DIRECT PERIPHERAL VENOPUNCTURE: ANOTHER NEW CHOICE OF TEMPORARY VASCULAR ACCESS

Abstract

Background. Femoral, subclavian, and internal jugular veins access have been widely used for temporary vascular access for hemodialysis, but their use has been associated with a significant complication rate. We report in three selected hemodialysis patients with the procedure of direct peripheral venopuncture as temporary vascular access to reduce complications.

Methods. We have demonstrated hemodialysis via direct puncture of peripheral veins of the antecubital fossa (cephalic vein in the process of arterial inflow to dialyzer and venous outflow from dialyzer to basilic vein) as temporary vascular access for these patients.

Results. Renal function of case 1 and case 2 progress to normal status after several sessions of dialytic therapy as well as quit hemodialysis, and case 3 successfully shifts to peritoneal dialysis following four sessions of dialytic therapy.

Conclusions. We recommend this short-term access contribute a important additional new choice in selected patients with acute, reversible renal failure, obstructive uropathy, initiation of peritoneal dialysis, patients on peritoneal dialysis with peritonitis, or under plasmapheresis therapy.

• Acute Renal failure
• Uremia
• Vascular access
• Hemodialysis

INTRODUCTION

Patients requiring hemodialysis frequently need temporary vascular access. Percutaneous venous catheterization, first described by Shaldon et al. [[1]] in 1963, is recently the method of choice for rapidly obtaining vascular access for hemodialysis. Because blood flows of 200–300 mL/min are required, venous cannulation is limited to large vessels such as the subclavian, internal jugular or femoral veins [[2]].

However, despite warnings in the literature on how to avoid injury to patients [[3]], there continue to be deaths from perforating injuries, a danger inherent in the catheter design [4-5]. More importantly, there continues to be a high incidence of venous thrombosis, stenosis, and systemic infectious rates [6-7].

In the three cases reported here, the patient exhibited rhabdomyolysis complicated with oliguric acute renal failure induced by a frog leaps, acute renal failure due to cardiogenic shock, and initiation of peritoneal dialysis with serious uremic symptoms and signs, hemodialysis was necessary for dialysis support in these cases. We report our favorable experience with direct venopuncture to cephalic vein in the act of arterial inflow to dialyzer and basilic vein while venous outflow from dialyzer to treat those patients. A new temporary vascular access with minimal complications has been developed and it is suitable for short-term hemodialysis in young patients with good venous vessels.

METHODS

Between February 1999 and June 1999, three patients were started on hemodialysis treatment in our unit with direct peripheral venous puncture as temporary vascular access. Dialysis is carried out in the usual fashion using the 16-gauge single needle technique. The 13 to 17-gauge single needles are usually used to direct arteriovenous fistula puncture for hemodialysis. The peripheral veins of the antecubital fossa are probably the sites of choice in patients with good venous vessels in whom the 16-gauge single needles are being planned as a temporary vascular access. Vascular access was approached via direct puncture of peripheral veins of the antecubital fossa with 16-gauge single needles owing to their good venous vessels. Arterial site of inflow to dialyzer through cephalic vein and venous outflow from dialyzer by way of basilic vein was practiced (Fig. 1).

Figure 1. Direct venopuncture to cephalic vein in the process of arterial inflow to dialyzer and venous outflow from dialyzer to basilic vein as temporary vascular access.

Blood flow through the extracorporeal circuit using standard arterial-venous tubing was maintained via a blood roller pump at a flow rate of 120 to 150 mL/min. The patients were dialyzed on hollow-fiber KF-201 dialyzer (polymer coupling membrane), and bicarbonate dialysis using Cobe or Baxter machines. The 16-gauge single needles were removed after every session of dialytic therapy.

RESULTS

Case 1

A 17-year-old male patient was admitted to the hospital with previous 12 hours dark brown urine. Generalized muscle ache of the patient also noted. Two days before presenting at the emergency department, he had performed the strenuous exercise as a frog leaps for more than 800 steps. Muscle pain and swelling gradually increased during exercise until the patient was difficult to move his lower extremities. Laboratory studies on admission revealed blood urea nitrogen 27 mg/dL, and creatinine 3.2 mg/dL. The remaining laboratory data were as follows: creatine kinase 480,007 U/L (normal, 15 to 130), lactate dehydrogenase 2,858 U/L (normal, 47 to 140), alanine aminotransferase 3,064U/L (normal, 0 to 34), and myoglobin 64,900 mg/mL (normal, <80). Urinary myoglobin level was 548 mg/mL. Urine was cloudy and dark brown and had trace amounts of ketones, blood, and protein. Specific gravity was 1.010. A diagnosis of acute rhabdomyolysis due to frog leaps related strenuous exercise was made. The patient was aggressively hydrated with normal saline solution and mannitol therapy to maintain a high urine output, and sodium bicarbonate was administered to keep the urine pH above 7.5.

