Can temporary dialysis catheters be placed in the right atrium?

Placement of Temporary Dialysis Catheters in the Right Atrium

Temporary dialysis catheters should not be placed in the right atrium due to increased risks of serious complications including atrial perforation, thrombus formation, and arrhythmias. 1, 2

Optimal Catheter Tip Positioning

Recommended Position

• For temporary dialysis catheters:
  • The catheter tip should be positioned at the caval-atrial junction or in the superior vena cava 1
  • Chest x-ray confirmation is mandatory after placement to verify proper positioning 1

Risks of Right Atrial Placement

• Right atrial placement of dialysis catheters is associated with:
  • Atrial perforation requiring surgical intervention 3
  • Right atrial thrombus formation 4, 5, 2
  • Pulmonary embolism 4
  • Cardiac arrhythmias 1
  • Cardiac tamponade 1

Evidence-Based Recommendations

The National Kidney Foundation KDOQI guidelines specifically address this issue:

1. For tunneled cuffed catheters:

   • "Fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The catheter tip should be adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood flow." 1
   • However, this recommendation for right atrial positioning applies only to catheters composed of soft compliant material such as silicone, not to temporary catheters 1

2. For non-cuffed (temporary) catheters:

   • "Chest x-ray is mandatory after subclavian and internal jugular insertion prior to catheter use to confirm catheter tip position at the caval atrial junction or the superior vena cava" 1

Catheter Placement Considerations

Preferred Insertion Sites

1. Right internal jugular vein (first choice) 1

   • Offers most direct route to the caval-atrial junction
   • Lower risk of complications compared to other sites
   • Associated with better flow rates

2. Alternative sites (in order of preference):

   • Right external jugular vein
   • Left internal/external jugular veins
   • Femoral veins (for short-term use only)
   • Translumbar access to inferior vena cava
   • Subclavian veins (last resort due to risk of stenosis) 1

Placement Technique

• Use real-time ultrasound guidance for insertion to reduce complications 1
• Fluoroscopic guidance is essential for proper tip placement 1
• For femoral catheters, minimum length should be 19 cm to minimize recirculation 1

Complications of Right Atrial Placement

A 2003 study found that all five hemodialysis patients with right atrial thrombi had catheter tips positioned in the right atrium. The authors concluded that "positioning the distal segment of the central venous catheters in the right atrium should be avoided" 2.

Another study reported that in four of five cases of right atrial thrombus, the catheter tip was positioned within the right atrium, suggesting that this placement increases the risk of this serious complication 4.

Duration Considerations

• Non-cuffed femoral catheters: Use for no more than 5 days and only in bed-bound patients 1
• Non-cuffed internal jugular catheters: Use for no more than 1 week 1
• For access needed longer than 3 weeks: Use tunneled cuffed catheters instead of temporary catheters 1

In conclusion, while tunneled cuffed catheters made of soft compliant materials may be positioned at the caval-atrial junction or in the right atrium under specific circumstances, temporary dialysis catheters should be positioned at the caval-atrial junction or in the superior vena cava to minimize the risk of serious complications.