Lai Chao-Han, Kan Chung-Dann, Wu Hsuan-Yin, Luo Chwan-Yau, Chao Chen-Min, Wen Jih-Sheng
Institute of Clinical Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan.
Am J Kidney Dis. 2009 Jan;53(1):112-20. doi: 10.1053/j.ajkd.2008.08.024. Epub 2008 Oct 30.
Over-the-wire exchange is a standard treatment for patients with tunneled hemodialysis catheters (THCs) that fail to maintain sufficient extracorporeal blood flow. However, this well-known procedure is unsuitable in the presence of exit-site infection (ESI). In such cases, a modified exchange technique with introduction of the new THC through a remote exit site and the preexisting subcutaneous tunnel may be a solution.
Quality improvement report.
SETTING & PARTICIPANTS: Since 2005, a total of 28 consecutive dysfunctional THCs with ESI in 23 patients who did not have tunnel infection or bacteremia before the procedures was included.
Introduction of the new THC through a remote exit site and preexisting subcutaneous tunnel.
Technical success, perioperative complications, infection rates, and catheter function were recorded for analysis.
There was only 1 failure, giving an overall technical success rate of 96%. The other 27 exchanged THCs achieved satisfactory flow during subsequent hemodialysis, and the ESI gradually resolved within 2 weeks. Although 8 episodes of new ESI occurred, no subcutaneous tunnel infection or bacteremia occurred within 120 days. Bedridden patients had more occurrences of new ESIs than nonbedridden patients (6 of 9 versus 2 of 13 patients; P = 0.03). Primary catheter patency rates were 100% at 30 days, 82% at 90 days, and 77% at 120 days. Secondary catheter patency rates were 100% at 30 days, 91% at 90 days, and 91% at 120 days.
A small number of cases and comparison with previous studies of THC exchange.
For dysfunctional THCs with ESI, exchange through remote exit sites and preexisting subcutaneous tunnels is feasible and can be used repeatedly for patients prone to ESI, such as the bedridden. This modified exchange technique is also preferable for operators who question the sterility of previous exit sites and are reluctant to use the over-the-wire technique.
导丝交换是治疗隧道式血液透析导管（THC）无法维持足够体外血流量患者的标准方法。然而，在存在出口部位感染（ESI）的情况下，这种广为人知的操作并不适用。在这种情况下，通过远离原出口部位的新出口部位及原有的皮下隧道引入新的THC的改良交换技术可能是一种解决方案。
质量改进报告。
自2005年以来，纳入了23例患者中连续28根功能失调且伴有ESI的THC，这些患者在操作前没有隧道感染或菌血症。
通过远离原出口部位的新出口部位及原有的皮下隧道引入新的THC。
记录技术成功率、围手术期并发症、感染率和导管功能以进行分析。
仅1例失败，总体技术成功率为96%。其他27根交换后的THC在随后的血液透析过程中实现了满意的血流量，且ESI在2周内逐渐消退。虽然发生了8次新的ESI，但在120天内未发生皮下隧道感染或菌血症。卧床患者新ESI的发生率高于非卧床患者（9例中的6例对比13例中的2例；P = 0.03）。导管初次通畅率在30天时为100%，90天时为82%，120天时为77%。导管二次通畅率在30天时为100%，90天时为91%，120天时为91%。
病例数量少且与之前THC交换研究进行比较。
对于伴有ESI的功能失调THC，通过远离原出口部位的新出口部位及原有的皮下隧道进行交换是可行的，并且可以反复用于易发生ESI的患者，如卧床患者。这种改良交换技术对于质疑原出口部位无菌性且不愿使用导丝技术的操作者来说也是更可取的。
