included 29 patients with ESRD. After catheter implantation, patients were monitored throughout the period of catheter permanence by means of blood samples collected weekly from a peripheral vein. Bacteria were isolated and identified according to CLSI recommendations. When catheters were removed for any reason, their tips were evaluated microbiologically. Results. A total of 194 blood samples from the 29 patients implanted with 55 catheters were analyzed. Of these, 15.5% (30 samples) demonstrated bacterial growth, principally Staphylococcus epidermidis (64.5%). Twenty patients (68.9%) presented at least one positive blood culture during follow-up. The median time for catheter colonization was 18.5 days (95% CI: 16.8–30.3). Of the 55 catheters implanted, 28 (50.9%) showed bacterial colonization, corresponding to 23.4 episodes/1000 catheter/days and 9.2 episodes of bacteremia /1000 catheter/days. Fifteen of 28 catheter tips analyzed showed bacterial growth (53.5%). In 14 of these (93.3%), there was agreement between the isolates from the catheter tip and blood cultures. Of 24 episodes of positive blood cultures from 20 different patients in 17 episodes (70.8%), the patients showed no clinical signs or symptoms of bacteremia. Conclusions. The high incidence of catheter colonization, the correlation between blood and catheter tip cultures, and the occurrence of frequent cases of asymptomatic bacteremia justify the proposal of routine peripheral blood collections to monitor patients undergoing hemodialysis with temporary dual-lumen catheters.     

深静脉置管血液透析患者真菌感染的易感因素及护理对策

目的探讨血液透析患者带涤纶环深静脉留置导管真菌感染的易感因素，为临床制订预防感染的护理措施提供理论依据。方法观察24例采用带涤纶环深静脉留置导管行维持性血液透析患者真菌感染发生率、临床表现、治疗转归，并分析易感因素。结果5例（20.83％）发生导管相关性真菌感染，感染真菌均为假丝酵母菌，药物敏感试验提示氟康唑敏感性最高；氟康唑导管内滴注治疗3例有效；导管相关性真菌感染与近期抗生素的应用、导管置入时间有关（均P〈0.05）。结论导管相关性真菌感染不可忽视，了解其临床特点、易感因素，采取针以性预防措施，对减少感染发生率、延长导管的使用寿命具有重要意义。     

A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients

Background Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons. Methods At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cutdown approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications. Results The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches. Conclusion The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.     

Double Catheterization of the Internal Jugular Vein for Hemodialysis: Indications, Techniques, and Clinical Results

Abstract: Central vascular catheters are used to access the central vascular system in both acute and chronic uremic patients undergoing hemodialysis. Among different approaches, the internal jugular vein seems to have less adverse effects. We describe our long-term experience with a two-catheter system. Percutaneous jugular vein cannulation was performed using Medcomp silicone rubber catheters. The study included 108 patients undergoing hemodialysis. One- and 2-year survival was 93 and 91%, respectively; 36 died because of unrelated causes. Blood flow rate was 284 mL/min; venous pressure at 1 year was 90 mm Hg. Complications included accidental withdrawal (6), dysfunction (4), catheter clotting (11), mediastinal hematoma (2), pneumothorax (1), and sepsis (7). Good long-term survival and a low complication rate make this system a safe and reliable method of access for long-term hemodialysis.     

Using Cuffed and Tunnelled Central Venous Catheters as Permanent Vascular Access for Hemodialysis: A Prospective Study

Background.?Adequate care of a hemodialysis patient requires constant attention to the need to maintain vascular access (VA) patency. VA complications are the main cause of hospitalization in hemodialysis patients. The native arteriovenous fistula (NAVF), synthetic arteriovenous grafts fistula (GAVF) and silastic cuffed central venous catheters (CVCs) are used for permanent vascular access (PVA). CVCs are primary the method of choice for temporary access. But using this access modality is increasing more and more for PVA in elderly hemodialysis patients and when other PVA is not possible. The primary aim of this study is to investigate survivals and complications of the CVCs used for long-term VA. Methods.?We prospectively looked at 92 CVCs (Medcomp Ash Split Cath, 14 FR × 28 cm (Little, M.A.; O'Riordan, A.; Lucey, B.; Farrell, M.; Lee, M.; Conlon, P.J.; Walshe, J.J. A prospective study of complications associated with cuffed, tunnelled hemodialysis catheters. Nephrol. Dial. Transplant. 2001, 16 (11), 2194–2200) with Dacron cuff) inserted in 85 (50 females, 35 males) chronic hemodialysis patients (the mean age: 56.6 ± 14.1 years) from 07 1999 to 01 2002. The overall survival and complications were followed up. Furthermore, the patients were evaluated for demographic and clinical characteristics. Data were analysed by chi-square, Wilcoxon rank and Kaplan–Meier survival tests. Results.?The median duration of CVC survival was 289 days (range: 10–720). Eleven (11.9%) CVCs were removed due to complications. In 79 (92.9%) patients, 1, in 5 (5.8%) patients, 2 and in 1 patient, 3 CVCs were inserted. Of the 85 patients, 56 have CVCs functioning. In addition, 27 (31.76%) patients have CVCs functioning for over 12 months, 17 (20%) patients have CVCs functioning for 6 months. The total incidence of CVC related infections was 0.82 episodes/1000 catheter days. Besides, thrombosis was occurred in 10 (10.8%) CVCs. The most frequent indications for CVC removal were patient death (69.4%), thrombosis (16.6%) and CVC-related infections (13.8%). Conclusions.?CVCs are primarily used for temporary access. But this study indicates that CVC may be a very useful alternative permanent vascular access for hemodialysis patients when other forms of vascular access are not available.     

Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Purpose

The aim of this study is to review the current evidence-based data regarding strategies for prevention of central venous catheter (CVC) infections at the time of catheter insertion and as a part of routine care.

Methods

We conducted a PubMed search from January 1990 to November 2010 using the following keywords: central venous catheter, clinical trials, pediatric, infection, prevention, antibiotic, chlorhexidine, dressing, antiseptic impregnated catheters, ethanol lock, impregnated cuff, insertion site infection, and Cochrane systematic review. Seven questions, selected by the American Pediatric Surgical Association Outcomes and Clinical Trials Committee, were addressed.

Results

Thirty-six studies were selected for detailed review based on the strength of their study design and relevance to our 7 questions. These studies provide evidence that (1) chlorhexidine skin prep and chlorhexidine-impregnated dressing can decrease CVC colonization and bloodstream infection, (2) use of heparin and antibiotic-impregnated CVCs can decrease CVC colonization and bloodstream infection, and (3) ethanol and vancomycin lock therapy can reduce the incidence of catheter-associated bloodstream infections.

Conclusion

Grade A and B recommendations can be made based on available evidence in adult and limited pediatric studies for multiple components of proper CVC insertion practices and subsequent management. These strategies can minimize the risk of CVC infections in pediatric patients.     

Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk‐Adjusted Cumulative Summation Learning Curve Analysis

The United Network for Organ Sharing recommends that fellowship‐trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk‐adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS‐approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24–28 cases and proficiency by 35–38 cases.