Introduction:

Hemodialysis is a blood-purifying treatment procedure that involves the use of a dialysis machine or a specific filter known as an artificial kidney, or dialyzer. The doctor must gain access to the patient’s blood vessels in order to get the blood into the dialyzer for purification. This is accomplished with minimal surgery, which is commonly performed on the arm. 

 Hemodialysis is the treatment procedure recommended to patients having chronic kidney disease or end stage renal failure (stage V). As the kidney fails to function normally, the nitrogenous products and fluids end up in the blood instead of being excreted out through urine. This is where hemodialysis comes into play, as an artificial vascular access is made to purify blood and free it from toxins. Dialysis catheters are artificial indwelling transcutaneous devices that allow renal replacement therapy to reach the intravascular or intraperitoneal spaces. Different types of catheters are exploited for different categories of dialysis, the catheters used for hemodialysis differ largely from those used in peritoneal dialysis. 

This report will emphasize and shed light on the different types of catheters used particularly in case of hemodialysis, their insertion procedure, the indications, contraindications and complications associated with these catheters. Lastly, the report would articulate the clinical significance and prospects of catheters in enhancing health related outcomes.

 Dialysis catheter insertion procedure:

A tunneled catheter is used in case of hemodialysis, it is tunneled as it is inserted under the skin.

Tunneled catheters can be broadly classified into categories, namely cuffed and non-cuffed. Tunneled catheters are used for temporary access whereas non cuffed counterparts are used in case of emergency situations.      

 Cuffed vs Non cuffed catheters

Mode of insertion: Catheters that are not cuffed are inserted percutaneously (under the skin) by an anesthetic or PICU staff. 

The tunneling and insertion of cuffed catheters is mainly done via pediatric surgery. 

Therapeutic applications: Tunneled cuffed catheters are used for a range of therapeutic applications, including “chemotherapy, parenteral nutrition, and apheresis”, and give dependable and rapid long-term intravenous access. The most common use is as a hemodialysis access device for individuals with renal failure. Non cuffed catheters are used in emergency.

Site of insertion: A tunneled catheter is a tiny tube that is inserted into a vein beneath the skin and allows long-term access to the vein. It’s typically worn around the neck. The internal jugular is the most common location, but it can also be found in the “groin region (femoral), liver (transhepatic), chest (subclavian), or back (trans lumbar) region”.

A non-tunneled central line is a form of IV catheter that is used for a brief period of time. A major vein in the neck, chest, or groin may be used to place a non-tunneled central line.

Tenure of usage: Non-tunneled catheters are temporary devices that are inserted into a major vein at the neck, chest, or groin area. It can be used for no longer than 3 weeks. 

Tunneled Catheters are recommended to be used for a longer period only when no other options of permanent vascular access are available. These tunneled central venous catheters can be retained in place for up to a year, providing patients with permanent access. For instance, when the blood vessels of the patient are not robust enough to withstand a fistula or a graft insertion. There are two openings in catheters one opening is the red or arterial opening that draws blood from vein from the vein and the other blue one venous one that allows purified blood to return to the body. 

Note: The Hickman catheter is inserted from the exit point to the input point. Permacath placement entails making an incision, inserting a guide wire, and threading the catheter under the skin. To keep the catheter steady, a permcath/permacath has a cuff that is also put under the skin.

  Cleaning regime and hygiene care with catheters

To prevent catheter related bacterial infections and clotting issues, maintaining proper hygiene with indwelling catheters is crucial. The following precautionary measures can be taken.

• Maintaining a clean and dry catheter dressing is important to avoid infections.

• Ensuring that the insertion site is clean, and that the dressing is changed after each dialysis session is important. If one needs to change their dressing between treatments, keeping an emergency dressing kit at home can be helpful. Learning from the dialysis team about how to change dressings in an emergency, would be necessitated.

• Removing the cap from the end of the catheter at all times is an imperative step. There must be no air in the catheter.

• If one has a transparent bandage that clings to the catheter site and the skin around it, they can wash or bathe. This type of dressing is recommended, because it is water-resistant, which aids in infection prevention. 

• If one is taking a bath, the catheter should not be submerged into the catheter site. Moisture would be more likely to get near the catheter site, which could lead to infections.

• To prevent bacteria from entering the catheter and the bloodstream, wearing a mask over one’s nose and mouth whenever the catheter is opened is needed. Professionals who change the dressing should also put on a mask and gloves.

• When the catheter isn’t being used for dialysis, the caps and clamps of the catheter must be kept completely closed. The dialysis catheter should only be used by the care team to collect blood, administer medications, or administer fluids.

• The dialysis team should be called and informed right away if the area around the catheter feels sore or appears red, this might be indicative of any bacterial infection or immunological allergic response, hence would require early detection of signs and symptoms. 

• Understanding the Kt/V(dialysis marker) and URR (urea reduction ratio) is an absolute prerequisite to monitor progress of dialysis. The Kt/V and URR are statistical rhetoric adopted by the kidney disease outcomes quality initiative (KDOQI). The renal parameters Kt/V and URR indicate how much dialysis one is receiving. Kt/V is recommended by the NKF (National kidney foundation). The Kt/V value should be at least 1.2, if one is getting enough dialysis. The URR should be at least 65 percent. If the numbers are too low, it’s probable that access is not functioning properly. Checking the access with the dialysis team would be required in that situation.

