Taking a multidisciplinary approach to maintaining haemodialysis vascular access: a challenging case in an infant: Answe
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CLINICAL QUIZ
Taking a multidisciplinary approach to maintaining haemodialysis vascular access: a challenging case in an infant: Answers Rebecca Anderson 1 & Brendan Cusack 1 & Elhamy Bekhit 2 & Bernadita Troncoso Solar 3 & Cathy Quinlan 1,4,5 & Joshua Kausman 1,4,5 Received: 15 July 2020 / Accepted: 24 July 2020 # IPNA 2020
Keywords Child . Haemodialysis . Central venous catheter . Migration . Malfunction . Fibrin sheath
Answers 1. A key feature of this patient’s central venous catheter (CVC) malfunction was an inability to aspirate from the catheter despite flushing well. This suggests one of three possible causes of obstruction: catheter tip thrombus, position of the catheter tip against a vessel wall, or a fibrin sheath enveloping the catheter tip. Slow contrast injection through a catheter can differentiate between a catheter tip thrombus (irregularity of the contrast jet as it exits the catheter) and a catheter that is resting against a vessel wall (asymmetric or oblique flow of contrast away from the catheter tip). Neither of these signs was observed in this case. The presence of a fibrin sheath is identified as initial pooling of contrast at the catheter tip in the early phase of the injection followed by tracking of contrast medium back along the length of the catheter on later images. A circumferential but incomplete fibrin sheath will cause the classic subtle sign of narrowing of the contrast jet as it exits the catheter with This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04726-w. * Joshua Kausman [email protected] 1
Department of Nephrology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
2
Department of Medical Imaging, The Royal Children’s Hospital, Melbourne, Victoria, Australia
3
Department of Urology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
4
Department of Paediatrics, University of Melbourne, Melbourne, Australia
5
Murdoch Children’s Research Institute, Melbourne, Australia
fanning out of contrast more distally [1]. The presence of a fibrin sheath is often misinterpreted as extravasation due to catheter fracture. In this case, both contrast studies were reported as suspicious for line breakage; however, no fracture in the line was identified on inspection of the catheter after removal. Despite a lack of clear evidence for a fibrin sheath on imaging studies, this was the most likely diagnosis in this case. 2. Initial management of a blocked central catheter at our institution includes instilling tPA into the catheter lumen for at least 2 h, with repeat dosing within 24 h if necessary. Second-line management options include instillation of HCl into the catheter lumen and consideration of ultrasound to further evaluate for thrombus [2]. This is consistent with the recommended initial treatment of obstruction by a fibrin sheath, which includes infusion of thrombolytic drugs either directly into the catheter lumen or intravenously. Unfortunately, thrombolytic treatment is often inadequate, with a reported succ
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