Dialysis Catheter Insertion: Step-by-Step Guide US

The insertion of catheter for dialysis is a critical procedure for patients with end-stage renal disease requiring hemodialysis, typically performed by nephrologists or interventional radiologists. Ultrasound (US) guidance significantly enhances the precision and safety of this procedure, reducing complications such as pneumothorax, a potential risk during central venous catheter placement. The National Kidney Foundation (NKF) emphasizes adherence to strict sterile techniques and meticulous catheter placement protocols to minimize infection risks associated with long-term catheter use. Furthermore, proper post-insertion care and regular monitoring by dialysis centers are essential for maintaining catheter patency and preventing complications like thrombosis, ensuring effective and reliable dialysis treatments.

Hemodialysis stands as a critical lifeline for individuals grappling with end-stage renal disease (ESRD). This life-sustaining procedure necessitates a method for efficiently extracting blood, cleansing it of impurities, and returning it to the body. This is where vascular access becomes paramount.

Without reliable vascular access, effective hemodialysis is simply impossible. It’s the gateway to delivering therapy and, ultimately, sustaining life.

The Crucial Role of Dialysis Catheters

Among the various methods of establishing vascular access, dialysis catheters play a significant role, especially in situations requiring immediate or temporary access. These catheters, strategically inserted into a large central vein, provide a conduit for the hemodialysis process. They allow for repeated and efficient access to the bloodstream.

While other forms of vascular access, such as arteriovenous fistulas (AVFs) and grafts (AVGs), are often preferred for long-term dialysis, catheters remain indispensable tools in specific clinical scenarios. This may include acute kidney injury or when a more permanent access solution is not yet feasible.

Article Scope: Insertion, Care, and Maintenance

This article aims to provide a comprehensive overview of hemodialysis catheters, focusing on three key aspects: insertion, care, and maintenance. Understanding each of these components is crucial for optimizing patient outcomes and minimizing potential complications.

We will delve into the procedures involved in catheter insertion, exploring the different techniques and considerations for patient safety.

Furthermore, we will examine the essential care protocols that must be followed to prevent infection and maintain catheter patency.

Finally, we will discuss the ongoing maintenance required to ensure the catheter functions optimally throughout its lifespan. By addressing these critical areas, we aim to equip healthcare professionals and patients alike with the knowledge needed to navigate the complexities of hemodialysis catheter management.

Hemodialysis stands as a critical lifeline for individuals grappling with end-stage renal disease (ESRD). This life-sustaining procedure necessitates a method for efficiently extracting blood, cleansing it of impurities, and returning it to the body. This is where vascular access becomes paramount.

Without reliable vascular access, effective hemodialysis is simply not possible. But vascular access, especially via central venous catheters, is not a solo endeavor. It requires a dedicated team of specialists, each bringing unique expertise to ensure patient safety and treatment success.

The Hemodialysis Team: Roles and Responsibilities

The management of hemodialysis catheters is a multifaceted process demanding a coordinated effort from a diverse team of healthcare professionals. Each member plays a vital role in ensuring optimal patient outcomes and minimizing potential complications. Let's explore the specific responsibilities of each team member.

The Orchestrator: The Nephrologist's Guiding Hand

The nephrologist serves as the central figure in the patient's hemodialysis journey. Their responsibilities encompass a wide range of crucial tasks, beginning with a thorough patient assessment to determine the suitability for hemodialysis.

This includes evaluating the patient's overall health, kidney function, and vascular anatomy. They prescribe the dialysis regimen, tailoring it to the individual's specific needs, and oversee the entire catheter management process, including insertion, maintenance, and removal.

The nephrologist monitors for potential complications and adjusts the treatment plan accordingly. Their comprehensive understanding of kidney disease and hemodialysis makes them indispensable to the team.

The Vascular Access Experts: Interventional Radiologists and Surgeons

Interventional radiologists and surgeons are the specialists responsible for the placement of hemodialysis catheters. Interventional radiologists utilize image-guidance techniques, such as ultrasound and fluoroscopy, to precisely insert catheters into central veins.

Their expertise in minimally invasive procedures minimizes patient discomfort and reduces the risk of complications. Surgeons, on the other hand, may perform surgical placement of catheters, particularly when more complex cases arise or when other access options are not viable.

