Chronic catheter placement.

Since the 1997 publication of the Disease Outcomes Quality Initiative (DOQI) vascular access guidelines for cuffed, tunneled catheter placement, additional evidence supporting these recommendations has been published, including additional documentation supporting the right internal jugular vein as the preferred site for insertion. Placing the catheter tip in the right atrium rather than in the superior vena cava will provide adequate blood flow to support effective hemodialysis. The right atrial positioning of the catheter tip will also accommodate catheter tip retraction and decrease the likelihood of malfunction. Overwhelming evidence now supports the use of ultrasound guidance to assist cannulation of the internal jugular vein. This evidence is based on several studies documenting anatomical variations of the internal jugular vein. Ultrasound guidance has significantly decreased the incidence of serious complications of jugular vein cannulation. Finally, a specific technique of catheter placement with variations for catheter types is described.