What are the procedural steps and requirements for the insertion of a double lumen catheter in a patient, considering their medical history and the need for safe and effective access for dialysis or renal replacement therapy?

Double Lumen Catheter Insertion: Procedural Requirements and Steps

For hemodialysis or renal replacement therapy, double-lumen catheters should be inserted via the right internal jugular vein as the preferred site, using strict aseptic technique, with tunneled cuffed catheters for anticipated use >3 weeks and non-tunneled catheters for short-term access <3 weeks. 1, 2

Pre-Procedure Patient Evaluation

Critical History Elements

• Previous central venous catheter placement - strongly associated with central venous stenosis that may preclude ipsilateral access 1
• History of transvenous pacemaker - correlates with central venous stenosis 1
• Previous arm, neck, or chest trauma/surgery - may have damaged target vasculature 1
• Dominant arm assessment - to preserve non-dominant arm veins for future arteriovenous fistula creation 1
• Coagulation status - abnormal coagulation may cause clotting or hemostasis problems 1

Physical Examination Requirements

• Bilateral upper extremity blood pressures - to assess arterial adequacy 1
• Examination for arm edema - indicates venous outflow obstruction 1
• Assessment for collateral veins - indicative of venous obstruction 1
• Evidence of previous catheterization sites - may limit available access 1

Catheter Selection Algorithm

Duration-Based Selection

• <3 weeks anticipated use: Non-cuffed percutaneous catheter acceptable 1
• >3 weeks anticipated use: Tunneled cuffed catheter (Broviac, Hickman type) mandatory 1
• Permanent access (exhausted other options): Tunneled cuffed catheter 1

Lumen Number Decision

• Single-lumen preferred when only dialysis/CRRT needed - infection rates 0-5% versus 10-20% with multi-lumen 1, 3
• Double-lumen standard for hemodialysis/CRRT - this is the catheter of choice 2
• Triple-lumen acceptable only when multiple simultaneous incompatible therapies required (e.g., dialysis + inotropes) with one lumen dedicated exclusively to each purpose 1, 3

Material Selection

• Silicone or polyurethane required for long-term use - less thrombogenic and traumatic than stiffer materials 1
• Antimicrobial-coated catheters (minocycline/rifampin or chlorhexidine/silver) should be considered for short-term use (<30 days) in high-risk patients but NOT for long-term PN 1, 3

Vein Site Selection Priority

First Choice: Right Internal Jugular Vein

• Preferred for mid-term use - facilitates mobilization, reduces infection risk 2
• Lower stenosis risk compared to subclavian 2

Second Choice: Left Internal Jugular Vein

• Acceptable alternative when right IJV unavailable 1

Third Choice: Femoral Vein

• Only for bed-bound patients 1
• Maximum 5 days duration for non-cuffed femoral catheters 1

ABSOLUTELY AVOID: Subclavian Vein

• Never use in patients with chronic kidney disease stage 3-5 - high risk of central venous stenosis destroys future permanent access options 1, 2
• Precludes entire ipsilateral arm for future arteriovenous fistula if stenosis develops 1

Procedural Steps for Insertion

Pre-Insertion Preparation

• Ultrasound guidance mandatory for internal jugular vein access 1
• Strict aseptic technique - full barrier precautions (sterile gown, gloves, large drape, mask, cap) 3
• Patient positioning - Trendelenburg position for IJV access to distend vein and reduce air embolism risk 1

Insertion Technique for Tunneled Cuffed Catheter

1. Local anesthesia at both venipuncture and tunnel exit sites 1
2. Ultrasound-guided venipuncture of target vein 1
3. Guidewire advancement under fluoroscopic guidance 1
4. Subcutaneous tunnel creation - typically 10-15 cm from venipuncture to exit site 1
5. Catheter advancement through tunnel with cuff positioned 2 cm inside tunnel 1
6. Dilator insertion over guidewire 1
7. Catheter tip positioning - lower third of superior vena cava or upper right atrium under fluoroscopy 1
8. Confirmation of blood return from both lumens 1

Catheter Tip Position Verification

• Fluoroscopic confirmation required - tip must be in lower SVC or upper right atrium 1
• Post-procedure chest X-ray to confirm position and exclude pneumothorax 1

Post-Insertion Management

Immediate Care

• Do not use until position confirmed radiographically 1
• Heparin lock both lumens if not immediately used 1
• Secure catheter to prevent displacement 1

Ongoing Catheter Maintenance

• Dedicate catheter exclusively to dialysis/CRRT when possible - dramatically reduces infection risk 1, 3
• Avoid blood sampling through catheter - increases manipulation and infection risk 1, 3
• Modified purge protocol - use only 2 mL per lumen instead of traditional 7-10 mL to reduce blood loss from 2680 mL/year to 888 mL/year 1

Maturation Time Before Use

• Non-tunneled catheters: Immediate use acceptable 1
• Tunneled cuffed catheters: Can be used immediately but ideally allow 3 weeks for tunnel adherence 1

Critical Pitfalls to Avoid

Vein Preservation Errors

• Never place subclavian catheters in CKD patients - destroys permanent access options 1, 2
• Never place catheter ipsilateral to maturing AV fistula - may compromise fistula development 3
• Avoid venipuncture of cephalic veins - preserve for future fistula creation 1

Infection Prevention Failures

• Never use dialysis lumen for medication boluses or blood sampling - dramatically increases CRBSI risk 1, 3
• Never interrupt inotrope infusion through dedicated lumen for other purposes 3
• Never skip full aseptic technique for any lumen manipulation 3

Timing Errors

• Do not insert catheter until dialysis actually needed - maximizes catheter lifespan 1
• Do not leave non-cuffed femoral catheters >5 days - infection risk escalates 1

Monitoring Requirements

For Dialysis Use

• Catheter flow rates should achieve 200-250 mL/min 4
• Monitor for inadequate flow, coagulation, displacement - most common failure modes 4

For Combined Dialysis + Inotrope Use

• Continuous ECG telemetry mandatory during inotrope infusion 3
• Plan transition to separate access as soon as clinically feasible 3

Infection Surveillance

• Monitor exit site daily for erythema, drainage, tenderness 1
• Catheter-related bloodstream infection rates: 10-20% with multi-lumen versus 0-5% with single-lumen 1, 3