Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 63

Figure 1. A chest x-ray showing small bilateral pleural effusions. Based on this image, the catheter tip was reported to be in the superior vena cava. hemodialysis temporarily held. Blood was drawn from the catheter and sent for blood gas analysis, which revealed pH 7.44, pCO2 38 mm Hg, and pO2 125 mm Hg, with an oxygen saturation of 97%. This confirmed the intraarterial position of the catheter. The patient’s coagulopathy was corrected. She subsequently underwent surgical removal of the arterial dialysis catheter with repair of the carotid artery at the catheter insertion site. A new tunneled dialysis catheter was placed in the left internal jugular vein under ultrasound guidance with catheter tip placement confirmed by fluoroscopy. During the hospital course, a kidney biopsy was attempted to determine the etiology of her nephrotic syndrome. The procedure was aborted due to technical difficulties. She was placed empirically on steroids for treatment of suspected glomerulonephritis. Residual kidney function never recovered where adequate volume management or solute clearance was possible. Thrice weekly hemodialysis was resumed while she continued steroids. Hemodialysis was initially tolerated with the help of intradialytic albumin, but the patient did not tolerate it over the succeeding sessions due to recurring hypotension. A right heart catheterization was ultimately done to evaluate her pulmonary hypertension. Results revealed mild pulmonary hypertension and a very low cardiac output. A repeat 24-hour creatinine clearance after 2 weeks of steroids revealed a clearance of 7 mL/ min. Due to her poor cardiac status, advanced age, and inability to tolerate dialysis, the patient and family decided to pursue comfort care and to stop dialysis. Figure 2. A CT scan with pulmonary embolus protocol showing the dialysis catheter to be in the ascending aorta. DISCUSSION Hemodialysis catheters are large-bore CVCs that have remained a frequent modality of both acute and chronic dialysis vascular access in the United States. A large percentage (80%) of patients initiating dialysis do so via a catheter, with some continuing to chronically dialyze through it due to the inability to obtain or unavailability of an adequate arteriovenous access. Hemodialysis catheters are classified into two categories: acute or nontunneled and chronic or tunneled catheters. Insertion of these catheters follows the same principles of CVC insertion, with the right internal jugular vein being the preferred insertion site due to easier catheterization, a relatively straight path to the superior vena cava and right atrium, high rates of cannulation success, and low rates