To the Editor,
Vein access is commonly used to carry out diagnostic and therapeutic procedures, but the right preparation is essential due to the complications. With vein access the patient’s position is crucial, dorsal decubitus being the most commonly used. Haemodialysis requires a permanent vascular access. However, the use of transitory catheters is an alternative as they provide immediate access to the bloodstream and enable effective dialysis to be performed in an emergency. They are used when it is impossible to use arteriovenous (AVF) or prosthetic fistulas because of an urgent need for dialysis or due to dialysis failure,1 or in acute kidney failure. In this last case, the access of choice is the femoral vein,2 followed by the jugular and subclavian veins. Occasionally, inserting a catheter into these veins in not possible due to clinical conditions (obesity, vein stenosis, generalized oedema, local infection, etc.), or orthopnoea in the case of thoracic veins. These situations may delay or hinder the procedure.3 In these cases a median approach to the internal jugular vein with the patient in a semi-seated position is proposed.
We describe here the technique, duration of catheterisation, complications, and outcome of patients who had a catheter inserted for haemodialysis with this approach between 1 September 2007 and 1 September 2008. Insertion protocols and medical histories were analysed.
The technique used was as follows: the patient was semi-seated, head turned away from insertion side. Then under local anaesthetic, the needle was inserted at a 45º angle with the skin at the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle, and is directed toward the ipsilateral nipple. It then followed the classic Seldinger technique.
An analysis was performed of 25 accesses in patients with AKF or acute on CKF4 requiring emergency haemodialysis. The right internal jugular vein was the most used, in 18 cases (72%), and was chosen in accordance with the doctor's experience. The duration of catheterisation was 25 (5) days; five (20%) were removed when treatment finished after kidney function was restored, 10 (40%) as the permanent vein access was started to be used, and 10 (40%) due to death secondary to the outcome of the underlying disease. The complications observed were prolonged bleeding at the site of insertion in 3 patients (12%) and increased vascular resistance in one patient (4%). There were no severe complications.
The femoral vein approach is recommended for emergency haemodialysis due to its low rate of complications. However, it has the disadvantage that catheterisation must not exceed 8 days, mainly due to the risk of infection-related complications or the patient has absolute contraindications such as thrombosis or local infection, or relative contraindications such as obesity, burns, etc. The internal jugular vein is the route of choice for inserting catheters for longer than 8 days, as this access can be used for long periods with a lower incidence of complications. Subclavian veins are no longer used as their cannulation is associated with many serious complications (haemothorax and pneumothorax) and because of the risk of vascular stricture.5 Looking at the literature, vein access techniques to the subclavian and internal jugular vein require the patient to be in dorsal decubitus. Sometimes this position is difficult due to dyspnoea or orthopnoea, which is not uncommon, especially if we consider that many patients with acute kidney failure have a pulmonary oedema. Thus, the femoral vein is contraindicated, and the semi-seated position is opted for, inserting catheters quickly and safely, guided by the anatomy of the neck. This could be an alternative technique with patients needing emergency dialysis or suffering from orthopnoea, as our experience shows that it results in fewer complications.