His urine output decreased to 250 mL/day with increasing serum blood urea nitrogen to 33 mg/dL and creatinine was 6 mg/dL on hospital day 2. Because he was poor response to aggressive fluid replacement and mannitol administration still, oliguric acute renal failure developed. Renal replacement therapy with hemodialysis was arranged. Owing to his good venous vessels, vascular access was approached through direct puncture of cephalic vein as arterial site of inflow to dialyzer with 16-gauge single needle, and venous outflow from dialyzer by way of basilic vein also utilized 16-gauge single needle, too. On account of high creatinine level and oliguria persisted, we arranged another two sessions of hemodialysis on hospital day 5 and day 7. Repeated puncture the same peripheral veins as temporary vascular access to keep the blood flow rate around 120 to 150 mL/min was accomplished. His diuretic phase developed on hospital day 8. His creatinine reduced to 2.9 mg/dL on hospital day 12 and he discharged with smooth hospitalization course.

He was cautioned to limit his exercise to short periods until he had conditioned himself to the routine. Follow-up of laboratory data revealed normal creatinine kinase levels and normal renal function (creatinine 0.8 mg/dL) at outpatient department.

Case 2

A 46-year-old male was brought to the emergency room with severe dizziness and transient loss of consciousness. He had a history of hyper tension for 7 to 8 years under medical control. On examination, he looked weakness. His blood pressure was 80/40 mmHg. Initial investigations revealed complete AV block with low escape rhythm, and moderate renal impairment with a serum creatinine of 3.1 mg/dL. Arterial blood gas analysis (oxygen at 5 L/min by face mask) showed metabolic acidosis with pH 7.251, PO₂ 104.2 mmHg, PCO₂ 40.5 mmHg, bicarbonate 17.4 mmol/L, and base excess —9.3 mmol/L. Seizure was noted then endotracheal tube was inserted with ventilator, and temporary pacemaker were performance due to cardiogenic shock unresponsive to inotropic agents.

Coronary angiogram revealed two vessels disease (left anterior descending branch and left circumflex branch) and percutaneous transluminal coronary angioplasty was accomplished on hospital day 1. Because of acute renal failure, cardiogenic shock with acute pulmonary edema, metabolic acidosis, and hyperkalemia (potassium 5.7 meg/L), continuos renal replacement therapy (CRRT) was performed in the intensive care unit with the vascular access via femoral double lumen catheter. Complete AV block starting at third degree became first degree, therefore CRRT was dis continuous owing to stable hemodynamics on hospital day 4. Low-grade fever developed off and on, and catheter of femoral double lumen was removed under impression of catheter-related infection on hospital day 8.

On account of blood urea nitrogen gradual elevated from 34 to 85 mg/dL, and creatinine elevated from 3.1 up to 16.2 mg/dL, conventional intermittent hemodialysis had been performed successfully with direct puncture of peripheral veins of the antecubital fossa as temporary vascular access, using blood flow 120 to 150 mL/min, on hospital day 14. Diuretic phase developed at the following day with renal function ongoing improvement. The hospital course was uneventful, and at follow-up after 2 months, his creatinine had fallen to 1.4 mg/dL at outpatient department.

Case 3

A 36-year-old male presented with nausea and vomiting for two months. He was diagnosed as polycystic kidney disease at the age of 32 years. Renal function had worsened gradually within recent four years. On admission, he had a pale skin and conjunctiva, bilateral moist rales, and legs pitting edema. Laboratory tests revealed elevated blood urea nitrogen and serum creatinine (233 mg/dL and 15.9 mg/dL respectively). Hematological studies showed a hemoglobin level of 6 g/dL and hematocrit 18%. Renal replacement therapy was suggested, and he favored peritoneal dialysis therapy.

Before initiation of continuous ambulatory peritoneal dialysis (CAPD), because of severe uremic symptoms and signs, hemodialysis was performed on hospital day 1, 4, 7, and 9. During 4 dialytic sessions, we practiced direct venopuncture to cephalic vein as arterial inflow to dialyzer and basilic vein while venous outflow from dialyzer into circulation in the process of temporary vascular access with blood flow 120 to 150 mL/min.

