1 PERMCATH (PERMANENT CATHETER) OR SUBCLAVIAN CATHETER I. BACKGROUND History One day in the early 1940s, Dr. Alwall from Lund entered his living room and asked his wife whether in her opinion blood could be washed. She answered that theoritically everything could be washed and this probably started the adventure of clinical dialysis. Nevertheless, very little credit is given to Dr. Alwall; however, without his important contribution dialysis would probably have died in its early stages since experiments of Scribner and Kolff were not encouraging at the beginning. Dialysis, used as a substitute therapy for patients suffering from chronic renal failure, was introduced in early 1960s in Seattle, Wash. when Scribber and his collaborators worked out a technique for long-term vascular access and designed a complete device for preparing the dialysis solution. Again, the important contribution of Dr. Alwall should be acknowledged. Long-term vascular access was obtained by inserting a rigid Teflon tube into both the radial artery and one of the forearm veins. The dialysate was prepared in a
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1
PERMCATH
(PERMANENT CATHETER)
OR SUBCLAVIAN CATHETER
I. BACKGROUND
History
One day in the early 1940s, Dr. Alwall from Lund entered his living room
and asked his wife whether in her opinion blood could be washed. She
answered that theoritically everything could be washed and this probably
started the adventure of clinical dialysis. Nevertheless, very little credit is given
to Dr. Alwall; however, without his important contribution dialysis would
probably have died in its early stages since experiments of Scribner and Kolff
were not encouraging at the beginning. Dialysis, used as a substitute therapy
for patients suffering from chronic renal failure, was introduced in early 1960s
in Seattle, Wash. when Scribber and his collaborators worked out a technique
for long-term vascular access and designed a complete device for preparing the
dialysis solution. Again, the important contribution of Dr. Alwall should be
acknowledged. Long-term vascular access was obtained by inserting a rigid
Teflon tube into both the radial artery and one of the forearm veins. The
dialysate was prepared in a container and refrigerated to avoid bacterial
contamination. A pump forced the dialysate into the filter in the opposite
direction of the bloodstream. The Kiil Kidney was used as a dialyzer. It was
composed of two sheets of plastic material cut into thin tubes which were
covered with sheets made of Cuprophan. During each dialysis session these
sheets formed two separate bags into which the blood was pumped by the
patient’s blood pressure. The same pressure permitted the blood to return into
the patient’s bloodstream, prior to heating through the venous line immersed in
a receptacle containing heated water.
Fig. 1. First generation of Scribner arteriovenous shunts
(Ronco, C., 2004: 2)
Vascular access is currently one of the biggest problems of chronic
dialysis. In 1972 Kopp et al. proposed a single-needle dialysis with a peristaltic
pump which alternatively aspirated and forced in order to achieve the
traumatism of a double puncture. The technique was proposed not just for
chronic dialysis patients but also for acute patients utilizing a jugular or a
femoral catheter as a vascular access. In 1973 for the same reason Van
Waeleghem et al. proposed a blood pump with a double head which allowed a
better blood flow and less recirculation of the vascular access. In 1980 Uldall et
al. designed a double-lumen catheter to place in the subclavia for short- and
medium-term treatments. With this type of access the patient undergoes just
one puncture of the vessels and the pump with a single head could achieve a
good blood flow with reduced recirculation of the vascular access. Since the
mid 1980s dialysis machines had blood pumps for single-needle treatments and
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systems for detecting blood flows and pressures in the blood circuit. At the
same time double-lumen catheters with different internal configurations were
developed (paralel flux or coaxial flux). In fact, to faciliate insertion, it is
possible to find catheter which are rigid at room temperature and soften once
they are inserted. Also different biomaterials are utilized including processes of
coating to prevent biofilm formation and infection/ thrombosis.
Fig. 2. Single-needle dialysis made it possible to treat patients with
difficult vascular access. For this, double-headed blood pumps
should be utilized. (Ronco C., 2004: 7)
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Fig. 3. Different double-lumen venous catheter. (Ronco C., 2004: 8)
Vascular access continues to be a significant economic, surgical, and logistic
problem for patients and their health care providers. In general, vascular access
success is directly related to the frequency of use of hemodialysis catheters, the
patency of the arteriovenous (AV) access (AVF versus AVG), and the prevalence
of subsequent catheter and access complications (i.e., infection, malfunction, and
thrombosis). The most cost-effective and lasting vascular access for hemodialysis
id the native (AVF) fistula, but an increasing number of patients have exhausted
their autogenous veins are required to have AVG or permanent cuffed dialysis
catheters.
