A Comparative Study for Ideal Positioning of Dialysis Catheter Tip in Pediatric Patients
Condition: Dialysis Catheter; Malposition
Study type: Interventional

Summary: 
      This prospective study will be conducted to compare between the efficacy of both ECG-guided
      technique and anatomical landmark technique to detect the ideal positioning of dialysis
      catheter tip and whether it will decrease the radiation exposure or no?
    

Detailed description: 
      This study will be conducted on 150 children and adolescents with end stage renal disease or
      any cause for urgent hemodialysis at our nephrology Unit at TUH during the period of the
      study and classified into two equal groups:

      Group A (control): insertion of dialysis catheter using the anatomical landmark-guided
      technique.

      Group B: insertion of dialysis catheter using the ECG-guided technique. Participants will be
      randomly assigned using an internet-based computer program (http://www.randomizer.org) either
      to the anatomical landmark group or to the ECG group.

      All patients included in the study will be subjected to:

        1. History taking including the cause of dialysis.

        2. Clinical examination.

        3. Investigations:

             -  Complete blood picture

             -  Bleeding and clotting time.

             -  International normalized ratio

             -  Serum potassium

             -  Serum creatinine, blood urea level.

        4. Procedure technique:

      A single anesthiologist will perform the procedures in both groups under complete a septic
      condition after consent taking from the child guardians. All participants will be cannulated
      in the right internal jugular vein (IJV). The participants were placed in Trendelenburg
      position and the dialysis catheter will be inserted using catheter-over-guidewire technique
      (the Seldinger technique) with the aid of ultrasound for scanning the neck by the superficial
      probe (7-13 MHz).

      In the ECG-guided technique, after inserting the dialysis catheter into right IJV, the
      guidewire will be then withdrawn until the tip to be exactly positioned at the entry of the
      Superior Vena Cava in the right atrium. This will be ECG guided: the p wave appears as
      biphasic wave in the RA then the catheter will be withdrawn at 0.5 cm intervals until the
      P-wave returned to a normal configuration. At that point, the catheter will be secured at the
      skin with suture and dressed with a transparent dressing.

      In the anatomical landmark technique: Before insertion, the catheter depth was calculated
      from the insertion point to the catheter tip point (midway the vertical line from the
      clavicular head of sternocleidomastoid to inter nipple line.

      After insertion of the dialysis catheter, the patient will be monitored for any hemodynamic
      deterioration and a repeat ultrasound-chest was done to rule out pneumothorax. An
      anterior-posterior CXR in supine position will be taken in all patients, to confirm the
      placement and positioning of the dialysis catheter.

      The whole length of the SVC was defined on CXR as the area from the lower border on the first
      right costal cartilage close to the sternum to the conventional radiographic SVC-RA junction.

      Post insertion CXR done in both groups to detect the adequate insertion length of the
      dialysis catheter, frequency of CXR for repositioning, time to dialysis catheter placement,
      and post procedural complications will be recorded.
    

Intervention name(s): Anatomical landmark guided dialysis catheter insertion; ECG guided dialysis catheter insertion
Intervention type(s): Procedure; Procedure
Intervention description(s): .: Before insertion, the catheter depth was calculated from the insertion point to the catheter tip point (midway the vertical line from the clavicular head of sternocleidomastoid to inter nipple line.; after inserting the dialysis catheter into right IJV, the guidewire will be then withdrawn until the tip to be exactly positioned at the entry of the Superior Vena Cava in the right atrium. This will be ECG guided: the p wave appears as biphasic wave in the RA then the catheter will be withdrawn at 0.5 cm intervals until the P-wave returned to a normal configuration. (At that point, the catheter will be secured at the skin with suture and dressed with a transparent dressing
Other intervention name(s): ultrasound guided dialysis catheter insertion using anatomical method; ultrasound guided dialysis catheter insertion using ECG technique
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 150 children and adolescents with end stage renal disease or any cause for urgent hemodialysis at our nephrology Unit at TUH during the period of the study and classified into two equal groups: Group A (control): insertion of dialysis catheter using the anatomical landmark-guided technique.
Group B: insertion of dialysis catheter using the ECG-guided technique.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention