How should an exposed dialysis catheter due to skin erosion be treated and what's the best approach for placing a new catheter to avoid recurrence in a patient with a history of skin erosion with tunneled catheters?

Management of Exposed Dialysis Catheter and Prevention of Recurrence

The exposed dialysis catheter due to skin erosion should be immediately removed and replaced with a new catheter at a different site, as exposed catheters represent a surgical emergency due to high risk of infection and bleeding. 1

Assessment and Management of the Exposed Catheter

• The exposed catheter over the clavicle represents a serious complication with high risk for infection, as the catheter is now colonized by microorganisms within 24 hours after insertion 1
• Skin erosion with catheter exposure is considered a surgical emergency that necessitates prompt recognition and definitive management 1
• The current catheter should be removed as it cannot be salvaged due to the breach in the protective barrier between the catheter and external environment 1
• Before removal, blood cultures should be obtained to rule out catheter-related bloodstream infection (CRBSI) 1
• Empiric antibiotic therapy should be initiated if there are any signs of infection, with coverage for both gram-positive and gram-negative organisms 1

Placement of New Catheter

• A new tunneled dialysis catheter should be placed on the contralateral side (right side in this case) 1
• The new catheter placement should avoid the previous tunneling technique that led to erosion 1
• For the new catheter, consider the following modifications:
  • Use a deeper subcutaneous tunnel that avoids pressure on thin skin areas 1
  • Avoid tunneling directly over bony prominences like the clavicle 1
  • Create the tunnel in a more inferior position on the chest wall, away from the clavicle 1
  • Consider a more lateral exit site placement to reduce tension on the skin 1

Prevention of Recurrence

• Given this patient's history of skin erosion on both sides, special attention must be paid to prevent recurrence:
  • Select a catheter with appropriate size and flexibility to minimize pressure on overlying skin 2
  • Create a deeper tunnel with more subcutaneous tissue between the catheter and skin 1
  • Consider placing the exit site in the lower chest or upper abdomen where skin is typically thicker 1
  • Use meticulous exit site care with dry gauze dressings rather than transparent film dressings 1
  • Apply antimicrobial ointment (povidone-iodine or mupirocin) at the exit site during dressing changes 1, 3

Ongoing Care and Monitoring

• After placement of the new catheter:
  • Perform dressing changes at each dialysis session using aseptic technique 1
  • Staff and patient should wear surgical masks during all catheter procedures 1
  • Monitor the exit site and tunnel for any signs of infection or skin thinning 1
  • Consider antibiotic lock solutions for the new catheter to prevent infection 4
  • Implement hub care protocols to decrease catheter-related bacteremia rates 1

Long-Term Considerations

• Evaluate the patient for creation of an arteriovenous fistula (AVF) or graft (AVG) as soon as possible 1
• The goal should be to transition away from catheter dependence, as guidelines recommend cuffed catheter use in less than 10% of patients 1
• If the patient continues to have issues with skin erosion, consider:
  • Alternative catheter materials or designs 2
  • Lower profile catheter hubs 2
  • More frequent assessment of the tunnel and exit site 1
  • Surgical consultation for possible alternative access planning 1

Pitfalls and Caveats

• Attempting to salvage an exposed catheter with local wound care alone is contraindicated due to the high risk of infection 1
• Placing a new catheter on the same side or using the same tunnel pathway will likely result in recurrent erosion 1
• Guidewire exchange is not appropriate in this case due to the exposed catheter and compromised tunnel 5
• Delay in addressing the exposed catheter increases risk of serious infection and potentially life-threatening complications 1
• Patients with thin, friable skin may require more frequent monitoring and specialized care to prevent recurrent erosion 1