The Patency Rate of the Primary and Exchanged Femoral Haemodialysis Catheters

Background: This prospective cohort study aims to evaluate the primary and exchanged femoral catheter patency rates, as well as mortality rates and determine the probable risk factors affecting femoral catheter survival. Methods: All 79 tunneled femoral catheters created in our hospital from 2017 to 2020 were included in this study. Patients having no other means for dialysis access other than the femoral catheter was recruited in this study. Data collected included patient age, sex, comorbidities (diabetes and hypertension), transplant history, dialysis duration, catheter complications, femoral access history, and primary and exchanged femoral patency rates. Patients were followed for 4–36 months. Results: The median catheter primary patency was 7 months (95% confidence interval [CI]: 5.77, 8.22) and the primary patency rates at 2, 4 and 6 months were 79%, 68% and 48%, respectively. The median exchanged catheter survival was 8 months (95% CI: 0.83, 15.17) and the exchanged patency rates at 1, 3 and 8 months were 72%, 64% and 32%, respectively. Of the patients (n = 62), 8% (5 patients) died because they had no other option for dialysis access. Conclusion: Tunneled femoral catheters have a low patency rate and should be the last option for haemodialysis patients when other probable accesses are not available.

Tunneled femoral dialysis catheter: Practical pointers

One of the most challenging aspects of providing end-stage kidney disease care is to achieve adequate long-term access to the bloodstream to support hemodialysis (HD) therapy. Although upper extremity arteriovenous fistula remains the vascular access of choice for patients on HD, complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower extremity. The current review focuses on the indications, contraindications, and clinically relevant practical procedural tips to successfully place a tunneled femoral dialysis catheter. The review highlights some of the prevailing misconceptions regarding femoral catheter placement practices.

A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Access recirculation and adequacy of hemodialysis in different types of vascular access

Introduction: Haemodialysis requires recirculation, and it happens when dialysed blood returningthrough the venous needle re-enters the extracorporeal circuit through the arterial needle, ratherthan returning to the systemic circulation. Significant recirculation should be expected, when there isan inadequate reduction in the values of urea. During End-Stage Renal Disease (ESRD), adequatedialysis is of utmost importance because it influences the morbidity and mortality of the patients.Methods and materials: The study was carried out in 200 patients who underwent haemodialysisat the dialysis unit in Kalyani kidney care centre, Erode. Patients were actively evaluated fromFebruary 2018 till November 2018. Patients were randomized and accordingly 64 patients wereenrolled in category I Arteriovenous fistula (AVF), 63 Patients in category II Internal JugularCatheter (IJC) and category III Femoral Catheter (FC) each and 10 patients in category IV PermCatheter (PC). Success recirculation was estimated and adequacy of haemodialysis was donevirtually. Calculated Kt/V was done in almost all patients. Results: The mean access recirculationrate was 6.3+5.1% in those with AVF, while in IJC and FC groups were 6.7+4.5% and 24.4+11.7%respectively. When the two groups were compared, AVF vs FC groups, the difference was statisticallysignificant (p value<0.001) and in IJC vs FC groups, the difference was statistically less significant(p-value <0.001) in both AR% and online Kt/V. Conclusion: An arteriovenous2QQ2 fistula has lessaccess recirculation, when compared to temporary catheters. On the other hand, the femoralcatheter has more access recirculation, when compared to the internal jugular catheter. Thedifference in calculated Kt/V with the three types of vascular access has no statistical significance.

P1528EPIDEMIOLOGICAL SURVEY OF A POPULATION UNDERGOING URGENT HEMODIALYSIS

Background and Aims Urgent hemodialysis is a very common situation in nephrology and is burdened with high morbidity and mortality. The aim of this work is to study the epidemiological, etiological, clinico-biological and indications of dialysis emergencies, the parameters of the session and the potential complications. Method This is a descriptive study conducted over a period of 12 months (January – December 2017), including all patients who have been admitted to the nephrology department for urgent management in hemodialysis. Results Our study collected a total of 318 patients (sex ratio =1.52), the mean age 60.54 ± [18-95 years]. Patients came mainly from the emergency department (69.8%). 40.9 % of the patients were diabetic and 66,4 % hypertensive, 15.1% had coronary artery disease. Among patients, 80.9% had chronic renal insufficiency, of which 29.6% were end-stage (28% hemodialysis and 1.6% peritoneal dialysis). Urgent hemodialysis was undertaken for threatening hyperkalemia in 58.2% of cases, a poorly tolerated uremic syndrome in 50.8% acute pulmonary edema (APO) in 36.5% of cases, and anuria greater than 12h were the indication in 44.4% of cases and a severe metabolic acidosis in 11.3% of cases. The average duration of the session was 3 hours. Ultrafiltration was necessary in 63.7% of the cases. The blood access was a femoral catheter in 80.6% of the cases. Blood transfusion was indicated in 13.8% of cases. Main complications were dominated by symptomatic arterial hypotension in 12.9% requiring stopping the session in half of cases hypoglycemia in 6.9%, neurological disorder in 6.6% chest pain in 3.5 %. After a year of follow up care, overall mortality was 40% in this population. On multivariate analysis, age (p=0.006) and neurological state according to the glasgow score (p=0.01) were retained as independent factors of mortality in this population. Conclusion A greater prevalence of urgent hemodialysis is observed in our country testifying to the accessibility of this method of extrarenal replacement. Hyperkalemia, uremic syndrom and PAO are the main indications for urgent hemodialysis. Early diagnosis, prompt and relevant management of these patients will determine their prognoses in the short and medium term.

