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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 2  |  Page : 184-185
Emergency resuscitative dialysis: The importance of identification of cannulation site


Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India

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Date of Web Publication3-May-2010
 

How to cite this article:
Rao P B, Gurjar M, Azim A, Baronia AK. Emergency resuscitative dialysis: The importance of identification of cannulation site. Ann Card Anaesth 2010;13:184-5

How to cite this URL:
Rao P B, Gurjar M, Azim A, Baronia AK. Emergency resuscitative dialysis: The importance of identification of cannulation site. Ann Card Anaesth [serial online] 2010 [cited 2022 Jan 29];13:184-5. Available from: https://www.annals.in/text.asp?2010/13/2/184/62931


Sir,

A 38-year-old female was admitted to ICU with shock and renal failure requiring urgent venous access for renal replacement therapy. A dialysis catheter was inserted in femoral vessel with some difficulty due to ongoing hypotension. Continuous renal replacement therapy was started. In due course of therapy the patient recovered from shock and also renal failure. The dialysis support was thus terminated after three days of commencement. The coagulation profile was normal. On removal of the dialysis catheter there was massive gush of arterial blood coming out of the insertion site leading to hemodynamic instability requiring fluid resuscitation and prolonged manual pressure to achieve hemostasis. Neither limb ischemia nor thromboembolism was encountered after catheter removal and compression following it.

Usually the physician can easily recognize an arterial puncture by the pulsatile blood flow and the bright red color. In patients with significant hypoxemia and/or reduced circulatory flow (shock), this distinction may be difficult. Therefore inadvertent arterial cannulation may be mistaken for a successful venous cannulation. Though ultrasound guided cannulation has resulted in substantial decrease in procedure related complications, [1],[2],[3] this practice is not yet the standard of care for want of ultrasound machines.

Although dialysis may be undertaken safely and effectively through an arterial catheter; [4] one must strive early identification of appropriate site of catheter placement, in order to avoid likely complications due to wrong vessel cannulation. When in doubt, we recommend determination of catheter placement after resuscitation by any one of the methods: 1) Identifying the vessel cannulated by the pressure measurement on pressure manometer present on the panel of dialysis machine 2) Connecting the catheter to pressure transducer to see the pressure waveform on the hemodynamic monitor; 3) blood gas analysis, of the sample from the catheter. [5]

If unintended arterial cannulation occurs, its identification and early removal should be planned, which will avoid complications such as limb ischemia or thromboembolism. Severe bleeding at time of catheter removal as it happened in this case may also be avoided. If subclavian artery has been cannulated, possible assistance from vascular surgeon may be necessary prior to catheter removal. It is reasonable therefore to conclude that dialysis may be carried out without checking the type of the vessel cannulated while carrying out emergency resuscitative dialysis, however, a check must be carried out soon after a stable situation is reached.

 
   References Top

1.Lameris JS, Post PJ, Zonderland HM, Gerritsen PG, Kappers-Klunne MC, Schutte HE. Percutaneous placement of Hickman catheters: Comparison of sonographically guided and blind techniques. AJR Am J Roentgenol 1990;155:1097-9.  Back to cited text no. 1      
2.Mallory DL, McGee WT, Shawker TH, Brenner M, Bailey KR, Evans RG, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Chest 1990;98:157-60.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med 1996;24:2053-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Frampton AE, Kessaris N, Hossain M, Morsy M, Chemla ES. Use of the femoral artery route for placement of temporary catheter for emergency haemodilysis when all usual central venous access sites are exhausted. Nephrol Dial Transpl 2008;10:582.  Back to cited text no. 4      
5.Taylor R, Palagiri A. Central venous catheterization: Concise definitive review. Crit Care Med 2007;35:1390-6.  Back to cited text no. 5      

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Correspondence Address:
Mohan Gurjar
Assistant Professor, Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226014, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.62931

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