Both interventional radiologists and surgeons collaborate closely with the nephrologist to determine the optimal catheter placement strategy.

The Front Line of Care: The Registered Nurse (RN)

The registered nurse (RN) is the patient's primary point of contact, providing continuous care and monitoring throughout the hemodialysis process. Their responsibilities include pre- and post-procedure care, ensuring the patient is properly prepared for catheter insertion and monitoring for any immediate complications afterward.

During hemodialysis sessions, the RN monitors the patient's vital signs, manages the dialysis machine, and administers medications as prescribed. They are also responsible for educating the patient about catheter care and maintenance.

Their vigilance and expertise are crucial for ensuring patient safety and comfort.

The Technical Foundation: Dialysis Technicians

Dialysis technicians work under the supervision of registered nurses and nephrologists to assist with the technical aspects of hemodialysis treatment. They are responsible for setting up and operating the dialysis machine, monitoring the patient's blood pressure and other vital signs, and assisting with catheter maintenance procedures.

Their technical skills and attention to detail are essential for the smooth and efficient delivery of hemodialysis treatment.

The Central Figure: The Patient's Active Role

The patient is an active participant in their own care, and their understanding of and involvement in catheter management is essential for optimal outcomes.

Patients are responsible for following instructions on catheter care, monitoring for signs of infection or other complications, and promptly reporting any concerns to their healthcare team.

Education empowers patients to take control of their health and minimize the risk of catheter-related problems.

Sedation and Pain Management: The Anesthesiologist/CRNA

An anesthesiologist or certified registered nurse anesthetist (CRNA) plays a crucial role in ensuring patient comfort during catheter insertion. They administer sedation or anesthesia to minimize pain and anxiety during the procedure.

Their expertise in pain management allows the interventional radiologist or surgeon to focus on the technical aspects of catheter placement, leading to a more efficient and successful outcome.

The collaborative efforts of the hemodialysis team are vital for ensuring patient safety and the effectiveness of treatment. Each member brings a unique set of skills and expertise to the table, contributing to a seamless and patient-centered approach to hemodialysis catheter management. This coordinated effort is critical for optimizing patient outcomes and improving the quality of life for individuals undergoing hemodialysis.

Where Hemodialysis Happens: Treatment Locations

[Hemodialysis stands as a critical lifeline for individuals grappling with end-stage renal disease (ESRD). This life-sustaining procedure necessitates a method for efficiently extracting blood, cleansing it of impurities, and returning it to the body. This is where vascular access becomes paramount.

Without reliable vascular access, effective hemodialysis is impossible. The locations where hemodialysis and related procedures occur are therefore central to the patient's experience and overall treatment success. Understanding the roles and resources of these various locations is vital for both medical professionals and patients alike.]

Dialysis Center/Unit: The Hub of Routine Treatment

The dialysis center or unit serves as the primary location for routine hemodialysis treatments and ongoing catheter care. These centers are specifically designed and equipped to provide the specialized support and monitoring that patients require during their dialysis sessions.

The dialysis center offers a structured environment with trained nurses and technicians who are proficient in managing dialysis machines, monitoring vital signs, and ensuring patient comfort.

Resources and Capabilities

Dialysis centers are equipped with multiple dialysis machines, comfortable patient seating or beds, and monitoring equipment to track blood pressure, heart rate, and other essential parameters.

Crucially, they adhere to strict infection control protocols to minimize the risk of catheter-related infections. They also provide education and support to patients on self-care practices related to their dialysis catheters.

Hospital Setting: Initial Placement and Complex Management

The hospital environment plays a crucial role in the initial placement of hemodialysis catheters, especially in acute cases or when patients have complex medical needs.

Hospitals offer a wide range of resources and specialized expertise that may not be available in outpatient dialysis centers.

Comprehensive Care for Complications

Hospitals are also essential for managing complications related to hemodialysis catheters, such as severe infections, significant thrombosis, or catheter malfunction requiring intervention. They provide access to specialized medical services, including interventional radiology, vascular surgery, and infectious disease specialists.

Interventional Radiology Suite: Precision Image-Guided Procedures

The interventional radiology (IR) suite is a specialized area within a hospital or outpatient imaging center where minimally invasive procedures are performed using image guidance.

For hemodialysis catheter placement, IR suites utilize ultrasound and fluoroscopy to precisely guide the catheter into the appropriate blood vessel, reducing the risk of complications.

