What are the recommended types of catheters for patients requiring dialysis?

Recommended Types of Dialysis Catheters

For patients requiring dialysis, tunneled cuffed catheters (TCCs) are recommended for temporary access of >3 weeks' duration, while arteriovenous fistulas remain the preferred permanent access option. 1

Hierarchy of Vascular Access Options

• Arteriovenous fistula (AVF) is the vascular access of choice for maintenance hemodialysis due to lower infection rates and better outcomes 1, 2
• Arteriovenous graft (AVG) should be considered when an AVF is not possible 2
• Tunneled cuffed venous catheters should be used only when other options are exhausted or as a bridge while waiting for AVF/AVG maturation 1

Types of Dialysis Catheters

Short-Term Catheters

• Uncuffed hemodialysis catheters (non-tunneled) should only be used in hospitalized patients and for less than 1 week 1
• Uncuffed femoral catheters should only be used in bed-bound patients and not left in place longer than 5 days 1
• Short-term catheter tips should be positioned in the superior vena cava and confirmed by chest radiograph or fluoroscopy 1

Long-Term Catheters

• Tunneled cuffed catheters (TCCs) are recommended for access lasting more than 3 weeks 1
• Long-term catheter tips should be positioned within the right atrium for optimal flow, confirmed by fluoroscopy 1
• Catheters capable of rapid blood flow rates (350 mL/min at prepump pressures not more negative than 250 mm Hg) are preferred 1

Catheter Materials and Design

• Silicone and polyurethane are the preferred materials for dialysis catheters 1
• Silicone is more compatible with infusates but more prone to compression and "pinch-off" 1
• Polyurethane is tougher and stiffer but more susceptible to degradation by various drug solvents 1
• Antimicrobial-coated catheters (minocycline and rifampin) have shown reduced risk of catheter-related bloodstream infections (CRBSI) 1

Preferred Insertion Sites

When choosing a vein for insertion of a dialysis catheter in patients with acute kidney injury (AKI), consider these preferences 1:

• First choice: right jugular vein
• Second choice: femoral vein
• Third choice: left jugular vein
• Last choice: subclavian vein with preference for the dominant side

Important Considerations

• Ultrasound guidance should be used for all dialysis catheter insertions 1
• Chest radiograph should be obtained promptly after placement and before first use of internal jugular or subclavian dialysis catheters 1
• Long-term catheters should not be placed on the same side as a maturing AV access, if possible 1
• Femoral catheters should be of sufficient length to reach the inferior vena cava to deliver adequate blood flow 1

Catheter Care Strategies

• Use of 2% chlorhexidine with 70% alcohol for exit-site care has been shown to reduce bloodstream infections by approximately 20% 3
• Proper patient education on catheter care is essential to prevent mechanical issues and infectious complications 4
• For catheter locking solutions, sodium bicarbonate has shown similar safety and efficacy compared to antibiotic locking solutions 5

Pitfalls to Avoid

• Prolonged catheter use is associated with increased mortality (51% increase) and severe infection (130% increase) compared to AVF/AVG 1
• Subclavian vein access should be avoided when possible due to risk of central venous stenosis, which may limit future access options 1
• There should always be a plan to either discontinue or convert any short-term catheter to a long-term catheter within 1 week 1
• Routine replacement of catheters at scheduled intervals is not recommended as it does not reduce infection rates 1

By following these evidence-based recommendations for dialysis catheter selection and management, healthcare providers can minimize complications and optimize outcomes for patients requiring dialysis.