But, in one study only 36,5% of ESRD (End-Stage Renal Disease) patients
were instructed to protect their forearm veins for subsequent AVFs and subclavian
catheters continue to be used for initial access (leading to continued problems
with outflow stenosis and thrombosis). Because approximately 40% of ESRD
patients have had less than 3 months of nephrology care, only 45% of patients
starting dialysis and 60% of patients after 30 days of dialysis had a permanent
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access (i.e., AVF or AVG) and subclavian catheters were used in 80% patients.
(Nissenson R. Allen and richard N. Fine, 2008: 49-40)
Vascular Access around the world
The Dialysis Outcomes and Practice Patterns Study (DOPPS) is undoubtedly a
rich international resource of epidemiological data pertaining to practice patterns
related to VA (Vascular Access) outcomes worldwide. A brief overview of the
study design of this major international effort is therefore pertinent. DOPPS phase
I was initiated as an international, prospective observational study of HD practice
patterns in 7 countries (France, Germany, Italy, Japan, Spain, the United
Kingdom, and the Unted States). Phase II began in the spring of 2002, and the
study has now been expanded to include 5 additional countries (Australia,
Belgium, Canada, New Zealand, and Sweeden). Briefly, nationally representative
samples of randomly selected HD facilities were recruited in each country.
Facility selection was stratified to provide proportional sampling by geographic
region and type of dialysis facility within each country. The DOPPS used uniform
data collection instruments translated into the native language of each country to
allow for direct comparison of HD practices across countries and dialysis
facilities.
Among incident HD patients, 65-67% of new ESRD patients in Japan and
Europe initiated HD with an AVF compared with 15% in the US. In contrast, 24%
new HD patients in the US compared wth only 3% in Europe and Japan used
synthetic grafts.
Catheter use is very common among new ESRD patients, with 60% of US
patients and 31% of HD patients in Europe starting dialysis with a catheter.
(Ronco C., 2004: 16)
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II.DEFINITION
Hemodialysis, is the most often used treatment for end-stage renal disease
(ESRD), more commonly known as kidney failure. During a hemodialysis
treatment, a machine pumps blood from the body by way of a flexible plastic
tube, cleans it and then returns it to the body through a separate tube. In order
to perform hemodialysis, an acces must be created. An acces is a site from
which blood can be safely removed and returned to the body. The acces site is
often referred to as the ‘lifeline’.
If the kidney disease has progressed quickly, and there is not enough time
to get a permanent vascular access before starting hemodialysis treatments. A
venous catheter can be used as a temporary access. Which is the insertion of a
tube into a vein in the chest/ subclavian vein (Subclavian Catheter), neck
(Jugular) or leg near the groin (femoral). (US Department of Health and
Human Services, National Institutes of Health, 2008: 2)
Subclavian Catheter is one of central venous catheter for hemodialysis
which has largebore double-lumen catheters that are inserted percutaneously
into subclavian vein. (Black, Joyce M., 2009: 36)
Subclavian catheter is kind of double lumen catheters, these are made of
plastic polymers and are used for temporary dialysis. They are inserted under
strict aseptic techniques percutaneously using a guide wire into a large vein in
subclavian. (Al khader, 2005)
Permanent catheter (subclavian catheter) is one of temporary access
options, which is placed the catheters into the subclavian vein under the
collarbone on the chest. Catheters which are used should be flexible, hollow
tubes which allow blood to flow in and out of the body. They are most
commonly used as a temporary access for up to three weeks. (www.aakp.org
accessed february 17th, 2011 at 11.09 pm)
Although brand names such as Quinton Catheter, VasCath, and PermCath
are commonly used as slang to describe hemodialysis catheters, in actuality
there is a wide assortment of available catheters. Temporary (nontunneled,
uncuffed) catheters are primarily composed of polyurethane, which is stiff at