          Complications and concerns pertaining to catheter usage: 

Clotting: Clots can form inside the catheter’s opening or outside the catheter’s entrance, blocking the opening. This may cause the blood to flow at a slower rate than that prescribed by concerned physician. The catheter should be checked and treated the same day if the blood flow rate remains low after more than one dialysis treatment. The clot may not completely obstruct the catheter if treated early. Hence early intervention is crucial for prevention of clotting. 

It’s critical to reestablish the recommended blood flow rate and treat any clots that form so that the catheter keeps working properly and the patient gets the dialysis, they require for alleviation of the renal dysfunction. 

Complications including thrombosis and infection, injuries to nearby organs such as the pleura (resulting in pneumothorax) or arteries, stenosis of the major veins, and device failure results in reduced blood flow rates and a shorter functional survival life in the patient. 

Improper placement (such as kinking at the point of entering the vein, poor position of the tip within the blood vessel, or picking a blood channel that is too narrow for the device), blood stasis, and hypercoagulability conditions of the blood can all cause dialysis catheter dysfunction.

Microbial infection: Even with a high blood flow rate, infection can arise. To avoid infection, make sure one follows the catheter care instructions exactly as they were given. One should be aware of the following signs and symptoms of a catheter infection and report them to their respective doctors or dialysis team as soon as possible so that one can receive prompt treatment. The following are some of the indications and symptoms of a catheter infection: Fever, Chills, Drainage from the exit location of the catheter, Around the catheter exit site, there may be redness or pain, Illness and a general sense of weakness. 

Therapeutic interventions to treat complications: Treatment options vary depending on the type of illness, but they could include:

• If the infection is an exit site infection, an ointment is applied directly to the diseased area.

• If there is drainage from the exit site, antibiotic medicine should be taken.

• If the infection has progressed to the blood, an intravenous IV antibiotic (a solution containing an antibiotic that is injected straight into a vein) may be used.

     Clinical significance of catheters in enhancing healthcare outcome:

Catheters used to treat chronic renal failure may need to be in place for several months and should be cleaned and cared for with the proper materials. Many dialysis catheters are composed of polyurethane, a thermoplastic that softens when exposed to body heat while maintaining tensile strength.

 Alcohol (a regularly used disinfectant), most antibiotics (excluding triple antibiotic ointment), and polyethylene glycol (a common component in ointments) all inhibit it.  

Some contemporary catheters are composed of silicone, which is more flexible and softer than polyurethane. As a result, the catheter must have larger walls to prevent the line from collapsing or kinking. It is more compatible with ointments, although iodine, another often used disinfectant, weakens it.

A multidisciplinary team involving Nephrologists, anesthesiologists, critical care nurses, and advanced non-medical practitioners are among those who insert and manage dialysis catheters. They should be aware of the distinctions and indications for the many types of dialysis catheters on the market, while most of them perform similarly, they are all susceptible to a variety of technical obstacles and complications. The catheter is normally looked after by the nurse who is caring for the patient.

A substantial proportion of patients with end-stage renal illness – up to 50% in some studies – require immediate initiation of renal replacement treatment via a central venous catheter. 

The Kidney Disease Outcome Quality Initiative now recommends that central venous catheters be used in less than 10% of chronic hemodialysis patients, and that catheter-based treatment regime should only be used if other options, such as AV fistulas and grafts, are ineffective or have failed.

Common FAQs:

What to do if the catheter is not functioning properly?

• If the physician orders a lower blood flow rate, it means the catheter isn’t working properly. If this happens more than once in a week, the catheter should be replaced. The patient will receive less dialysis when the blood flow rate decreases. To get the right amount of dialysis, the patient would require a longer hemodialysis session than usual.

• The pre-pump arterial pressure alerts could be another clue that the catheter isn’t working properly. These sounds alert the medical staff that the catheter (or other vascular access) is preventing a free blood draw. This could indicate that a clot is growing in the catheter, preventing blood flow.

What can be done to remove catheter associated blockage? 

Tissue plasminogen activator (tPA)., a “clot-busting” drug, is used to treat the condition. Most dialysis centers can administer the drug while the patients are seated in their dialysis chair, saving them a trip to the hospital. 

tPA can be given soon before the patient’s next dialysis appointment, if they are nearing the conclusion of the treatment. Enquiring with the doctor about one can get them this drug before their next therapy session.

The catheter can become entirely occluded if the clot is not treated when signs and symptoms of an early clot are discovered. One may be needed to go to the hospital or vascular lab to have the catheter evaluated and maybe replaced with a new one.

How is the medication given to such patients with indwelling catheters?

The drug is injected straight into the catheter opening by the respective healthcare professional. To break down the clot, it must stay inside the catheter for 30 minutes. If enough blood flow is not restored after 30 minutes, the doctor can repeat the procedure.

How to check the working efficiency of the catheter?