The Tenckhoff catheter was set up for CAPD on hospital day 3. After one week course of CAPD education and skills training, he started regular CAPD from that time till now.

Previous 3 cases using direct peripheral venopuncture are summarised in Table 1.

Table 1. Summary of 3 Cases Using Direct Peripheral Venopuncture

	Case 1	Case 2	Case 3
Underlying disease	Acute renal failure due to rhabdomyolysis	Acute renal failure due to cardiogenic shock	Chronic renal failure in uremic stage
Vascular access	Cephalic & basilic veins	Cephalic & basilic veins	Cephalic & basilic veins
Blood flow rates	120–150 mL/min	120–150 mL/min	120–150 mL/min
Session	3	1	4
Outcome	Recovery	Recovery	Shifting to CAPD

DISCUSSION

Acute vascular access provides a rapid and temporary method of supplying the extracorporeal blood flow needed to perform hemodialysis. Clinical situations requiring emergent hemodialysis, such as volume overload, hyperkalemia, or certain types of poisonings, demand acute access placement. Acute access is also preferable for patients expected to require dialysis only temporarily, such as those with acute renal failure. Patients with chronic renal failure need acute access until permanent access can be established. Finally, acute vascular access may be needed for other blood purification interventions such as plasmapheresis [8-10].

The most popular locations for percutaneous venous cannula insertion are the subclavian, femoral, and internal jugular veins. The femoral vein has numerous advantages for percutaneous venous cannulation. Because of high venous pressure and mobility in the femoral region, it is customary to remove the catheter after each dialysis treatment to avoid bleeding or catheter dysfunction. The most common complications of femoral vein catheter insertion are infection and deep venous thrombosis [11-16]. Nonetheless, placement of either subclavian or internal jugular vein access can result in acute arterial puncture or pneumothorax [[13]], [[15]] or serious systemic infection [[12]], [16-19], while subclavian venipuncture can lead to chronic subclavian vein stenosis and can jeopardize the future success of fistulae or graft placement in the involved extremity [20-22].

We have demonstrated hemodialysis via direct puncture of peripheral veins of the antecubital fossa (cephalic vein in the act of arterial inflow to dialyzer and basilic vein while venous outflow from dialyzer) as temporary vascular access for these patients. We believe this access method has a number of advantages. The most important is its availability for short-term dialysis with minimal complications and cares. It also provides immediate availability for hemodialysis. The incidence of infection is very low due to no catheter retention and its related infection. This approach may significantly reduce the length of hospital stay for patients in whom it is used because of its low complication. This type of vascular access approach itself is economical and simple. This technique has many advantages, however, it also has some limitations, for example: repeated venopuncture sometimes results in damage to the veins, thrombophlebitis, extravasation, as well as poor blood flow rates (≤ 150 mL/min), and is not suitable for small vessels. The advantages and disadvantages of the various insertion sites are listed in Table 2.

Table 2. Advantages and Disadvantages of Acute Hemodialysis Catheter Insertion Sites

Insertion Site	Advantages	Disadvantages
Femoral	Ease of insertion, particularly in unstable patients	Patient discomfort
		Limited patient mobility
	Low incidence of insertion complications	Short functional life
Subclavian	Patient comfort	Technical expertise required for insertion
	Extended functional life
		Risk for serious insertion and delayed complications
Internal jugular	Extended functional life	Technical expertise required for insertion
	Decreased risk for serious complications	Patient discomfort
		Catheter difficult to secure
Caphalic vein and basilic vein	Patient comfort	Selected patients with good peripheral vessels
	Ease of insertion
	Minimal incidence of insertion complications	Inadequate blood flow rates

In conclusion, we described three cases about a young man who suffered from rhabdomyolysis after strenuous exercise and complicated with oliguric acute renal failure, acute renal failure induced by cardiogenic shock and patient with severe uremic symptoms and signs during initiation of peritoneal dialysis. We used direct puncture of peripheral veins as temporary vascular access for hemodialysis and those patients’ condition improved following several sessions of dialytic therapy. If the peripheral veins are large enough to keep adequate blood flow rate during hemodialysis, this short-term access provides a significant another new choice in selected patients (they have good peripheral vessels) with acute, reversible renal failure, obstructive uropathy, initiation of peritoneal dialysis, patients on peritoneal dialysis with peritonitis, or under plasmapheresis therapy. In our experiences, we recommend the cephalic vein and basilic vein should be the best selection sites for peripheral venopuncture with single needles.