The KDIGO AKI guideline state the below order of preference for vascular access for RRT in AKI:
When choosing a vein for insertion of a dialysis
catheter in patients with AKI, consider these
preferences (Not Graded):
– First choice: right jugular vein;
– Second choice: femoral vein;
– Third choice: left jugular vein;
– Last choice: subclavian vein with preference for
the dominant side.
Regarding coagulopathy, AAGBI Safe Vascular Access seems to preference femoral if risk of bleeding (however as stated not considered higher as INR not >1.8.
And states regarding minimum length of adult CVC catheters:
Fixed-length catheters:
-15 cm for right internal jugular vein (IJV),
– 20 cm for left internal jugular or right axillary/subclavian vein, and
– 24 cm for left axillary/subclavian or femoral vein,
are the usual minimum selection length for adults.
So the answer would seem be Femoral 25cm line? (that’s what I’d do anyway!)
I’ve used 25’s on some of our larger clientele, but tricky to track down when needed. Usually hidden at the back of the stock cupboard and upset the nurse in charge whilst hunting for them…
Great questions…call me a coward but I disagree with Q5 – whilst i can see the merit in a rotigotine patch this is a specialist intervention. Neurologists would be delighted 24h day to speak to one of us on how to administer the patch and whether that is the right management given what dopamine needs that patient has. For example, would you go for a 1mg/24 patch, or perhaps go for 4mg? Or maybe go a little wild and put two on – one on each arm? The BJA seems to suggest calling an expert….
But, i can see – the semantics and the joy of these questions….as is calling a neurologist a treatment? maybe for insomnia?
So – rotigotine – could be the best ‘treatment’. Guess my point is to be careful reading the question – in the exam dont just put rotigotine! If perhaps it says what is the next best management?
I was having a look into question 4 –
The KDIGO AKI guideline state the below order of preference for vascular access for RRT in AKI:
When choosing a vein for insertion of a dialysis
catheter in patients with AKI, consider these
preferences (Not Graded):
– First choice: right jugular vein;
– Second choice: femoral vein;
– Third choice: left jugular vein;
– Last choice: subclavian vein with preference for
the dominant side.
Regarding coagulopathy, AAGBI Safe Vascular Access seems to preference femoral if risk of bleeding (however as stated not considered higher as INR not >1.8.
And states regarding minimum length of adult CVC catheters:
Fixed-length catheters:
-15 cm for right internal jugular vein (IJV),
– 20 cm for left internal jugular or right axillary/subclavian vein, and
– 24 cm for left axillary/subclavian or femoral vein,
are the usual minimum selection length for adults.
So the answer would seem be Femoral 25cm line? (that’s what I’d do anyway!)
Agreed…. also out of interest has anyone put in a 25cm line before? I think most of my femorals have been 20s.
Still 25cm femoral seems like right option
I’ve used 25’s on some of our larger clientele, but tricky to track down when needed. Usually hidden at the back of the stock cupboard and upset the nurse in charge whilst hunting for them…
Yep, I’m with you Chris – as per KDIGO guidance (also ignoring the fact that LIJ vascaths are s***!!!)
Question 5 also……
https://academic.oup.com/bjaed/article/17/4/145/2907855
Hi Chris, Q4 : why not Femoral 25cm line as per KIDGO recommendations?
Hi Taqua,
I agree with your assessment which concurs with numerous previous comments. Answer updated to reflect the guidance. Thankls
Great questions…call me a coward but I disagree with Q5 – whilst i can see the merit in a rotigotine patch this is a specialist intervention. Neurologists would be delighted 24h day to speak to one of us on how to administer the patch and whether that is the right management given what dopamine needs that patient has. For example, would you go for a 1mg/24 patch, or perhaps go for 4mg? Or maybe go a little wild and put two on – one on each arm? The BJA seems to suggest calling an expert….
But, i can see – the semantics and the joy of these questions….as is calling a neurologist a treatment? maybe for insomnia?
So – rotigotine – could be the best ‘treatment’. Guess my point is to be careful reading the question – in the exam dont just put rotigotine! If perhaps it says what is the next best management?