Advantages of Image Guidance

Image guidance allows for real-time visualization of the blood vessels and surrounding structures, enabling the interventional radiologist to navigate the catheter with accuracy. This approach is particularly valuable in patients with challenging anatomy or a history of prior catheter placements.

Operating Room (OR): Surgical Precision

In some instances, surgical placement of a hemodialysis catheter in the operating room (OR) may be necessary. This is usually reserved for cases where percutaneous access is not feasible or when a more durable, long-term catheter is required.

When Surgery is Indicated

Surgical placement may also be considered when complications arise during percutaneous insertion or when other surgical procedures are being performed concurrently. The OR environment provides a controlled, sterile setting with advanced monitoring capabilities.

[Where Hemodialysis Happens: Treatment Locations Hemodialysis stands as a critical lifeline for individuals grappling with end-stage renal disease (ESRD). This life-sustaining procedure necessitates a method for efficiently extracting blood, cleansing it of impurities, and returning it to the body. This is where vascular access becomes paramount.

Decoding Catheters: Types, Concepts, and Terminology

Understanding the nuances of hemodialysis catheters is crucial for both medical professionals and patients undergoing treatment. From the basic types of catheters to the advanced technologies guiding their placement, a firm grasp of terminology and core concepts is essential. This section breaks down the complexities of catheter types, insertion techniques, and the critical principles that underpin their safe and effective utilization.

Hemodialysis and the Central Venous Catheter (CVC)

Hemodialysis, in essence, is a renal replacement therapy. It filters waste, removes excess fluid, and restores electrolyte balance in patients whose kidneys have failed. Central venous catheters (CVCs) serve as a direct conduit for blood to be extracted and returned during this process.

A CVC is a tube inserted into a large vein, typically in the neck, chest, or groin, providing immediate access to the bloodstream for hemodialysis. While CVCs offer a rapid solution, their long-term use is often discouraged due to increased risk of complications compared to other vascular access options like arteriovenous fistulas (AVFs) or grafts (AVGs).

Tunnelled vs. Non-Tunnelled Catheters: A Tale of Two Approaches

Hemodialysis catheters are broadly categorized into tunnelled and non-tunnelled types, each designed for specific durations and clinical scenarios.

Tunnelled Catheters

Tunnelled catheters are designed for more prolonged use, typically weeks or months. These catheters are surgically implanted, with a portion of the catheter tunneled under the skin before entering the vein.

This tunnelling process creates a barrier against infection, as the subcutaneous tunnel acts as a physical impediment to bacterial migration along the catheter tract. Tunnelled catheters often feature a Dacron cuff that promotes tissue ingrowth, further stabilizing the catheter and reducing the risk of dislodgement and infection.

Non-Tunnelled Catheters

In contrast, non-tunnelled catheters are intended for short-term access, usually days to weeks. These catheters are typically inserted percutaneously directly into a central vein, without the tunnelling process.

Non-tunnelled catheters provide immediate access for dialysis but carry a higher risk of infection and thrombosis due to the direct entry point into the bloodstream. Their use is generally reserved for acute kidney injury or when a more permanent access option is not yet available or feasible.

Guiding the Way: Ultrasound and Fluoroscopy

The accurate placement of hemodialysis catheters is paramount to ensure optimal blood flow and minimize complications. Ultrasound and fluoroscopy are two primary imaging modalities used to guide catheter insertion.

Ultrasound Guidance

Ultrasound guidance utilizes real-time sound waves to visualize the target vein and surrounding structures. This technique allows the operator to precisely guide the needle and guidewire into the vein, reducing the risk of arterial puncture or other complications. Ultrasound is particularly valuable for cannulating veins in patients with challenging anatomy or those with a history of multiple central lines.

Fluoroscopy Guidance

Fluoroscopy guidance employs real-time X-ray imaging to visualize the catheter's trajectory within the vascular system. This technique is often used to confirm catheter tip placement and ensure that the catheter is not kinked or malpositioned. Fluoroscopy can also be helpful in navigating complex venous anatomy or identifying venous stenosis.

Essential Concepts for Catheter Management

Beyond the physical characteristics and insertion techniques, several fundamental concepts are vital for the successful management of hemodialysis catheters.

