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