New Dialysis catheter problems

[caffeinatedRN]

You have dialysis orders on a patient post perm cath placement. Patient arrives from the OR, you verify placement and get them ready for the tx. You check the catheter for patency and have no issues - noting a smooth push and pull. You hook the patient up, everything runs ok for a little bit... and then the problems start. You start getting the venous and/or arterial pressure spikes, alarms, and overall feeling of frustration. You stop the machine and flush the catheter, noticing a huge difference with sluggishness of pull and push. Your wonderful, tedious adventure of a poor functioning perm cath has begun!

This doesn't seem to happen on all perm caths immediately post surgery, just most of them. The possible theories are post surgical trauma induced swelling which either constricts the catheter and/or displaces it a bit...or the increased clotting response r/t trauma - or both. Does anyone know exactly why this happens? What are some ways around this?

Postponing dialysis is generally out of the question. Stopcocks (3-way) have been useful to limit the stopping of the tx and constant disconnection of lines to flush ports with saline syringes (reduces infection risk as well). Heparin is generally a no-go right after surgery for obvious reasons. Some MDs may give a little heparin bolus (usually don't), some may suggest a Retavase/Alteplase medication instilled, others just say: try your best.

Any suggestions?

[melindaketo]

After 11 years of hemo experience what I have usually noted is that after a few days the new catheter works fine. It's most likely post op swelling setting in. Once that swelling goes down the flow improves. Does this sound right?

[caffeinatedRN]

Yes, that's what I lean towards. That 10% or so that don't give problems - I'm just curious if that is just a result of a skilled surgeon...something controllable.

[pbilbrey]

I agree it could be due to edema, It could also have gotten up against the wall.

Sometimes can lay client down more have turn the head one way or the other, cough see if any of those work. Some will even try placing an IV bag on the site to see if that helps. Can also turn the BFR down see if that helps but if you notice a sluggish that was not there before the start something has changed. If in acute setting could always ask for another CXR it could have coiled or something since had just been put in.

The alteplase isn't used anymore where I work due to high risks involved. Besides if a brand new cath shouldn't have a clot issue that fast unless the pt has clotting issues.

[drugstorecowgirl214]

As a previous poster said the tip gets up against the wall of a vessel or the can slip a bit. So, if the cath was too short to start with it won't "pull" as easily or if at all. Again, the pt will need it exchanged.

These problems aren't at all uncommon. I work in a renal vascular access center and we do these type cases often.