A case of severe hypercalcemia with arterial and venous thrombosis

We present a case of severe hypercalcemia with extensive venous and arterial thrombosis that led to the patient’s demise in the setting of possible multiple endocrine neoplasia (MEN) type 2a. A 35-year-old female presented to the emergency with nausea and vomiting for one week. Physical examination revealed dry mucous membranes, a thyroid nodule on left side and epigastric tenderness. Initial investigations revealed evidence of renal impairment and hypercalcemia. Parathyroid hormone (PTH) level was very high. Ultrasound of the thyroid showed a solitary left thyroid nodule with mixed cystic and solid isoechoic echogenicity. The patient developed progressive dyspnea and hypoxemia, which mandated mechanical ventilation. Dialysis was initiated via the right femoral catheter and stopped due to extensive venous thrombosis of the right lower limb. Pulmonary emboli were excluded and pulmonary edema was confirmed by computed tomography. The patient was subsequently intubated for persistent respiratory distress. The same condition occurred in the right upper limb. Fine needle biopsy of the left thyroid nodule revealed medullary thyroid cancer. The consulting team preferred to manage her conservatively as she was rapidly-deteriorating. She developed progressive shock and multi-organ failureed. Citation: Algethamy HM, Shikdar YA, Alansari TA. A case of severe hypercalcemia with arterial and venous thrombosis. Anaesth pain intensive care 2020;24(1):__ DOI: https://doi.org/10.35975/apic.v24i1. Received – 1 December 2019, Reviewed – 11 December 2019, 2 January 2020, Accepted – 10 January 2020;

Vascular Access Profile of End Stage Renal Disease Patients on Maintenance Hemodialysis: Experience from a Tertiary Care Center of Bangladesh

Background: A well-functioning vascular access (VA) is essential to provide efficient hemodialysis (HD) therapy. There are 3 main types of access: arterio-venous fistula (AVF), arterio-venous graft (AVG) and central venous catheter (temporary or permanent). The aim of our study was to find vascular access profile of ESRD patients on maintenance hemodialysis in a tertiary care hospital. Methods: This cross-sectional study was carried out in the Department of Nephrology and Dialysis of BIRDEM General Hospital, Dhaka, Bangladesh from November to December, 2015. After taking informed consent from the patients, data were collected from face to face interview and record books of the patients. Results: Total patients were 107, male were 78 (72.9 %) and female were 29 (27.1%). The mean age was 57.3 ± 11.4 (range 32-80) years. Mean duration of CKD was found 5.7 ± 4.2 (range 1-20) years. Maximum dialysis duration was 6.5 years with mean of 1.7 ± 1.3 years. Near two-thirds (68.2%) of the patients were on thrice-weekly dialysis and one-third (31.8%) were on twice-weekly dialysis. The vascular access at initiation of dialysis was temporary catheter in majority (91.6%) of study participant and AV fistula in 8.4% cases. Of temporary catheter one-third (33.7%) were temporary jugular catheter and two-third (66.3%) were temporary femoral catheter. Among jugular catheter 9.1% were left sided catheter and rest (90.9%) were right sided catheter. Among the femoral catheter 70.8% and 29.2% were right and left side respectively. The current vascular access was AV fistula in 90.7%, temporary catheters 4.7%, permanent catheter 3.7% and AVG 0.9% in study patients. Of AVF near one third (29.9%) were radio-cephalic and 70.1% were brachial (62.6% brachio-cephalic, 7.5% brachio-basilic) fistulas. About seventeen percent (16.8%) patients had AVF failure. Conclusion: Temporary dialysis catheters were the most common initial vascular access. Less than one-tenth patients started dialysis with AV fistula. More than two-thirds patients were on thrice weekly dialysis. AV fistula was the most common current vascular access with very small number of permanent catheter and AV graft. Bangladesh Crit Care J March 2019; 7(1): 26-28