Infection Control: A Cornerstone of Catheter Care

Infection control is of paramount importance in preventing catheter-related bloodstream infections (CRBSIs), a significant cause of morbidity and mortality in hemodialysis patients. Rigorous adherence to sterile technique during catheter insertion and maintenance is essential. This includes thorough skin antisepsis, use of sterile barriers, and meticulous hand hygiene.

Routine catheter exit site care with antiseptic solutions and regular dressing changes are also critical components of infection prevention. Healthcare providers should be vigilant in monitoring patients for signs of infection, such as fever, chills, redness, or drainage at the catheter exit site.

Catheter Patency: Keeping the Blood Flowing

Maintaining catheter patency, or the ability of the catheter to allow adequate blood flow, is essential for effective hemodialysis. Thrombosis, the formation of blood clots within the catheter, is a common cause of catheter dysfunction.

To prevent thrombosis, catheters are routinely flushed with heparin or other anticoagulant solutions between dialysis sessions. Regular assessment of catheter blood flow rates and prompt intervention for any signs of dysfunction are crucial. Catheter Dysfunction, if identified, is typically managed with thrombolytic agents or mechanical thrombectomy to restore patency.

The Importance of Exit Site Care

Catheter exit site care is a key component of infection prevention. Patients and caregivers should be educated on proper hygiene practices, including daily cleaning of the exit site with antiseptic solutions and application of a sterile dressing. Any signs of redness, swelling, drainage, or pain at the exit site should be promptly reported to the healthcare team.

Informed Consent and Sterile Technique

Informed consent is an ethical and legal requirement. Before catheter insertion, patients must be fully informed about the risks, benefits, and alternatives to the procedure. This ensures they can make an autonomous decision about their care. Sterile technique must be maintained throughout the entire catheter insertion and maintenance process.

Anticoagulation

Anticoagulation plays a critical role in preventing catheter-related thrombosis. Heparin is often used to flush catheters between dialysis sessions. In some cases, patients may require systemic anticoagulation to prevent recurrent thrombosis.

The Hemodialysis Toolkit: Instruments and Supplies

Hemodialysis catheter insertion and maintenance hinge on a precise and carefully orchestrated interplay of instruments and supplies. Each component plays a crucial role in ensuring procedural success, patient safety, and long-term catheter functionality. Understanding the purpose and application of these tools is paramount for all involved in the hemodialysis process.

Core Components: Catheters and Access

At the heart of the procedure lies the dialysis catheter itself. Several types exist, each designed with specific features. Examples include the Quinton Permcath, a tunneled catheter known for its long-term durability, and the Medcomp Tesio, another type of tunneled catheter with a split-tip design intended to optimize flow rates.

The selection of catheter type depends on factors such as the duration of dialysis required, the patient's vascular anatomy, and the clinician's preference.

Gaining access to the vasculature requires meticulous technique and specialized tools. A needle is used to initially puncture the vein, providing the entry point for subsequent instrumentation.

Imaging and Guidance: Precision in Placement

Accurate catheter placement is crucial to avoid complications and ensure optimal dialysis efficacy. Ultrasound machines are frequently employed to visualize the target vein in real-time, guiding the needle during the initial puncture.

This minimizes the risk of arterial puncture or other vascular injury.

Alternatively, fluoroscopy machines, which utilize X-ray technology, can be used to visualize the catheter's trajectory as it is advanced through the venous system.

Fluoroscopy provides a continuous view of the catheter's position, allowing for precise adjustments and minimizing the risk of malposition.

A guidewire is then advanced through the needle and into the vein. This acts as a rail, allowing the catheter to be safely introduced over it. The guidewire’s flexibility and maneuverability are essential for navigating the venous anatomy.

Incision, Dilation, and Securing the Catheter

Once the guidewire is in place, a scalpel may be used to create a small incision at the insertion site, facilitating the passage of the catheter. A dilator is then advanced over the guidewire to gradually enlarge the puncture site.

This reduces the resistance encountered when inserting the catheter, minimizing trauma to the vessel wall.

After the catheter is positioned correctly, it must be securely anchored to prevent dislodgement. Sutures are used to fix the catheter to the skin, ensuring that it remains in the intended location.

Maintaining Sterility: Aseptic Technique

Maintaining a sterile field is of paramount importance in preventing catheter-related infections. Antiseptic solutions, such as chlorhexidine, are used to thoroughly clean the skin around the insertion site.

