1. Tunnelled catheter locking with heparin: Comparative study of slow and rapid administration Vanesa Fernandez Head nurse Fresenius Medical Care Services Cartagena y San Pedro del Pinatar, Spain Malmö, 3 September 2013

2. 1 Introduction 2 Objectives Methods 3 Results 4 Outline FME © Copyright - Tunnelled catheter locking with heparin...Page 2 EDTNA/ERCA, Malmö 31 August - 3 September 2013 Conclusions 5

3. Introduction (1) Tunneled catheter Increasing incidence and prevalence Advantages Immediate use Sometimes it is the only choice of vascular access (diabetic patients, metabolic diseases, vascular dysfunction, severe cardiovascular disease). Infectious and mechanical complications Objective: To obtaining higher Qb (as much as possible), usually lower than AV- Fistula (AVF) To maintain patency of the tunneled catheter, as this is critical to get a high Qb FME © Copyright - Tunnelled catheter locking with heparin...Page 3 EDTNA/ERCA, Malmö 31 August - 3 September 2013

4. Introduction (2) Locking One of the major goal is to ensure permeability of the catheter between hemodialysis sessions by means of sealing. PREVENT RETROGRADE FILLING OF THE LUMEN AVOID THROMBOSIS MAINTAIN PERMEABILITY ↑ QB ↑ DOSAGE OF DIALYSIS FME © Copyright - Tunnelled catheter locking with heparin...Page 4 EDTNA/ERCA, Malmö 31 August - 3 September 2013

5. Objectives The Spanish Society of Nephrology Guidelines recommend locking with a sodium heparin concentration of 20 U/ml, or - if this is not available - 1% heparin. Opinions on the locking regime differ: Conventional slow regime (HEPS) or a rapid regime with fast clamping (HEPR) Objective: To compare the efficacy and complications of the session with both methods. FME © Copyright - Tunnelled catheter locking with heparin...Page 5 EDTNA/ERCA, Malmö 31 August - 3 September 2013

6. Methods (1) 32 patients recruited, mean age 66.3 years, 60% male patients, 53.2 months of haemodialysis 37% vascular and diabetic cases, 25 patients completed the study. All patients have tunneled central venous catheters. We performed a prospective cross-over study in a prevalent haemodialysis population (2 centers). All patients gave their informed consent to participate in the study. FME © Copyright - Tunnelled catheter locking with heparin...Page 6 EDTNA/ERCA, Malmö 31 August - 3 September 2013

7. Methods (2) FME © Copyright - Tunnelled catheter locking with heparin...Page 7 EDTNA/ERCA, Malmö 31 August - 3 September 2013 16 patients HEPS 8 weeks 16 patients HEPR 8 weeks 16 patients HEPR 8 weeks 16 patients HEPS 8 weeks DESIGNDESIGN Dialysis efficacy variables: Qb, Kt, VTR Complication related variables: Urokinase requirements and times, investment of branches, additional washes and recovery arterial and venous cap

8. Results: Efficacy (1) FME © Copyright - Tunnelled catheter locking with heparin...Page 8 EDTNA/ERCA, Malmö 31 August - 3 September 2013

9. Results: Efficacy (2) FME © Copyright - Tunnelled catheter locking with heparin...Page 9 EDTNA/ERCA, Malmö 31 August - 3 September 2013

10. Results: Complications (at least in one session) FME © Copyright - Tunnelled catheter locking with heparin...Page 10 EDTNA/ERCA, Malmö 31 August - 3 September 2013 p=0.001 p=0.002 p=0.003 p=0.001

11. Results o Among the patients where the plug was not removed and additional flushes were needed the number does not differ significantly. o There were no significant differences in the number of urokinase protocols o However, investment for branches is higher (p=0.024) with HEPR (6.73±3.11) than HEPS (1.25±1.30). FME © Copyright - Tunnelled catheter locking with heparin...Page 11 EDTNA/ERCA, Malmö 31 August - 3 September 2013

12. Conclusions (1) No differences were noted in dialysis efficacy between dialysis catheter lock with heparin administered slowly versus quickly with positive pressure, nor in Qb, Kt, duration or TRV. So, both methods are able to maintain lumen permeability in patients with tunneled permanent catheters as vascular access for haemodialysis or on-line haemodiafiltration. FME © Copyright - Tunnelled catheter locking with heparin...Page 12 EDTNA/ERCA, Malmö 31 August - 3 September 2013

13. Conclusions (2) Nevertheless, there were fewer complications with the slow administration regarding the need of urokinase, additional flushes, dialysis session with inverted branches, or difficulty in plug recovery. Therefore, based on these results we recommend the slow administration method as elective procedure. FME © Copyright - Tunnelled catheter locking with heparin...Page 13 EDTNA/ERCA, Malmö 31 August - 3 September 2013

14. FME © Copyright - Comparative assessment of nutritional status in haemodialysed...Page 14

15. Acknowledgments FME © Copyright - Tunnelled catheter locking with heparin...Page 15 Javier Fernández-CaroNurse Fresenius Medical Care Dialysis Centre, Cartagena, Spain. Rosario Perez Nurse Fresenius Medical Care Dialysis Centre. Caritagena, Spain Tania Ortega Nurse Fresenius Medical Care Dialysis Centre. San Pedro del Pinatar, Spain Rhoda Pallares Nurse Fresenius Medical Care Dialysis Centre. Caritagena, Spain Maria Teresa Parisotto Director, Nursing Care Management Fresenius Medical Care - NephroCare Coordination, Bad Homburg, Germany EDTNA/ERCA, Malmö 31 August - 3 September 2013