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Volume: 20 Issue: 3 March 2022 - Supplement - 1

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Use of Peripheral Insertion Central Venous Catheter in Kidney Transplant Patients: An Alternative

Abstract

Kidney transplantation continues to be the treatment of choice in patients with end-stage chronic kidney disease. Unfortunately, most patients in the adult population have coexisting diseases. Anemia, platelet dysfunction, and changes to the cardiovascular system are not the exception in the evolution of the disease. This group of patients has an increased risk of intraoperative and postoperative complications associated with the general conditions of their body and other complications related to the surgical procedure. For this reason, adequate control of fluids and electrolytes under adequate monitoring and hemodynamic support are essential; these can optimize the patient’s vital signs and improve the conditions of the implant to guarantee proper functioning. In this series, 18 kidney transplant recipients with peripheral insertion central venous catheter were reviewed. There was an acceptable rate of success with proper placement. No complications inherent to the installation technique were found. In all patients, the installation was successful.


Key words : Coexisting diseases, Hemodynamic support, Intraoperative complications

Introduction
The incidence of kidney disease in the world population has been increasing. The prevalence is approximately 13.1% in the adult population. In the United States, 1 in 10 adults have chronic kidney failure (patients >65 years of age), equaling about 26 million people.1 In developing countries, chronic kidney disease is associated with advanced age, obesity, diabetes, and high blood pressure. In Mexico, chronic kidney disease is the result of various chronic degenerative diseases, among which diabetes mellitus and arterial hypertension stand out, which both show similar manifestations in the population. In Mexico, the incidence of patients with chronic renal failure is estimated at 377 cases per million inhabitants and a prevalence of 1,142 per million population.2

The current functional status and the complications of kidney disease can affect different organs and systems, influencing patient prognosis. Patients with kidney disease have been shown to have higher levels of inflammation and procoagulant markers, which are associated with adverse cardiovascular events; these are the main causes of death in this patient group.3

Patients with kidney disease have different cardiovascular risk factors prior to transplant, such as dyslipidemia, arterial hypertension, atherosclerosis, diabetes mellitus, and peripheral arterial disease, among others, that contribute to important intraoperative hemodynamic events.2,4

Structural changes in the heart can also occur, such as left ventricular hypertrophy, increased end-diastolic pressure, and ventricular dilatation and dysfunction. In 1 study, 13% to 34% of patients on dialyses showed low left ventricular ejection fraction of less than 50%.4

Between 13% and 50% of patients with chronic kidney disease tend to have pulmonary hypertension, which increases over time for those patients who require renal replacement therapy with dialysis; this may be due to volume overload, changes in cardiac contractility, and high flows from the arteriovenous fistula.5

Electrolyte alterations, particularly hyperkalemia and changes in serum sodium and calcium levels, in addition to states of metabolic acidosis and changes in capillary permeability with interstitial fluid leakage, tend to cause interstitial and pulmonary edema, increasing the state of stress and hypoxia. Bleeding due to platelet dysfunction caused by uremia and preexisting chronic anemia secondary to insufficient erythropoietin production are important risk factors to consider during surgery, representing a challenge in the management of these patients.6

Consequently, an understanding of the cardiovascular system and its routes of ingress is indispensable to the management and care of these patients. The use of ultrasonography has revolutionized access to the central vessels. The first publication in this regard was in 1984, which described the placement of a central venous catheter through the internal jugular vein. In the 1990s, a series of studies with proposals for ultrasonograph-guided techniques were increased to reduce the rate of complications and improve the success rate in their placement.7,8

Central access through the peripheral vein approach has become popular in different medical disciplines, showing successful results and reducing the rate of complications in critical patients. These benefits have led to recently created training for its installation in various hospital centers.9

Materials and Methods
Under the approval of the Ethics and Research Committee of the General Hospital of Queretaro (Santiago de Querétaro, Mexico) and the support of the transplantation department, 18 patients were included in this study. Patients were candidates for kidney transplant from a living donor and for placement of a peripherally inserted central venous catheter (PICC) during perioperative management. Inclusion criteria were as follows: age over 18 years, physical and functional status (per the American Society of Anesthesiologists classification system) of 3 or 4, presence of chronic end-stage kidney disease, patients scheduled for surgery, and consent to participate in the procedure. No financial support was provided to any site, and there were no conflicts of interest.

For this study, variables that were used to evaluate the invasive procedure included catheter insertion characteristics (insertion date, anatomical site placement), type of catheter (caliber and product brand), associated complications (adverse symptoms, site injuries, and related anatomical structures), and information related to the use of the intravenous catheter (types of intravenous fluids and medications, active vasopressor support).

All patients were under balanced general anesthesia by intravenous induction. All catheters were placed by the same operator with sterile technique and field placement; a 5F central venous catheter of 2 lumens of 55 cm in length was inserted in the peripheral venous access of the forearm guided by portable ultrasonography with a 10- to 5-MHz linear transducer. All data were collected and processed using SAS statistical software.

Results
The installation of the catheter was successful in all 18 patients. Among these, there were 10 men and 8 women with mean age of 52 ± 9 years. The average body mass index (in kilograms divided by height in meters squared) was 24.6 in men and 22.1 in women. The mean time of installation of the PICC catheter was 12 ± 3 minutes. In 4 patients, a technical difficulty occurred for insertion of the catheter, resulting in its installation in the contralateral arm and in alternate veins. No infections associated with the puncture site were noted. No patient reported pain. In addition, there was no documentation of hematoma formation or peripheral nerve injury. The most accessible site for insertion of the PICC catheter was the basilica vein (in 39% of patients), as shown in Figure 1 (right).

In all patients, venous access was used for the administration of vasoactive drugs and supply of intravenous fluids as well as adjuvant medications, doses of steroids, antibiotics, diuretics, and mannitol, with no noted incidents or complications. The correct position of the PICC catheter was corroborated with a control chest radiography (Figure 2), finding the tip at the junction of the superior cava with the right atrium. Only 2 patients had catheter dysfunction in the postoperative period during hospitalization due to the lack of heparinization of the ports in use. Figure 3 shows placement of the kidney graft in a recipient during surgery.

Discussion and Conclusions
The PICC catheter can be an alternative to cannulate a central line, thus avoiding arterial punctures, hematoma formation, nerve injuries, and puncture of the pulmonary pleura. The PICC catheter had an acceptable and reliable success rate for proper placement. No complications inherent to the installation technique were found; in addition, direct ultrasound visualization allowed certainty of placement. Because of its low rate of complications and easy use, the PICC catheter can be an option in patients with kidney disease who represent a challenge due to the complexity of their vascular access.

Peripheral venous insertion may be helpful in renal patients with thrombosed venous access and a history of multiple punctures or who have shown difficulty with access to the chest and neck. This method can reduce the risks of arterial puncture, nerve injury, and complications associated with the conventional technique.


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Volume : 20
Issue : 3
Pages : 153 - 155
DOI : 10.6002/ect.MESOT2021.P79


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From the Cardiothoracic Anesthesia and Ultrasound Perioperative from the Departments of Transplantation and Anesthesiology, Servicios de Salud Del Estado de Queretaro, Hospital General de Querétaro, Santiago de Querétaro, México
Acknowledgements: The author has no sources of funding for this study and has no conflicts of interest to declare.
Corresponding author: Juan Carlos Delgado Márquez, Cardiac Surgery and Transplant programme. Av. Jose Antonio Garcia Jimeno num 1000, Col. Jardines de la Hacienda, CP 76180. Santiago de Querétaro, Mexico
Phone: +52 01 442 430 0924.120
E-mail: cjuanc@hotmail.com.