Preoperative Diagnosis: End-stage renal disease

Postoperative Diagnosis: Same

Procedure Performed: Left subclavian dual lumen hemodialysis catheter placement

Indications for Procedure: The patient is a 53-year-old female with renal failure due to hypertensive nephropathy. She is in need of vascular access for renal dialysis and is admitted to the day surgery unit for central line placement.

Description of Procedure: With the patient in the supine position the left shoulder area was prepped with Betadine scrub and appropriately draped. Lidocaine 1% without epinephrine was instilled into the skin and surrounding tissue in the area of the mid-shaft of the left clavicle. The patient was repositioned in Trendelenberg. The left subclavian vein was entered on the first pass of a #17 gauge needle. The beveled needle was rotated inferiorly. A J-tipped guide wire was inserted through the needle and advanced without difficulty. The needle was removed and the patient returned to the supine position. Lidocaine 1% was instilled into the soft tissue approximately 2 inches lateral and inferior to the initial puncture site. The soft tissue between the sites was also instilled with Lidocaine. The initial wound was enlarged with a #11 blade. A skin puncture was made in the previously anesthetized skin. Using blunt dissection a subcutaneous tunnel was made between the two puncture sites. The exposed tip of the guide wire was threaded retrograde through the tunnel. The patient was returned to Trendelenberg position. A venodilator was inserted over the guide wire and advanced via Seldinger technique. The dilator was removed. An 8-inch dual lumen hemodialysis catheter was inserted over the guide wire and again advanced via Seldinger technique without difficulty. The guide wire was then removed. Excellent blood flow was confirmed back to both ports. Both ports were then flushed with heparinized solution. The catheter was tied into place with three 2-0 silk sutures. A 3-0 silk suture was used to close the proximal wound. Betadine was applied to both wounds. A dry sterile dressing was applied. Post-insertion chest x-ray confirmed correct catheter position. The patient tolerated the procedure well, but did become slightly hypertensive on one occasion. The patient was discharged to the recovery area in stable condition.