Site selection for temporary dialysis catheter

AKImedium

A 25-year-old man admitted to the ICU 5 days ago with fever has a right internal jugular central venous catheter for vasopressors. BP is 80/42 mm Hg, temperature 38.6°C, and BMI 24 kg/m². He has bilateral coarse crackles and generalized edema. Urine output was 30 mL over 24 hours. Chest radiograph shows bilateral pulmonary opacities. Potassium is 6.6 mEq/L, total CO₂ 10 mEq/L, BUN 93 mg/dL, creatinine 5.4 mg/dL, and phosphorus 7.1 mg/dL. Hemodialysis is planned. Bedside ultrasound of the right internal jugular vein shows a catheter-associated thrombus. What is the best approach to obtain dialysis access?

  1. A.Place a temporary dialysis catheter in the left IJ vein
  2. B.Exchange the CVC for a temporary dialysis catheter in the right IJ vein
  3. C.Place a temporary dialysis catheter in the right femoral veinCorrect
  4. D.Refer for tunneled dialysis catheter placement in the left IJ vein

Explanation

The best approach is to place a temporary dialysis catheter in the right femoral vein. This critically ill patient has oliguric AKI with hyperkalemia of 6.6 mEq/L, severe metabolic acidosis, and volume overload, so dialysis access is needed urgently. The KDIGO AKI guideline recommends a preferred order of sites for nontunneled dialysis catheters: the right internal jugular vein first, then the femoral veins, then the left internal jugular vein, and the subclavian vein of the dominant side last. The right internal jugular vein offers a short, straight path to the right atrium with the best flow and lowest dysfunction rates, but here it contains a catheter-associated thrombus. The femoral vein is the next choice. In the Cathedia trial, femoral and jugular catheters had similar rates of catheter colonization overall, and infection risk was higher at the femoral site only in patients with a BMI above about 28 kg/m²; this patient's BMI is 24. Femoral access also avoids the risk of pneumothorax in a hypoxemic patient with bilateral infiltrates and preserves upper-extremity veins for future permanent access if kidney function does not recover. A catheter of adequate length, usually 24 cm or longer, reduces recirculation. The left internal jugular vein is a reasonable site but is ranked after the femoral vein because its tortuous course through the left brachiocephalic vein is associated with more catheter dysfunction and lower delivered flow, and it may compromise future left arm access. Exchanging the existing catheter over a guidewire in a thrombosed right internal jugular vein risks embolizing thrombus and placing the new catheter within a clot, with poor flow and early dysfunction. A tunneled dialysis catheter is not appropriate in a patient with active fever and possible bacteremia who needs urgent dialysis, and placement in the left internal jugular vein delays treatment and adds the disadvantages of that site.

Why each option

A.
The left internal jugular vein follows a tortuous course causing more dysfunction and lower flow, so KDIGO ranks it after the femoral vein.
B.
Exchanging the catheter over a wire in a thrombosed vein risks embolizing clot and placing the new catheter within thrombus, causing early dysfunction.
C.
Correct. With thrombus in the right internal jugular vein, KDIGO ranks the femoral vein next, and with BMI 24 its infection risk matches jugular sites.
D.
A tunneled catheter is inappropriate during active fever and possible bacteremia, and arranging it would delay urgently needed dialysis for hyperkalemia and acidosis.

Reference: KDIGO 2012 Clinical Practice Guideline for Acute Kidney Injury; Parienti JJ, JAMA 2008 (Cathedia trial: femoral versus jugular dialysis catheters)

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