40 Years of Continuous Renal Replacement Therapy. Группа авторов

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Fig. 1. The right internal jugular (RIJ) vein is the preferred access site because it is the straightest route allowing the highest blood flow (>300 mL/min). Femoral access is a reasonable alternative with no particular preference between right- (RF) or left-sided (LF) insertion. The subclavian (Scl) approach should be avoided.

      Catheter Colonization and Infection Risk

      Causal analysis of 20,000 catheter days demonstrated no difference in catheter-related infection between the RIJ and the femoral site. When stratifying to body mass index, a higher femoral catheter colonization rate was observed in the highest body mass index tercile [8].

      Catheter Dysfunction

Choice of vascular access site, catheter design, and competence of nursing staff in assuring correct circuit priming and monitoring, are all essential determinants of circuit survival [9, 10]. Early catheter dysfunction usually results from inadequate positioning (e.g., insertion in the wrong vessel, malposition of the catheter tip, catheter kinking) but may also be seen with strictures and hypovolemia [9, 10]. Late catheter dysfunction is most often due to thrombosis [9, 10]. Poor access causes blood flow reduction in the circuit leading to premature circuit clotting [9, 10]. The left internal jugular vein has a more tortuous path, which can lead to inadequate blood flow and early filter dysfunction [9, 10]. The subclavian access enhances the risk of catheter kinking and should be reserved for placing silicone catheters for chronic dialysis [1–3]. Femoral veins, though easily accessible in case of emergent resuscitation, do impair patient’s mobility and nursing care [11]. Low central venous pressure, high abdominal pressure, and high or very negative thoracic pressures may all result in a decreased catheter flow.

      Catheter Lock

When not in use, the CRRT catheter should be locked either by controlled saline infusion or by heparin or citrate provision to prevent fibrin adhesion [11]. A 30% citrate solution guarantees optimal patency of the catheter at the lowest bleeding risk. It also reduces the risk for Staphylococcus and Candida catheter sepsis by inhibiting biofilm formation inside the catheter [12].