Patient < 10 kg NO YES YES Surgery to place small bore tunneled vs non-tunneled CVC (IJ approach pending size and expected duration of therapy; surgeons preference for side)Does patient havean existing port or HDcatheter? YES PIV is an option ?Duration oftherapy LONG PIV (if possible to increase PIV stability/life) in dominant arm (preferred; if unsure of hand dominance, place PIV in RIGHT> left upper extremity )0-5 d6-14 da)Long PIV (pt./family to understand may need repeated PIV placement), vsb)Surgery to place small bore non-tunneled CVC (IJ approach)(***Midline catheter only with discussion/approval by Nephrology attending)YES NODoes patient have a HD catheter OR do you anticipate HD catheter placement in Next 2 wk? UPPER EXTREMITY PICC (either side OK)–once HD catheter removed, considerreplacing HD catheter with CVC & removing PICC Access port –OR -use order sets to allow HD catheter use** **HD catheter use OUTSIDE of dialysis unit OK a) nurses on select floors (A4N, PICU) OR by select nursing staff [VAT team], and b) for select needs -Blood draws, short course (< 5days) IV medications &/or TPN NO *This guideline is intended for the non-emergentCVC request (i.e. access for TPN, lab draws, IVF/IV antibiotics).In emergent situations (sepsis/hypotension), ideal CVC placement would be upper extremities. Placement of Lower extremity CVC should include discussion with member of transplant surgery team. ***Discussion with nephrology attending & transplant surgeons for access options (UE PICC, midline, CVC) If more access is needed 15-60 d (or) red infusateSurgery to place small bore non-tunneled CVC (IJ approach, pending expected length of therapy and current clinical situation); (***PICC only with approval by nephrology attending) NO *** this situation is intended for a) the rare CKD patient where is has been discussed & documented that he/she would not be considered a candidate for future Renal Replacement Therapy (i.e. dialysis, transplant), and/or b) extremely difficult access situations. Use of a midline or PICC requires a verbal discussion with the family of risks as well as verbal discussion & approval by the nephrology attending to the VAT team nurse a)Surgery to place small bore non-tunneledCVC (IJ approach)b)***Only with approval by Nephrology attending: PICC vs midline, with no preference for right vs left upper extremitya)Surgery to place small bore non-tunneled CVC (IJ approach)b)***Only with approval by Nephrology attending: PICC, with no preference for right vs left upper extremity< 14 d15-60 d Surgery to place small bore tunneled CVC (IJ approach) > 60 d > 60 daysSurgery to place tunneled CVC (IJ approach)
Line Selection Guideline for Nephrology Patients
Guideline · Aug 2019 · 2 min read
In brief
In brief
Clinical guideline for selecting appropriate vascular access lines in nephrology patients requiring hemodialysis or other renal replacement therapy. Addresses catheter type, placement site, and access preservation strategies.
Written by the GCMD Library team from the guideline.
Initial Patient Weight Stratification
The guideline first stratifies patients by weight threshold of 10 kg, which determines subsequent catheter selection options. This weight cutoff influences vessel size considerations and catheter type appropriateness for pediatric patients.
Existing Access Assessment
Clinicians must evaluate whether the patient has existing vascular access including ports or hemodialysis catheters. This assessment determines whether existing access can be utilized or if new access placement is required.
Short-Term Access (0-5 Days)
For therapy duration under 5 days, peripheral IV (PIV) placement is preferred when feasible. Long PIV should be placed in the dominant arm (right preferred if dominance uncertain) to maximize stability and catheter life.
Intermediate Duration Access (6-14 Days)
For 6-14 day therapy, options include long PIV with family counseling about potential replacement needs, or surgical placement of small-bore non-tunneled central venous catheter via internal jugular approach. Midline catheters require specific nephrology attending approval in this population.
Hemodialysis Catheter Considerations
Patients with existing HD catheters or anticipated HD catheter needs within 2 weeks require special planning. Upper extremity PICC placement is recommended with plan to replace HD catheter with CVC and remove PICC once dialysis catheter is no longer needed.
