Temporary Dialysis Line (Right IJ)

• Anatomic obstruction: Non-compressible vein due to thrombus, anatomic variance or distortion of landmarks. 
• Infection over site of insertion.
• Inability of your patient to lie flat. 
• Uncooperative/combative patient 
• Coagulopathy (if absolute indication for hemodialysis choose a compressible site (IJ, femoral))
• Provider discomfort with procedure 

1. Remove the headboard off the bed + optimize your environment (poles out of way, bed appropriate height etc.). Place side table within arm’s reach near the head of the bed and have the ultrasound screen easily viewable.
2. Place patient in slight Trendelenburg position and slide them towards the head of the bed.
   1. If internal jugular vein demonstrates significant collapse with respiration, consider placing patient at steeper Trendelenburg angle or bolus IV fluids.
3. Turn the patients head slightly to the left and apply chlorhexidine to the identified area of interest (between sternocleidomastoid muscles, well above the clavicle), ensuring there is 2 – 3 minutes for the solution to dry.

1. Open central line kit on side table, put on mask and hairnet provided, and establish a sterile field on the side table. 
2. Drop on the table: your gloves, 3 IV locks, 3 sterile saline vials, 2 citrate tubes, sterile US jelly, probe cover.
3. Put on the sterile gown, have a colleague tie up the back. Put on sterile gloves. 
4. Have assistant open trialysis line kit in sterile fashion, then take the kit and place on opened central line tray table. 
5. Prepare lidocaine: Have assistant drop in lidocaine 5mL in to basin on tray. Draw up lidocaine into 5cc syringe, add on the 25g needle.
6. Prepare trialysis line: Flush all three lines with sterile saline. 
   1. For trialysis = clamp blue + red port, purple port remains unclamped. 
   2. For Niagara = clamp red port, blue port remain unclamped as wire will exit here.
7. Prepare other equipment: Remove cap from introducer needle, remove cap from the guidewire and slide the plastic sleeve forward to straighten the curved wire tip.
8. Apply drape to patient, around target injection site (sterilized with chlorhexidine).
9. Prepare ultrasound: With help of nursing colleague, apply sterile probe cover to linear probe (that already has a small line of non-sterile US gel on it), then add sterile gel to your probe. 

1. Once again examine the relevant area of insertion and track the veins trajectory and anatomy. 
2. Inject lidocaine in the soft tissue at the area of planned insertion, aspirating prior to injection to ensure you are not within a vessel.
3. Insert needle at 30-degree angle to the skin approximately 5 mm proximal to the probe. Once needle tip is visible, slide probe away (until needle tip is no longer seen), then move the needle towards probe. 
   1. Walk the needle towards the IJ vein. 
   2. While inserting needle pull back on syringe to ensure constant negative pressure. 
4. Advance the needle into the IJ.
   1. When the internal jugular vein is entered there should be easy blood flow into the syringe. Put down the US probe and transfer hold of needle to non-dominant hand. 
5. At this stage you can either remove the syringe while stabilizing the needle hub or, if you are using the blue syringe, feed your wire through the hole at the end of the syringe. 
6. Advance the guidewire while stabilizing your needle at the skin level until 3 marks are seen – this represents 30cm of wire. Ensure you never let go of the wire. 
   1. If you removed the syringe to insert the wire, ensure flow is non-pulsatile and cover the needle hub with your thumb to avoid air entrapment. 
   2. If you meet resistance at any point, remove the wire and aspirate with a syringe to ensure you are still in the vessel. If you do not get blood back, use your ultrasound to re-identify where your needle is. Never advance the needle further if you are unsure where the tip is. 
7. Remove needle, keeping guidewire in place. Ensure you ALWAYS have one hand on your wire.
8. Confirm guidewire IJ position with ultrasound in both cross sectional + longitudinal views.
   1. Important to see wire travelling into vessel + remaining in vessel throughout. 
   2. If you are not confident in your needle trajectory into the IJ, do not proceed to dilation. 

1. Create a skin incision with the scalpel along the path of the wire (approx. 0.5 cm).  
2. Perform serial dilation keeping one hand always holding the wire. 
   1. Remember you just need to dilate the soft tissue; use your ultrasound to estimate how much soft tissue depth there is before you enter the vessel. 
   2. Serial dilations with the smallest dilator (central line kit), medium then largest dilator (both from dialysis line kit), keeping sterile gauze over the site of dilation to minimize bleeding.
3. With one hand on the wire always, slide the dialysis catheter over the wire up to the skin. 
4. Slowly bring the wire out through the catheter. Once the wire leaves the catheters purple port, hold onto the wire there then advance catheter fully into IJ vein past the skin.
   1. Note: In Trialysis = wire comes out the purple port. In Niagara = wire comes out the blue port.
5. Remove wire. Once wire out, then clamp purple port. 
   1. In Niagara = remove the wire and the blue stiffener in a single motion then clamp. 
6. Individually unclamp all ports + withdraw blood + flush with sterile saline, then re-clamp.
7. Flush both red/blue ports with citrate and re-clamp. 
   1. Each port is labelled with how much citrate is needed ie 1.5mL, 1.6mL.
8. Apply central line caps to all ports. 
9. Suture line in place on both sides, cover with Tegaderm.
10. Obtain CXR. 
11. Assess for pneumothorax + ensure roughly correct position of line.
12. Document procedure. 

Procedural steps written by: Muralie Vignarajah MD

Staff Reviewed by: Dr. Elenor Henry (Emergency Medicine)