What is the recommended care for a patient with a permanent catheter (perm cath) and internal jugular catheter (IJ cath) to prevent complications?

Permanent Catheter and Internal Jugular Catheter Care

For permanent hemodialysis catheters placed in the internal jugular vein, prioritize the right internal jugular site, use maximal sterile barrier precautions during insertion, prepare skin with 0.5% chlorhexidine in alcohol, inspect the exit site daily, and maintain strict aseptic technique during all catheter manipulations to minimize infection and thrombotic complications. 1, 2

Optimal Site Selection for Permanent Catheters

• The right internal jugular vein is the preferred site for tunneled permanent hemodialysis catheters because it provides the most direct route to the caval-atrial junction and is associated with lower complication rates compared to left-sided or femoral approaches. 1, 3

• The right internal jugular approach reduces risks of poor blood flow, stenosis, and thrombosis that are more common with left internal jugular placement, which also jeopardizes the left arm's vasculature for future access. 1

• Avoid femoral vein placement for permanent catheters due to significantly higher infection rates (particularly at the groin exit site) and increased thrombotic complications. 1, 2

• The subclavian site should be avoided in hemodialysis patients and those with advanced kidney disease because of the risk of subclavian vein stenosis, which can compromise future permanent access options. 1, 2

Insertion Technique and Precautions

• Use ultrasound guidance during internal jugular catheter insertion to reduce the number of cannulation attempts and minimize mechanical complications such as carotid artery puncture, hematoma, and malposition. 1, 2

• Apply maximal sterile barrier precautions including cap, mask, sterile gown, sterile gloves, and a sterile full-body drape during catheter insertion. 1, 4

• Prepare the skin with 0.5% chlorhexidine in alcohol before insertion; if chlorhexidine is contraindicated, use tincture of iodine, iodophor, or 70% alcohol as alternatives. 1, 4

• Allow antiseptics to dry completely according to manufacturer recommendations before catheter placement. 1

• Confirm catheter tip position at the caval-atrial junction or superior vena cava with chest X-ray after insertion and before use to exclude complications and ensure optimal blood flow. 1, 3

Daily Catheter Site Care

• Inspect the catheter exit site daily by palpation through the dressing to detect tenderness, or by visual inspection if using a transparent dressing. 1, 2

• Use either sterile gauze or sterile transparent semi-permeable dressing to cover the catheter site. 1

• If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until resolved. 1

• Replace the catheter site dressing immediately if it becomes damp, loosened, or visibly soiled. 1

• Do not use topical antibiotic ointment or creams on dialysis catheter insertion sites, as this can promote fungal infections and antimicrobial resistance. 1

Catheter Access and Maintenance

• Use the minimum number of catheter lumens essential for patient management to reduce infection risk. 1, 2

• Maintain strict aseptic technique during all catheter manipulations and dialysis connections. 1

• For nonfunctional catheters without signs of infection, consider treatment with thrombolytic agents (historically urokinase at 5,000 U/mL to fill the catheter lumen, though current practice may use alteplase) rather than immediate replacement. 1

• Do not submerge the catheter or catheter site in water; showering may be permitted with appropriate waterproof covering. 1

Monitoring for Complications

Infectious Complications

• Internal jugular catheters carry higher infection risk than subclavian catheters, with catheter-related bacteremia rates of approximately 6.5 episodes per 1,000 catheter days for temporary catheters. 1, 5

• Monitor for signs of exit site infection (erythema, tenderness, purulent drainage), tunnel tract infection, or systemic infection (fever, chills, bacteremia). 1

• Remove the catheter promptly if exit site, tunnel tract, or systemic infections develop that do not respond to conservative management. 1

• Staphylococcus aureus and coagulase-negative staphylococci account for the majority of catheter-related bloodstream infections. 5

Thrombotic Complications

• Be aware that subclinical internal jugular vein thrombosis occurs in approximately 40% of patients with jugular catheters, though most remain asymptomatic. 6

• Monitor for signs of symptomatic thrombosis including arm swelling, pain, or superior vena cava syndrome. 2

• The cumulative risk of thrombosis increases linearly with duration of catheterization. 5

Mechanical Complications

• Early mechanical complications include carotid artery puncture (4.5-11.3%), local bleeding, hematoma, and catheter malposition. 7, 8

• Monitor for inadequate blood flow rates during dialysis, which may indicate catheter malfunction, malposition, or thrombosis. 8

• Catheter tip malposition increases risk of thrombosis, vessel erosion, and cardiac complications. 2

When to Remove or Replace the Catheter

• Promptly remove any catheter that is no longer essential for patient care to minimize complication risk. 1

• Remove catheters immediately if there are signs of tunnel tract infection, persistent bacteremia despite appropriate antibiotics, or catheter-related septic thrombophlebitis. 1

• For catheters inserted during medical emergencies where aseptic technique could not be ensured, replace within 48 hours. 1

• Consider catheter exchange over a guidewire for nonfunctional catheters without signs of infection, though this does not reduce infection risk compared to new site insertion. 5

Common Pitfalls to Avoid

• Do not use the left internal jugular vein when the right side is available, as left-sided placement has higher rates of stenosis, thrombosis, and poor blood flow. 1

• Avoid placing catheter tips too proximal in the superior vena cava or into the right atrium proper, as this increases thrombosis and cardiac perforation risk. 2, 3

• Do not delay catheter removal once permanent vascular access (arteriovenous fistula or graft) has matured, as prolonged catheter use increases cumulative infection and thrombosis risk. 1

• Diabetic patients have significantly higher risk of exit site infections (hazard ratio 10), requiring more vigilant monitoring. 5