What are the plans for the third packing of the Internal Jugular (IJ) site for Angelica Mae Madrigal Regalado, a 28-year-old female with Chronic Kidney Disease (CKD), Stage 5, and secondary complications?

From the Guidelines

The plan for Angelica Mae Madrigal Regalado, a 28-year-old female with Chronic Kidney Disease (CKD), Stage 5, is to avoid using the Internal Jugular (IJ) site for the third packing due to the high risk of central venous stenosis and thrombosis associated with long-term catheter use, as recommended by the clinical practice guidelines for vascular access 1.

Patient Preparation for Permanent Hemodialysis Access

To minimize the risk of complications, it is essential to prioritize the creation of a functional permanent access, such as an arteriovenous fistula (AVF) or arteriovenous graft (AVG), which can provide adequate blood flow for dialysis and reduce the need for temporary access 1. The patient should be counseled about the importance of preserving upper-extremity veins and avoiding the use of peripherally inserted central catheters (PICCs) due to the high incidence of upper-extremity thrombosis and central venous stenosis 1.

Vascular Access Options

The patient's treatment plan should focus on creating a permanent vascular access, such as an AVF or AVG, which can be used for long-term dialysis. The Work Group recommends that AVFs be created at least 6 to 8 weeks before the anticipated need for dialysis therapy to allow for maturation and to minimize the risk of complications 1. If an AVG is required, it should be placed 3 to 6 weeks before use to allow for maturation and to reduce the risk of infection and other complications 1.

Monitoring and Management

The patient requires close monitoring of her bleeding site, with regular dressing changes and assessment for signs of infection. Hemostatic agents may be applied locally to control the bleeding, and complete blood count and coagulation studies should be monitored to assess the severity of the acquired coagulopathy 1. Additionally, the patient's hyperkalemia, anemia, and hypertension should be managed with appropriate medications and dietary restrictions, and her fluid status should be carefully monitored to prevent overload while maintaining adequate hydration.

Key Considerations

• Avoid using the Internal Jugular (IJ) site for the third packing due to the high risk of central venous stenosis and thrombosis 1
• Prioritize the creation of a functional permanent access, such as an AVF or AVG, to minimize the risk of complications 1
• Monitor the patient's bleeding site, complete blood count, and coagulation studies closely, and manage her hyperkalemia, anemia, and hypertension with appropriate medications and dietary restrictions 1

From the Research

Plans for the Third Packing of the Internal Jugular (IJ) Site

There are no specific research papers that provide plans for the third packing of the Internal Jugular (IJ) site for Angelica Mae Madrigal Regalado, a 28-year-old female with Chronic Kidney Disease (CKD), Stage 5, and secondary complications. However, the following information can be gathered from the available studies:

• The selection of the type of permanent vascular access (VA) and its location is crucial in patients with CKD 2.
• The internal jugular vein is a reliable and preferred route for hemodialysis catheterization, with a low complication rate 3.
• Ultrasound-guided placement of internal jugular vein catheters is very safe with a high success rate and few complications, and can be performed in high-risk patients 4.
• The use of central venous catheters (CVC) should be reserved for temporary use only, whenever possible, and their main indications include the need for urgent hemodialysis, inability to establish an adequate VA, and hemodialysis for short periods while waiting for a living donor kidney transplant 2.

Considerations for CVC Placement

When considering CVC placement, the following factors should be taken into account:

• The first choice for CVC placement is the right internal jugular vein, followed by the left internal jugular vein, the external jugular vein, and the femoral veins 2.
• The tip of the CVC should be placed at the entry of the right atrium for nontunneled catheters and within the right atrium for tunneled catheters 2.
• Placement of CVC in the jugular and subclavian vein should be confirmed radiologically 2.
• The use of femoral catheters should be limited to hospitalized (bedridden) patients due to higher infection and dislodgement rates 2.

Complications Associated with CVC Placement

The following complications can be associated with CVC placement:

• Infection 3
• Venous thrombosis 3
• Catheter thrombosis 3
• Hematoma 3
• Wrong cannulation 3
• Hemothorax and pneumothorax 3
• Traumatic pneumothorax 5
• Catheter-associated deep venous thrombosis 5
• Catheter-associated infections 5