Sterile drapes are then applied to create a barrier between the non-sterile environment and the insertion site. Healthcare personnel must wear sterile gloves and gowns to further minimize the risk of contamination.

Medication and Flushing: Ensuring Patency

Local anesthetic, such as lidocaine, is injected into the insertion site to numb the area and minimize patient discomfort during the procedure.

A syringe is used to administer the anesthetic and to flush the catheter with normal saline to ensure patency. Heparin, an anticoagulant medication, is routinely instilled into the catheter lumens between dialysis sessions to prevent clotting and maintain catheter function.

Protecting the Site: Dressings

Finally, a dressing is applied to the exit site to protect it from contamination and promote healing. Dressings are typically changed regularly to maintain cleanliness and allow for visual inspection of the site for signs of infection.

The meticulous use and maintenance of this toolkit are central to safe and effective hemodialysis catheter management.

Navigating the Rules: Regulations and Best Practices

Hemodialysis catheter insertion and maintenance hinge on a precise and carefully orchestrated interplay of instruments and supplies. Each component plays a crucial role in ensuring procedural success, patient safety, and long-term catheter functionality. Understanding the purpose and application of... the regulatory framework and best practices is equally vital for optimal patient outcomes. Compliance with these guidelines ensures patient safety, minimizes complications, and promotes optimal dialysis delivery.

Regulatory Landscape for Hemodialysis Catheters in the U.S.

The use of hemodialysis catheters in the United States is subject to a complex web of regulations aimed at ensuring patient safety and quality of care. These regulations stem from various federal and state agencies, as well as professional organizations.

Federal Regulations and Guidelines

The Centers for Medicare & Medicaid Services (CMS) plays a significant role through its Conditions for Coverage (CfCs) for dialysis facilities. These CfCs set standards for patient care, including vascular access management. Compliance with CMS regulations is essential for facilities to receive Medicare reimbursement.

The Food and Drug Administration (FDA) also plays a crucial role by regulating the devices themselves. Dialysis catheters, guidewires, and other related products must receive FDA clearance or approval before they can be marketed and used.

State Regulations

In addition to federal regulations, individual states may have their own regulations regarding hemodialysis catheter placement and maintenance. These regulations can vary significantly from state to state, so it is crucial for healthcare providers to be aware of the specific requirements in their jurisdiction.

Professional Organization Guidelines

Several professional organizations, such as the American Society of Nephrology (ASN) and the National Kidney Foundation (NKF), have developed guidelines and recommendations for vascular access management. These guidelines provide evidence-based recommendations for catheter insertion, care, and maintenance.

Best Practices for Infection Control

Infection is a major complication associated with hemodialysis catheters, and implementing effective infection control measures is paramount.

Following established best practices can significantly reduce the risk of catheter-related bloodstream infections (CRBSIs).

CDC Guidelines

The Centers for Disease Control and Prevention (CDC) provides comprehensive guidelines for preventing infections related to vascular access devices, including hemodialysis catheters. These guidelines emphasize the importance of:

• Hand hygiene: Performing thorough hand hygiene before and after any contact with the catheter or insertion site is critical.

• Aseptic technique: Strict sterile technique must be used during catheter insertion, dressing changes, and any other procedure involving the catheter.

• Skin antisepsis: Preparing the skin with an appropriate antiseptic solution, such as chlorhexidine, prior to catheter insertion and dressing changes.

• Catheter site care: Regularly assessing and cleaning the catheter exit site to prevent infection.

• Dressing changes: Changing the catheter dressing according to established protocols.

• Antimicrobial lock solutions: Utilizing antimicrobial lock solutions may be beneficial in certain high-risk patients.

Strategies for Infection Prevention

Beyond the CDC guidelines, several other strategies can help reduce the risk of CRBSIs:

• Choosing the appropriate catheter: Selecting the most appropriate type of catheter for the patient's individual needs.

• Proper catheter insertion technique: Using ultrasound guidance during catheter insertion can reduce the risk of complications.

• Staff education and training: Ensuring that all healthcare personnel involved in catheter care are properly trained in infection control practices.

• Surveillance and monitoring: Implementing a system for monitoring CRBSI rates and identifying areas for improvement.

