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.
Key Considerations
- The patient's CKD stage 5 and secondary complications require careful management of her vascular access to minimize the risk of further complications.
- The use of peripherally inserted long-term catheters (PICCs) and venous ports is associated with a high incidence of upper-extremity thrombosis and central venous stenosis, making them a less desirable option for patients with CKD 1.
- Ideally, patients should have a functional permanent access at the time of dialysis therapy initiation, which can be achieved through the creation of a primary fistula or placement of an arteriovenous graft (AVG) 1.
Recommendations
- The patient should be evaluated for a permanent vascular access, such as a primary fistula or AVG, to minimize the risk of complications associated with long-term catheter use.
- The patient's current dialysis schedule should be maintained through her functioning vascular access, while the IJ catheter site is avoided for further use.
- Close monitoring of the patient's coagulation parameters, anemia, and hyperkalemia is necessary to prevent further complications.
- Pain management and management of other conditions, such as hypertension and possible heart failure, should be continued with appropriate medications and interventions.
Vascular Access Management
- The patient's vascular access should be managed according to the Rule of 6s, which includes a blood flow of approximately 600 mL/min, a diameter greater than 0.6 cm, and a depth of approximately 0.6 cm from the skin surface 1.
- Regular hand-arm exercises, with or without a lightly applied tourniquet, may improve the chances of successful fistula development and should be recommended to the patient 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: