Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders>>>>>Renal Replacement Therapy
Question 2#

A 44-year-old male with a long-standing history of insulindependent diabetes mellitus is admitted to the intensive care unit (ICU) with diabetic ketoacidosis. He has acute kidney injury (AKI) and is being started on hemodialysis in the ICU.

Which of the following is the LEAST preferred route for vascular access insertion for renal replacement therapy (RRT)?

A. Right internal jugular vein
B. Left internal jugular vein
C. Femoral vein
D. Subclavian vein

Correct Answer is D

Comment:

Correct Answer: D

The site and length of vascular access catheters play an important role in the provision of optimal RRT. The subclavian vein is the least preferred route for vascular access insertion intended for RRT. Contact of the catheter with the vessel wall and subsequent thrombosis could result in vessel stenosis, jeopardizing the possibility for an arteriovenous fistula in case the patient remains dialysis-dependent.

Right internal jugular vein is the preferred vein for hemodialysis access as the vein takes a straight path into the superior vena cava (SVC). Access through the left internal jugular vein requires the catheter makes two right angles prior to reaching the SVC resulting in a higher incidence of catheter dysfunction. The length of the catheter is equally important with optimal flows occurring when the catheter tip is positioned in the right atrium SVC junction for internal jugular access and in the inferior vena cava for femoral access. Appropriate lengths of catheters need to be chosen for this purpose. The right internal jugular, femoral, left internal jugular, and subclavian are recommended in order as options for vascular access in patients requiring RRT. The right internal jugular vein should be the first consideration for hemodialysis access. 

References:

1. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl. 2012;2(1). Section 5, Chapter 5.4.
2. Gemmell L, Docking R, Black E. Renal replacement therapy in critical care. BJA Educ. 2017;17(3):88-93.
3. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis. 2006;48(Suppl 1):S2-S90.
4. Hernández D, Díaz F, Rufino M, Lorenzo V, Pérez T, Rodríguez A, et al. Subclavian vascular access stenosis in dialysis patients: natural history and risk factors. J Am Soc Nephrol. 1998;9(8):1507-1510.