How to deal with dialysis catheters in the ICU setting.

Acute kidney insufficiency (AKI) occurs frequently in intensive care units (ICU). In the management of vascular access for renal replacement therapy (RRT), several factors need to be taken into consideration to achieve an optimal RRT dose and to limit complications. In the medium and long term, some individuals may become chronic dialysis patients and so preserving the vascular network is of major importance. Few studies have focused on the use of dialysis catheters (DC) in ICUs, and clinical practice is driven by the knowledge and management of long-term dialysis catheter in chronic dialysis patients and of central venous catheter in ICU patients. This review describes the appropriate use and management of DCs required to obtain an accurate RRT dose and to reduce mechanical and infectious complications in the ICU setting. To deliver the best RRT dose, the length and diameter of the catheter need to be sufficient. In patients on intermittent hemodialysis, the right internal jugular insertion is associated with a higher delivered dialysis dose if the prescribed extracorporeal blood flow is higher than 200 ml/min. To prevent DC colonization, the physician has to be vigilant for the jugular position when BMI < 24 and the femoral position when BMI > 28. Subclavian sites should be excluded. Ultrasound guidance should be used especially in jugular sites. Antibiotic-impregnated dialysis catheters and antibiotic locks are not recommended in routine practice. The efficacy of ethanol and citrate locks has yet to be demonstrated. Hygiene procedures must be respected during DC insertion and manipulation.