Tunneled Permcath in LTACH Patient – Nurse Clinicians in Action – 38

Tunneled Permcath in LTACH Patient describes how an LTACH patient with chronic kidney disease and respiratory failure, as well as a complex medical history that included lower bilateral DVTs and a pacemaker, needed an Acute/Temp Vascath replaced with a Tunneled Central Line Permcath for hemodialysis.

Tunneled Permcath in LTACH Patient

– Clinical Case

An older patient with chronic kidney disease was in an LTACH and had recently received a trach for respiratory failure. There was already a temporary dialysis catheter (aka, Vascath) in place, but the patient now needed a Tunneled Permcath for longer-term hemodialysis. Because the patient had several conditions in his medical history, including lower bilateral DVTs, renal disease, and a pacemaker, it was important that the comprehensive, complex medical history be considered before placing a vascular access device.

This LTACH had been partnering with Vascular Wellness for vascular access for many years and recently added large bore advanced central lines – including dialysis catheters – to their available, on-demand services. As such, the facility contacted Vascular Wellness late in the day to schedule the Tunneled Permcath vascular access procedure for the following morning.

Tunneled Permcath in LTACH Patient

– Diagnosis and Treatment

While Vascular Wellness was already placing Tunneled Permcaths for other clients, this was the first one for this particular client, so the Vascular Wellness clinician allocated extra time for the procedure to help ensure a full understanding by the medical team, staff, and patient.  The first Vascular Wellness advanced clinician arrived at the facility early the next morning to help the team set up for the procedure, and the second clinician arrived soon thereafter.

Upon arriving at the patient’s bedside, the lead vascular access nurse clinician conducted a thorough review of the medical history and performed a detailed patient assessment. The clinician noted the temporary dialysis catheter in the patient’s right internal jugular which had been placed approximately two weeks prior by someone other than Vascular Wellness. The clinician closely examined this line to determine if a catheter exchange could be performed.

The Vascular Wellness nurse clinician quickly determined that a catheter exchange was contraindicated. The dressing was soiled with dried blood around the site, the line was sutured in several places, and the device had been placed high up in the neck – all of which made the patient a poor candidate for a line exchange.

The nurse clinician proceeded to carefully remove the old large-bore line, clean the site, and remove the old sutures. With that complete, she placed a Tunneled Permcath lower in the neck without difficulty. Within ten minutes of completion of the procedure, the X-ray had arrived and cleared the Tunneled Permcath for immediate use.

The facility was thrilled that the line was cleared for use so soon after placement. Prior to contracting with Vascular Wellness for the placement of dialysis catheters, patients had to be transported for these procedures, which added tremendous complexity and cost and created long delays in patient treatment.

Vascular Access Experts

– Key Points

As Vascular Access Experts, Vascular Wellness pioneered nurse-placed Tunneled Permcaths. Vascular Wellness’ nurse-placed Permcaths at the bedside have many advantages over the primary alternative of physician-placed devices in an Operating Room (OR) or Interventional Radiology (IR) Suite, including lower costs, less coordination, faster treatment, and greater facility, physician, and patient satisfaction.

As physician-placed Permcaths are dependent on an OR or IR suite and medical personnel availability, they are typically not able to be performed the same day due to already scheduled procedures and, unlike Vascular Wellness’ 7 days/week coverage, generally not after-hours, weekends, or holidays. Transportation within a facility or to another facility to get to the OR or IR room is costly and requires significant coordination of resources. Furthermore, unlike nurse-placed procedures at the bedside where only local sedation is needed, physician-placed Permcaths require patients to fast prior to their Permcath procedure because of the need for anesthesia, which can cause additional delays in treatment. All of these moving parts can cause Delay Cascades for the patient, which are unnecessary delays in receiving critical care therapies that can result in medical complications, increased length of stay, worsening patient condition, waste of clinical resources, and more (see References below).

In addition, Vascular Wellness uses innovative technologies to help ensure ideal placement and maximize comfort for the patient. Because Permcaths are long-term tunneled dialysis catheters and utilize a tissue ingrowth cuff, they need to be placed precisely to optimize both function and longevity. Traditionally, fluoroscopy is used to position the wires and final catheter placement. This is a type of X-ray that uses ionizing radiation to visualize the catheter. Vascular Wellness eliminates the cost and risk of this radiation by using ultrasound and tip detection and confirmation technologies that remove the need to expose patients to radiation.

Utilizing Vascular Access Board Certified (VA-BC) nurse clinicians from Vascular Wellness to provide expertly placed advanced procedures such as Acute/Temporary Vascath and Tunneled Permcath dialysis catheters at the bedside increases patient safety, reduces patient risk, injury, and chance of infection, decreases costs, and improves overall satisfaction by all stakeholders.

References regarding “Delay Cascade”

1. Heart & Lung. Volume 49, Issue3, Page 273-286, May-June 2020
2. Journal of Infusion Nursing. 43(4): p222-228, July-August 2020
3. Journal of the American College of Emergency Physicians Open.  2020 Dec; 1(6): 1660–1668

Nurse Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have encountered and participated in treatment. These cases involve challenging situations or intriguing clinical presentations and may involve more than one Vascular Wellness clinician, as our clinicians have the ability to consult each other while in the field, as well as an on-call Clinical Administrator via a HIPAA (Health Insurance Portability and Accountability) compliant communication app. In addition, our extensive training program and diverse client base, including Level 1 Trauma Centers, Short Term Acute Care Hospitals, Long Term Acute Care Hospitals, and Skilled Nursing Facilities, provide our clinicians with a wide array of clinical experience and why we believe our clinicians, as a group, are the most experienced and best trained and supported vascular access clinicians.

If you require Vascular Access or want to learn more, speak to the team at Vascular Wellness today.
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Vascular Wellness provides:
(1) Comprehensive vascular access services to North Carolina, Oklahoma, South Carolina, and Virginia; and
(2) Customized vascular access services to Arkansas, Delaware, Georgia, Mississippi, Pennsylvania, Tennessee, and West Virginia; and
(3) Support vascular access services to Ohio and Kentucky.