HD Catheter Use Outside Dialysis Unit
HD catheters may be used outside the dialysis unit by trained nursing staff on select floors (A4N, PICU) or by VAT team members. Approved uses include blood draws and short-course IV medications or TPN for less than 5 days duration.
Extended Duration Access (15-60 Days)
For therapy lasting 15-60 days or requiring red infusate, surgical placement of small-bore non-tunneled CVC via IJ approach is recommended. PICC placement requires specific nephrology attending approval in CKD patients.
Long-Term Access (>60 Days)
Therapy duration exceeding 60 days warrants surgical placement of tunneled central venous catheter via internal jugular approach. This provides more durable access appropriate for extended treatment courses.
Special CKD Patient Considerations
For chronic kidney disease patients not candidates for future renal replacement therapy or those with extremely difficult access, midline or PICC placement may be considered. This requires documented discussion with family about risks and verbal approval from nephrology attending.
Emergent Situation Modifications
This guideline addresses non-emergent CVC requests for TPN, lab draws, and IV therapy. In emergent situations like sepsis or hypotension, upper extremity CVC placement is ideal, and lower extremity CVC requires discussion with transplant surgery team.
Statements in this guideline
For patients under 10 kg with an existing port or HD catheter, access the port or use order sets to allow HD catheter use.
HD catheter use outside of the dialysis unit is acceptable for nurses on select floors (A4N, PICU) or by select nursing staff (VAT team), and for select needs including blood draws and short course (less than 5 days) IV medications and/or TPN.
For patients under 10 kg without existing access, if PIV is an option and therapy duration is 0-5 days, place a long PIV in the dominant arm (preferred; if unsure of hand dominance, place PIV in RIGHT greater than left upper extremity).
For patients under 10 kg without existing access, if PIV is an option and therapy duration is 6-14 days, place a long PIV (patient/family to understand may need repeated PIV placement) versus surgery to place small bore non-tunneled CVC (IJ approach).
Midline catheter in patients under 10 kg is only acceptable with discussion and approval by nephrology attending.
For patients under 10 kg without existing access, if PIV is not an option and therapy duration is 15-60 days or red infusate, surgery should place small bore non-tunneled CVC (IJ approach, pending expected length of therapy and current clinical situation).
PICC in patients under 10 kg is only acceptable with approval by nephrology attending.
For patients under 10 kg without existing access, if PIV is not an option and therapy duration is greater than 60 days, surgery should place small bore tunneled CVC (IJ approach).
For patients 10 kg or greater with therapy duration less than 14 days, surgery should place small bore non-tunneled CVC (IJ approach), or with approval by nephrology attending, PICC versus midline with no preference for right versus left upper extremity.
For patients 10 kg or greater with therapy duration 15-60 days, surgery should place small bore non-tunneled CVC (IJ approach), or with approval by nephrology attending, PICC with no preference for right versus left upper extremity.
For patients 10 kg or greater with therapy duration greater than 60 days, surgery should place tunneled CVC (IJ approach).
For patients 10 kg or greater who have or are anticipated to have HD catheter placement in the next 2 weeks, place upper extremity PICC (either side OK), and once HD catheter is removed, consider replacing HD catheter with CVC and removing PICC.
This guideline is intended for non-emergent CVC requests (i.e., access for TPN, lab draws, IVF/IV antibiotics).
In emergent situations (sepsis/hypotension), ideal CVC placement would be upper extremities.
Placement of lower extremity CVC should include discussion with member of transplant surgery team.
Use of a midline or PICC in nephrology patients requires a verbal discussion with the family of risks as well as verbal discussion and approval by the nephrology attending to the VAT team nurse.
Midline or PICC use is intended for the rare CKD patient where it has been discussed and documented that he/she would not be considered a candidate for future renal replacement therapy (i.e., dialysis, transplant), and/or extremely difficult access situations.