Renal Replacement Catheter Placement

Published Date: 19th July 2016

Publication Authors: Lyons MW, Miller T

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BACKGROUND.  This audit was conducted in response to work conducted by Kam et al¹ analysing tracer uptake from adjacently positioned central venous catheters (CVC) and haemofiltration (HF) lines. They found that if the CVC was positioned less than 2cm distal to the tip of the HF catheter, or proximal to it, then notable tracer (creatinine) uptake was observed. In clinical practice this would result in under dosing.

OBJECTIVE.  To establish the rate of relative misplacement occurring on the critical care unit at Whiston University Teaching Hospital, Liverpool. The standard for the audit was that all line placements meet the criteria described by Kam.

METHOD.  A retrospective data collection was performed using the hospital's electronic data management system (EDMS) and radiology viewer. An eighteen month period (1st June 2009 - 30th November 2010) was chosen and a list of all patients receiving renal replacement therapy (RRT) during this time obtained from ongoing audit data. Admissions were analysed on EDMS and the patients receiving long term dialysis through fistulae, Hickman lines, or peritoneal dialysis catheters were excluded from data collection. Those non-dialysis patients needing acute RRT had the point of HF line insertion identified. Those patients with a HF line then had their records checked for the concurrent use of a CVC and its insertion site. If the patient had both lines positioned in the superior vena cava, then chest radiographs were examined to ascertain whether relative placement of each was deemed acceptable according to Kam's criteria. Occasions of bifemoral placement were also sought.

RESULTS.  Data collection identified 136 separate incidences when RRT was offered. Of these, 27 patients received long term RRT and were excluded. 1 further case had insufficient data evident for inclusion. 1 case had a HF inserted without the presence of a CVC. Of the remaining 107 incidences, 11 cases were highlighted with radiological confirmation of inappropriate line positioning in the superior vena cava (both internal jugular and subclavian approaches). One case was also deemed inappropriate based on bifemoral catheterisation without documented tip insertion distances. In no circumstance did repositioning occur. Critical care unit mortality was 5/12 (41.7%) in those with misplacement compared with 32/94 (34.0%).

CONCLUSIONS.  The audit revealed a relative misplacement rate of 11.2% which was above the desired standard. This was likely given that the research was very recent, and was yet to be disseminated. There was no significant mortality difference given the small numbers although the absolute risk reduction observed was 7.7%.

Lyons, MW and Miller T. (2012).  Renal replacement catheter placement on a general intensive care unit . Intensive Care Medicine. 38 (Supplement 1), S262 

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