Temporary Non-Tunneled Hemodialysis Catheter Placement Procedure Note

Procedure Date/Time: [Procedure date and time]

Location: [Bedside location and unit]

Operator: [Operator name and credentials]

Assistants: [Assistants or None]

Service: [Service/department]

Indication: [Urgent HD / CRRT / Bridge for access failure / Other] (If Other, briefly specify.)

Procedure

Temporary Non-Tunneled Hemodialysis Catheter Placement

[French size] Fr, [number of lumens]-lumen catheter placed in [Right IJ / Left IJ / Right femoral / Left femoral] under [real-time ultrasound guidance / landmark technique], with maximal sterile barrier precautions [used / not fully used]; immediate complications [none / occurred].

Indications and Clinical Context

[Brief narrative summarizing primary indication for urgent dialysis, planned modality, why existing access is unavailable or unsuitable, and expected duration or transition plan if known] (2–4 sentences. Include risk modifiers such as coagulopathy, high ventilator settings, anatomic limitations, or prior central venous issues only if present.)

Pre-Procedure Assessment and Safety Checks

Allergies: [Relevant procedural allergies including chlorhexidine, iodine, latex, lidocaine / None known]

Coagulation/Bleeding Risk: [Anticoagulation status and relevant labs with values and timing / Labs not available at time of procedure]

Consent: [Informed consent obtained from patient or surrogate including discussion of risks / Emergent consent exception: brief rationale]

Time-Out: Time-out performed confirming correct patient, procedure, site/side, and equipment availability.

Site Selection: [Right IJ / Left IJ / Right femoral / Left femoral]. [Rationale for site selection] (For IJ sites, note dialysis access preservation considerations. If femoral site chosen, document specific rationale.)

Ultrasound Assessment: [Pre-procedure ultrasound findings: vein identified, patency, compressibility, position relative to artery, absence of thrombus / Ultrasound not used: reason]

Preparation and Sterile Technique

• Hand hygiene performed
• Maximal sterile barriers: cap, mask, sterile gown, sterile gloves, full-body sterile drape
• Skin antisepsis with [chlorhexidine-alcohol / alternative agent] applied and allowed to dry
• Sterile ultrasound probe cover and sterile gel used (Include only if ultrasound used.)
• Patient positioning: [Trendelenburg for IJ / Supine for femoral / Other with rationale]
• [Deviation from sterile technique and mitigation plan] (Include only if applicable.)

Anesthesia

Local Anesthetic: [Agent], [concentration], [total volume]

Sedation: [None / Minimal anxiolysis / Moderate sedation] (If moderate or deep sedation, reference separate sedation record.)

Catheter Specifications

Type: Temporary non-tunneled hemodialysis catheter

Manufacturer/Model: [Manufacturer and model if available]

French Size: [Size] Fr

Length: [Length] cm

Lumens: [Number of lumens]

Priming Volume per Lumen: [Volume if known]

Procedure Narrative

• Site: [Anatomic site and laterality]
• Technique: Seldinger
• Needle passes: [Number of attempts]
• Guidance: [Real-time ultrasound guidance / Landmark technique with reason]
• Venous confirmation prior to dilation: [Ultrasound visualization of guidewire in vein / Non-pulsatile blood return / Both]
• Dilation performed and catheter advanced to [depth] cm at skin
• Guidewire removed intact (Required explicit statement.)
• Hemostasis achieved
• Estimated blood loss: [Volume] mL

Post-Placement Assessment

Functional Check: [Both lumens aspirate freely and flush without resistance / Issue described]

Lock Solution: [Type, concentration, and volume per lumen / Lock solution per institutional protocol; details in MAR]

Securement: [Sutures / Securement device / Both]; [sterile occlusive dressing / CHG-impregnated dressing] applied

Complications: [None / Complication type and interventions performed]. Procedure [completed / aborted]. (Required field—never omit.)

Confirmation and Clearance

Confirmation Method: [CXR ordered / Point-of-care ultrasound / No imaging required per local policy for femoral site]

Use Status: [Catheter NOT to be used until imaging reviewed and placement confirmed / CXR reviewed: tip position appropriate, no pneumothorax—Catheter CLEARED for dialysis use] (Must contain unambiguous language about whether catheter may be used.)

Post-Procedure Plan

• Catheter access restricted to dialysis-trained staff per protocol
• Dressing care: keep clean, dry, intact; change per protocol or if soiled/loose
• Monitor insertion site for bleeding, swelling, and signs of infection
• Daily necessity review; plan for removal or transition to permanent access

(All required fields must be present. If information is unavailable, explicitly document "not available" rather than omitting.)