• Learning everything you can about the current treatment plan, including the blood flow rate and how often and for how long one needs treatments.

• Strict adherence to the treatment plan.

• Keeping regular checks with dialysis appointments

• Arriving on time for scheduled hemodialysis treatments

• Asking the doctor how much dialysis one should be getting. 

• Keeping a record of the Kt/V and URR numbers. Talking and seeking advice from the physician and entire dialysis team if the numbers are not as good as they should be.

• The patient should check the flow rate the doctors prescribed.

• To check given clot-dissolving medicine if the flow rate drops?

• To ensure if dialysis treatment is disrupted if the clot-dissolving medications are taken? And what follows to the rest of the treatment if that’s the case?

• The patient must also ask doctors about the different therapeutic interventions and methods that would be used to insert the clot-busting drug or any medications into the catheter and how long they must wait for it to function?

• The patients should also report and seek advice regarding the symptoms and indicators of an infection?

How should one take a bath with indwelling catheters in place?

• It is preferable to take a shower rather than a bath. While showering, keeping the bag or valve linked to the catheter is needed. If one has a leg bag, make sure it’s always below the level of your bladder. Urine may occasionally seep down the urethra.

• Use of perfumes, deodorants strictly inhibited. One must stay away from scented soap, perfume, talcum powder, antiperspirants, bubble bath, bath salts, and creams/lotions.

• Washing from front to back is recommended for women, especially after a bowel movement.

• Uses of catheters in men:

If men are not circumcised, drawing back the foreskin and cleaning the area would be needed underneath to avoid building a smegma ring, which can cause irritation and soreness.

After that, the foreskin must be returned to its original position. If not, a painful swelling known as paraphimosis may occur. If this happens, getting medical help right away is necessitated.

If the foreskin is too tight to draw back (phimosis), one can damage themselves. Informing the nurse, will help the patient to clean beneath the foreskin with a syringe full of lukewarm tap water.

Can catheters be reused?

The number of times one can use a catheter is limited by the manufacturer.

Some catheters are only used once, while others can be used multiple times. Single-use catheters should not be reused, according to the Department of Health.

The following information will be helpful if one decides to reuse a catheter.

Using many catheters at the same time, rotating their use is a possibility provided the following measures are taken into consideration. 

Replacing the catheter is essential as directed by the manufacturer, which is normally every three months, but one may need to replace it more frequently if necessary.

If the surface becomes rough or sticky, discarding the catheter is required.

Filling a water bottle with cooled, boiling water every morning to use for cleaning the catheters while you’re gone.

Before handling or cleaning the catheter, sanitizing or washing hands is very important.

Helpline for general concerns regarding catheters use and hemodialysis?

• Finding a doctor or a general practitioner or nephrologist in the locality, where the patient resides.

• Finding a GP (General practitioner) urgent care clinic (external site)

• Visiting healthdirect.com (external website) or calling toll free number 1800 022 222 for procuring further information.

      Resources for patients with hemodialysis and catheters: 

• Dialysis Patient Citizens- Dialysis Patient Citizens (DPC) is the nation’s biggest patient-led group dedicated to improving dialysis patients’ quality of life. https://www.dialysispatients.org/

• Kidney Smart® Kidney Smart provides no-cost kidney education classes that may be completed from the convenience of one’s own home. https://www.davita.com/education/kidney-smart-classes

• National Kidney Foundation (NKF) In the United States, the National Kidney Foundation, Inc. is a large non-profit health organization.

The National Kidney Foundation is a prominent non-profit health organization dedicated to preventing kidney illness, improving the health and well-being of people with kidney disease, and increasing the number of kidneys available for transplantation. https://nkfs.org/

• Dialysisfinder.com- Dialysis Center search. https://www.dialysisfinder.com/

• Find a Dialysis Center – DaVita.com. To discover the DaVita Kidney Care dialysis center that best meets patient’s needs, use the Find a Dialysis Center Tool or contact a placement specialist.

• Life Options Rehabilitation Program. Life Options is a research, research-based education, and outreach programme started in early 90’s to help people with chronic renal disease live longer and better lives. https://lifeoptions.org/

• American Kidney Fund. The American Kidney Fund was created as a non-profit organization with public funding. The AKF offers a wide range of kidney health awareness, education, and preventative activities. It offers financial support to those in need. https://www.kidneyfund.org/

Cost of catheters in India and common types?

• Catheter prices in India typically range from INR 20 to INR 90 per piece. The cost of a 100 no’s urine catheter ranges from INR 1200 to INR 9000. Silicone foley catheters and Medicare healthcare rubber foley catheters are commonly available catheter tubes. 

Conclusion: 

The importance of indwelling catheters in aiding patients with renal dysfunction is of paramount importance. Both cuffed and non-cuffed catheters can be utilized in hemodialysis and have different modes of insertion, functionality and working tenure. When comparing the long-term use of transcutaneous central venous catheters to other modalities of vascular access, complications originating from vascular access constitute a substantial cause of morbidity and mortality in dialysis patients. To limit the danger of infection, it is critical to maintain a high level of hygiene like adopting proper hand hygiene practices and proper use of catheters.