Merit Medical ProGuide Chronic Dialysis Catheter - Manual (Page 5)

PRECAUTION: Avoid air embolism by keeping extension tubing clamped at all times when not in use
and by aspirating then irrigating the catheter prior to each use. Always aspirate first then irrigate the
catheter prior to each use. With each change in tubing connections, purge air from the catheter and all
connecting tubing and caps.
10. Correctly position the cuff and tunneled portion of the catheter.
11. Confirm proper tip placement with fluoroscopy. The distal “venous” tip should be positioned at the
junction of the superior vena cava and right atrium or into the right atrium for optimal blood flow.
WARNING: Failure to verify catheter placement with fluoroscopy may result in serious trauma or
fatal complications.
12. Secure and dress the catheter as noted in “Securement and Dressing”
INSERTION TECHNIQUE (2) - COMMON STEPS
PERCUTANEOUS ENTRY INTO RIGHT INTERNAL JUGULAR VEIN
WITH AN OVER-THE-WIRE TECHNIQUE
VENOUS ACCESS AND GUIDE WIRE INSERTION
1. K-DOQI Guidelines recommend the use of ultrasound guidance.
NOTE: Mini access (“micropuncture”) is recommended. Follow manufacturers guidelines for proper
insertion technique.
Insert the introducer needle with an attached syringe and advance it into the target vein, in the
direction of blood flow. Aspirate gently as the insertion is made. Aspirate a small amount of blood to
ensure the needle is correctly positioned in the vein.
PRECAUTION: If arterial blood is aspirated, remove the needle and apply immediate pressure to the site
for at least 15 minutes. Ensure that the bleeding has stopped and that no hematoma has developed
before attempting to cannulate the vein again.
2. When the vein has been entered, remove the syringe leaving the needle in place and place thumb over
the hub of the needle to minimize blood loss and / or air embolism.
3. Insert the distal end of the marker guide wire into the needle hub (or mini access introducer hub) and
pass it into the vasculature.
PRECAUTION: If using the “J” tipped wire provided, draw the tip of the wire back into the straightener
so that only the tip of the wire is exposed.
4. Advance the guide wire with forward motion until the tip resides in the junction of the superior vena
cava and right atrium.
WARNING: Cardiac arrhythmias may result if the guide wire is allowed to pass into the right atrium.
CAUTION: Do not advance the guide wire or catheter if unusual resistance is encountered.
CAUTION: Do not insert or withdraw the guide wire forcibly from any component. The wire may break
or unravel. If the guide wire becomes damaged and must be removed while the needle (or sheath
introducer) is inserted, the guide wire and needle should be removed together.
PRECAUTION: The length of the guide wire inserted is determined by the size of the patient and the
anatomical site used.
PRECAUTION: Always confirm proper guide wire position using fluoroscopy. Depth markings on the
wire will help determine indwelling depth.
5. Remove the needle (or mini access introducer), leaving the guide wire in place. The guide wire should
be held securely during the procedure. The introducer needle must be removed first.
CATHETER PREPARATION AND SUBCUTANEOUS TRACT DILATION
1. The ProGuide catheter is packaged with a guide wire stiffening stylet positioned in the venous lumen to
facilitate placement using the over-the-wire technique.
2. Withdraw the stiffening stylet approximately 2-3 cm and confirm that the stylet tip is not visible at the
end of the catheter.
3. Irrigate the arterial lumen and stiffening stylet with heparinized saline and clamp the red arterial
extension prior to catheter insertion.
WARNING: The heparin solution must be aspirated out of both lumens immediately prior to using the
catheter to prevent systemic heparinization of the patient.
WARNING: To minimize the risk of air embolism, keep the catheter clamped at all times when not in use
or when attached to a syringe, IV tubing, or bloodlines.
WARNING: Patients requiring ventilator support are at increased risk of pneumothorax during
subclavian vein cannulation.
CAUTION: Do not clamp the dual lumen portion of the catheter body. Clamp only the clear
extension tubing.
PRECAUTION: Only clamp the catheter with the in-line tubing clamps provided.
4. Determine the catheter exit site on the chest wall, approximately 8-10 cm below the clavicle that is
below and parallel to the venous puncture site.
PRECAUTION: A tunnel with a wide, gentle arc lessens the risk of catheter kinking. The distance of the
tunnel should be short enough to keep the bifurcated junction from entering the exit site, yet long
enough to keep the cuff 2-3 cm (minimum) from the skin opening site.
5. Make a small incision at the desired exit site of the tunneled catheter on the chest wall. The incision
should be wide enough to accommodate the cuff, approximately 1 cm.
6. Use blunt dissection to create the subcutaneous tunnel opening at the catheter exit site for the white
tissue ingrowth cuff, midway between the skin exit site and the venous entry site, approximately 2-3 cm
minimum from the catheter exit site.
WARNING: Do not over-expand the subcutaneous tissue during tunneling. Over-expansion may delay or
prevent cuff in-growth.
7. Make a second incision above and parallel to the first, at the venous insertion site. Enlarge the
cutaneous site with a scalpel and create a small pocket with blunt dissection to accommodate the small
remaining catheter loop (“knuckle”) of the catheter.
8. Attach the tunneler to the catheter’s venous lumen. Slide the tip of the catheter over the tri-ball
connection until it rests adjacent to the sheath stop.
9. Slide the tunneler sheath over the catheter making certain that the sleeve covers the arterial lumen.
This will reduce the drag in the subcutaneous tunnel as the apposition bump and arterial port pass
through the tissue.
10. With the blunt tunneler, gently lead the catheter and tunneler connection into the exit site and create a
subcutaneous tunnel from the catheter exit site to emerge at the venous entry site.
CAUTION: The tunnel should be made with care to avoid damage to surrounding vessels. Avoid
tunneling through muscle.
CAUTION: Do not pull or tug the catheter tubing. If resistance is encountered, further blunt
dissection may facilitate insertion. The catheter should not be forced through the tunnel.
11. After tunneling the catheter, the tunneler can be removed by sliding the tunneler sheath away from the
catheter and pulling the tunneler from the distal tip of the catheter.