Ensuring Patient Safety Through Compliance

Adhering to regulations and implementing best practices are essential for ensuring patient safety and optimizing outcomes for individuals undergoing hemodialysis. Facilities should establish clear protocols for catheter insertion, care, and maintenance, and regularly audit their practices to ensure compliance.

Continuous quality improvement initiatives are critical for identifying and addressing potential gaps in care. By prioritizing patient safety and implementing evidence-based strategies, healthcare providers can minimize complications and improve the quality of life for patients with end-stage renal disease.

Troubleshooting: Complications and Their Management

Navigating the Rules: Regulations and Best Practices Hemodialysis catheter insertion and maintenance hinge on a precise and carefully orchestrated interplay of instruments and supplies. Each component plays a crucial role in ensuring procedural success, patient safety, and long-term catheter functionality. Understanding the purpose and application of each item ensures seamless workflow and preparedness for unexpected challenges. However, despite meticulous technique and adherence to best practices, complications can arise. Prompt identification and effective management are paramount to preserving vascular access and ensuring optimal patient outcomes.

Catheter-Related Infections: A Persistent Threat

Infection remains a significant concern with hemodialysis catheters, representing a leading cause of morbidity and mortality in dialysis patients. Catheter-related bloodstream infections (CRBSIs) can lead to sepsis, endocarditis, and other serious systemic complications.

Prevention strategies are multifaceted and should be rigorously implemented.

Adherence to strict aseptic technique during insertion and maintenance is the cornerstone of infection control. This includes thorough hand hygiene, use of sterile barriers, and meticulous skin preparation with chlorhexidine-based antiseptic solutions.

Exit-site care is equally critical. Patients and caregivers should be educated on proper cleaning techniques, using antiseptic solutions and sterile dressings to protect the catheter insertion site. Routine monitoring for signs of infection, such as redness, swelling, drainage, or tenderness, is essential.

If an infection is suspected, prompt diagnosis and treatment are crucial. Blood cultures should be drawn to identify the causative organism and guide antibiotic therapy. In some cases, catheter removal may be necessary to eradicate the infection, particularly if the patient fails to respond to antibiotic treatment or if a biofilm has formed on the catheter surface.

Thrombosis: Maintaining Catheter Patency

Thrombosis, or blood clot formation, is another common complication that can compromise catheter function. Clots can form within the catheter lumen or around the catheter tip, obstructing blood flow and reducing dialysis efficiency.

Prophylactic measures to prevent thrombosis include the use of anticoagulant medications, such as heparin or warfarin. These medications help to thin the blood and prevent clot formation. Catheter locking solutions containing heparin or citrate are also commonly used to maintain catheter patency between dialysis sessions.

Regular assessment of catheter function is essential for detecting early signs of thrombosis. Reduced blood flow rates, prolonged dialysis times, or increased arterial pressures may indicate catheter obstruction.

If thrombosis is suspected, thrombolytic agents, such as tissue plasminogen activator (tPA), can be administered to dissolve the clot. In some cases, mechanical thrombectomy may be necessary to remove the clot physically. Ultimately, prevention is key, as repeated thrombosis can lead to permanent catheter damage and loss of vascular access.

Catheter Dysfunction: Identifying and Resolving Issues

Catheter dysfunction encompasses a range of problems that can impair catheter performance. These include kinking, migration, or damage to the catheter itself.

Kinking can occur due to improper positioning or external compression of the catheter. Repositioning the catheter or adjusting the patient's position may resolve the issue. In some cases, surgical intervention may be necessary to correct catheter malposition.

Catheter migration, where the catheter tip moves out of its intended location, can also lead to dysfunction. Fluoroscopy or ultrasound imaging can be used to confirm catheter placement and guide repositioning.

Damage to the catheter, such as cracks or leaks, can compromise its integrity and increase the risk of infection. Damaged catheters should be promptly replaced to prevent further complications.

A systematic approach to troubleshooting catheter dysfunction is essential for identifying and resolving the underlying cause. This includes a thorough assessment of the patient's history, physical examination, and imaging studies.

Addressing catheter dysfunction promptly is crucial for maintaining adequate dialysis delivery and preventing further complications.

So, there you have it! That's the general rundown of dialysis catheter insertion. Remember, this is just a guide, and hands-on experience and proper training are crucial. Always prioritize patient safety and follow your institution's protocols. Good luck with your next catheter insertion for dialysis!