What are the recommendations for Quinton (double lumen catheter) placement for dialysis in patients with impaired renal function?

Recommendations for Quinton Catheter Placement for Dialysis

For patients requiring dialysis access, the right internal jugular vein is the preferred site for Quinton (double lumen) catheter placement, with ultrasound guidance mandatory during insertion and confirmation of tip position by chest radiograph before use. 1

Vein Selection Priority

When choosing a vein for dialysis catheter insertion, follow this order of preference:

1. First choice: Right internal jugular vein
2. Second choice: Femoral vein (with limitations)
3. Third choice: Left internal jugular vein
4. Last choice: Subclavian vein (avoid if possible)

The right internal jugular vein is preferred because it offers a more direct route to the right atrium than left-sided veins, with lower risk of complications and better blood flow rates 1.

Catheter Type Selection

For Short-Term Use (≤1 week):

• Use uncuffed nontunneled dialysis catheters
• Only appropriate for hospitalized patients
• Femoral uncuffed catheters only for bed-bound patients and for less than 5 days 1

For Long-Term Use (>1 week):

• Use tunneled cuffed catheters (TCCs)
• Have plan to convert any short-term catheter to long-term catheter within 1 week 1

Proper Placement Technique

1. Use ultrasound guidance for all dialysis catheter insertions (Level 1A recommendation) 1
2. Tip position:
   • Short-term catheters: Position tip in the superior vena cava
   • Long-term catheters: Position tip within the right atrium for optimal flow 1
3. Confirm placement with chest radiograph before first use (Level 1B recommendation) 1
4. For femoral catheters: Use catheters at least 19-24 cm long to reach the IVC to minimize recirculation 1

Important Considerations

• Avoid subclavian vein for catheter placement due to high risk of central venous stenosis, which can permanently exclude the possibility of using the entire ipsilateral arm for future vascular access 1
• Avoid placing catheters on the same side as a maturing arteriovenous access 1
• For patients with kidney transplant potential: Avoid femoral catheter placement to prevent stenosis of the iliac vein (used for kidney transplant anastomosis) 1
• Blood flow requirements: Select catheters capable of delivering blood flow rates of 350 mL/min at prepump pressures not more negative than 250 mm Hg 1

Catheter Complications and Management

Common Complications:

• Infection (exit site, tunnel, or systemic)
• Thrombosis
• Inadequate blood flow
• Central venous stenosis

Prevention Strategies:

• Strict adherence to aseptic technique during insertion
• Proper exit site care
• Avoid subclavian placement
• Use ultrasound guidance for insertion

Long-Term Considerations

While tunneled cuffed catheters can provide reliable access for dialysis, they should be considered a bridge to more permanent access when possible. Studies have shown that mortality is 2.2 times higher for patients who remain on hemodialysis catheters compared to those using arteriovenous fistulas 1. Patients with catheters also experience higher rates of infection and lower blood flow rates, potentially requiring longer dialysis times 1.

For patients in whom creation of conventional vascular access is difficult, tunneled catheters can provide reliable access for extended periods, with some studies showing functional catheters for over a year 2, 3, 4.

Remember that proper catheter placement and maintenance are essential for maximizing catheter lifespan and minimizing complications in patients requiring dialysis access.