Goldstein S

Thrombotic Complications of Indwelling Central Catheters Used for Chronic Hemodialysis

A new double-lumen silicone-rubber dialysis catheter, designed to be placed surgically in central veins, is now available. There is little published data concerning the long-term use of this catheter for hemodialysis, but a review of the literature suggests that pericatheter thrombus formation with or without occlusion of major veins has been a complication of chronic central venous catheterization with a variety of catheters, in both dialysis and nondialysis settings. We had this catheter placed in four diabetic patients who had severe problems related to maintenance of adequate vascular access. Two of the four patients underwent venography within 3 months of catheter placement because of impaired catheter function and were found to have thrombi on the outside of their catheters. These thrombi could not be dissolved with fibrinolytic agents, and the catheters were removed surgically without incident. The other two patients have no radiologic evidence of thrombus formation 4 and 7 months, respectively, after catheter placement. We suggest that proper selection of patients for this type of vascular access should be the subject of future studies and that patients with malfunctioning catheters undergo venography to rule out the presence of significant catheter related thrombosis.

Comparison of Coaxial and Side-By-Side Double Lumen Subclavian Catheters With the Single Lumen Catheter

Subclavian catheters are increasingly being used for vascular access. Many double lumen catheters (DLCs) have been designed to alleviate the need for a single-needle machine. Clinical studies comparing the safety of various DLCs with single lumen catheters (SLCs) are scarce. This study compares our experience with Sh-SLCs (Single-Shiley), Vas-DLCs (Coaxial-Vascath), and Qu-DLCs (Side-by-Side, Quinton). Similar aseptic insertion and handling techniques were used. The catheters were filled with heparin at the end of dialysis (HD) and no interdialytic infusions were given. Fifty-two Sh-SLCs were inserted in 46 patients for 253 HDs, 71 Vas-DLCs in 47 patients for 185 HDs, and 51 Qu-DLCs in 38 patients for 215 HDs. HDs/catheter were 4.9, 2.6, and 4.2, the percent incidence of septicemia was 2%, 7%, and 0%, and the catheter failure was 11%, 48%, and 16% for Sh-SLCs, Vas-DLCs, and Qu-DLCs, respectively (P less than 0.05 Vas-DLC v Sh-SLC and Qu-DLC). The poor flow problems were more frequent on the left side with Vas-DLCs (16/31) and Qu-DLCs (7/17), but not with Sh-SLCs (2/25). Other major complications were not noted. These results suggest that infections and mechanical problems may be more frequent with Vas-DLCs than Sh-SLCs and Qu-DLCs. Use of Qu-DLCs is a safe and may be preferred since a single-needle machine is not required. Insertion of a DLC on the right side may be preferred due to higher mechanical problems on the left side.

Retroperitoneal feeding tube for peritoneal dialysis patients

Treatment of the cachetic, hypoalbuminemic, peritoneal dialysis patient represents a vexing patient management problem. In the past, when the cause of inanition was intractable vomiting secondary to gastroparesis, the solution was to create a transperitoneal percutaneous enterogastrostomy. This endoscopic procedure bypassed the nonfunctioning stomach and allowed for adequate nutrition. When hypoalbuminemia is present, the patient is predisposed to the possible complications of peritoneal sepsis, dialysis fluid leak, and wound dehiscence. The authors report a unique, enteric feeding tube that is a solution to the problem of continuing adequate, complication-free dialysis in a cachetic, hypoalbuminemic peritoneal dialysis patient with no available site for either temporary or permanent hemodialysis vascular access. The procedure does not violate the peritoneal cavity and has proven to be effective, acceptable to the patient, apparently safe, and easy for both staff and patient use.

Variable Efficacy of Calcium Carbonate Tablets

Orally administered calcium carbonate tablets are commonly prescribed as a calcium supplement and for their phosphate-binding effects in renal failure patients. Two cases are reported in which a commercially available brand of calcium carbonate tablets appeared to be ineffective. Formal investigation of the bioavailability of this product revealed it to have impaired disintegration and dissolution and a lack of clinical efficacy. Recommendations that will enable physicians to avoid prescribing and pharmacists to avoid dispensing ineffective calcium carbonate tablets are proposed.