ACCESS VASCULAR

FOR
HEMODIALYSIS

dr. Sahal Fatah, Sp.BTKV

Cardio Thorax Vascular Department

Dr. Kariadi Hospital Semarang
 Central Venous Catheter For
Hemodialysis
 Type of catheter
 Single,
 Double,
 Triple lumen.

 Double lumen  venovenous dialysis/filtration.

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 Common routes
Internal Jugular Subclavian Femoral
Advantages :
Easy, used immediately, do not add to the
burden of heart
Disadvantages :
  Blood flow is not sufficient
  Not used
Complications :
V subclavian (hematothoraks /
pneumothorax)
Treatment :
Rinsing regularly between dialysis using
heparin solution
 Contraindications / cautions
 Coagulopathy
 Undrained pneumothorax on contralateral side
 Agitated, restless patient.

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 Complications

 Arterial puncture
 Haemorrhage
 Arrhythmias.
 Infection (Usually skin, occasionally sepsis
or endocarditis).
 Pneumothorax.
 Air embolism, venous thrombosis,
haemothorax, chylothorax (all rare).
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 Troubleshooting
 Excessive bleeding at the insertion
Direct compression & correct coagulopathy
 Local infection
(Staph. Epidermidis or Staph. Aureus) rises
> 5 days.
 Removal + change of site
Cellulitic or blood cultures taken through the
catheter are psoitive.

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 Pre Procedure Issues
Prior to beginning the
procedure, be sure that it is
indicated. You must obtain
a signed informed
consent.
Complete the identifying the
correct patient and
procedure.
Assure that both the level of
coagulation and
oxygenation are adequate.
 Pre Procedure Issues

You must employ strict

sterile technique.

Wash your hands (with

surgical hat and mask
already in place) with
bactericidal soap.

Scrub hard and let dry.

 Pre Procedure Issues

Surgical mask, gown

and gloves are required
for all personnel within
3 feet of the bed.
 Pre Procedure Issues

Put on your gloves

properly. Keeping your
hands covered by the
surgical gown, pick up
the glove and stretch it
over your covered hand.
 Central venous catheter - insertion

Landmarks
 Internal jugular :
 Halfway between mastoid process and sternal notch
 Lateral to carotid pulsation and medial to medial
border of sternocleidomastoid.
 Aim toward ipsilateral nipple, advancing under body of
sternocleidomastoid until vein entered.

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Landmarks
 Subclavian :
 3cm below junction of 1/3 lateraly and 2/3 medialy of
clavicle.
 Turn head to contralateral side.
 Aim for point between jaw and contralateral shoulder
tip.
 Advance needle subcutaneously to hit clavicle.
 Scrape needle around clavicle and advance further
until vein entered.
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Landmark

 Femoral :
 Locate femoral artery in groin.
 Insert needle 3 cm medially and angled
rostrally.
 Advance until vein entered.

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 Insertion technique

The Seldinger technique

1. Clean area with antiseptic and surround with

sterile drapes.
2. Anaesthetise local area with 1% lidocaine.
3. Flush lumen(s) of catheter with saline.
4. Use metal needle to locate central vein.
5. Pass wire (with ‘J’ or floppy end leading)
through needle into vein. Only minimal
resistance at most should be felt.
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6. Remove needle leaving wire extruding from skin
puncture site.
7. Depending on size/type of catheter to be
inserted, a rigid dilator (+ preceded by a scalpel
incision to enlarge puncture site) may be passed
over the wire to form a track through the
subcutaneous tissues to the vein.
8. Remove dilator.
9. Thread catheter over wire. Ensure end of wire
extrudes from catheter to prevent accidental loss
of wire in vein. Insert catheter into vein to depth
of 15-20cm. Remove wire.
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4. Check for flashback of blood down each lumen
and respiratory swing, then flush with saline.
5. Suture catheter to skin. Clean and dry area.
Cover with sterile transparent semi-permeable
dressing.
6. A chest X ray is usually performed to very
correct position of tip (junction of superior vena
cava & right atrium ) and to exclude a
pneumothorax. Unless in an emergency
situation, a satisfactory position should
generally be confirmed before use of the
catheter.
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 Carotid Pulse

Trachea

External
Jugular Sternocleidomastoid M.

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