Instruction Manual

connecting the Upper Catheter, ensure that the catheter is
oriented so that the cu and exit site face laterally.
4. Tie a non-absorbable suture, such as 2-0 or 0-polypropylene,
around each catheter, behind the barb on the Titanium Connec-
tor. The two sutures may then be tied to each other to further
prevent tubing separation.
5. Test the integrity of the junctions by pulling rmly on each
catheter in turn while holding the connector. Do not dislodge
the deep (rectus) cu during this pull test.
Implanting the Upper Catheter with
an Upper Abdomen Exit-Site
1. Make a 2.0 - 3.0 cm horizontal incision at the marked second-
ary incision site, Rectangle .
2. At the secondary incision site, Rectangle , perform
dissection in the subcutaneous tissue to the anterior rectus
fascia. On the surface of the fascia, create a subcutaneous pock-
et to contain the preformed arcuate bend of the Upper Catheter.
In addition, perform dissection caudally on the surface of the
fascia to facilitate passage of the ExxTended Catheter Tunneling
Tool tip from the primary (lower) incision to the secondary
(upper) incision.
3. Insert the blunt, bullet-shaped end of the Tunneling Tool into
the primary incision site.
4. Guide the Tunneling Tool along the surface of the fascia to
the secondary incision site.
NOTE:
a. Make sure that the Tunneling Tool stays in the relatively loose
avascular areolar tissue plane between the muscle fascia and
subcutaneous tissue. Do not insert the tool and catheter into
the subcutaneous fat. Doing so may cause the catheter to
kink during certain patient activities.
b. Do not cross the patient’s midline of the abdomen or chest.
c. Follow the marked Tunnel Track, as indicated by the Stencil,
when feasible.
d. If a laparoscopic catheter implantation approach is being
used, the presence of a pneumoperitoneum provides a rm
fascial surface that facilitates passage of the Tunneling Tool.
5. Advance the Tunneling Tool far enough through the second-
ary incision site so that it can be grasped with the other hand.
6. Attach the proximal end of the Upper Catheter to the barbed
tip of the ExxTended™ Catheter Tunneling Tool.
7. Secure the catheter end onto the tip with a suture.
8. Carefully pull the Tunneling Tool out through the secondary
incision site far enough so that the Tool can be laid down.
NOTE: Do not twist the catheter. Observe the radiopaque stripe
to ensure that the catheter remains straight.
9. Continue to pull the catheter gently until the marker ring is
visible at the secondary incision site.
NOTE:
a. When the marker ring is visualized on the surface of the fas-
cia at the secondary incision site, the length of the catheter
between the marker ring and the deep (rectus) cu should
be relatively straight.
b. Do not dislodge the deep (rectus) cu.
c. Do not twist or rotate the catheter. Observe the radiopaque
stripe to ensure that the catheter remains straight. Excess,
non-straightened tubing may cause future kinking and ow
failures under some conditions.
10. Cut the catheter free of the Tunneling Tool.
NOTE:
a. Do not attempt to use the end of the catheter that was
inserted over the barbed tip of the Tunneling Tool. It is
stretched too much to be able to hold the connector
securely.
b. When cutting the catheter free of the Tunneling Tool, make a
straight, perpendicular cut of the tubing with suture scissors.
Always verify that the cuts are perpendicular to the catheter
tubing so that the connector ts well in the catheter.
11. Infuse a minimum of 60 mL of sterile saline to verify patency,
and that there are no twists or kinks in the catheter.
NOTE: If the abdomen was insuated during laparoscopic
insertion, deate the abdomen to avoid false uid outow rates.
Finalizing Catheter Placement
Merit Medical Systems, Inc. provides three options for tunneling
the catheter through the skin exit-site location. The technique
for creating the exit-site will vary according to the particular tool
selected to perform this function. A plastic retrograde Tunnelor®
Tool , plastic antegrade Faller Trocar, and stainless steel ante-
grade Faller Trocar are sold separately.
1. The exit site location should be lateral to the primary site.
The exit-site should be approximately 3-4 cm distal to the exit
site cu if possible.
NOTE: For reduced infection and optimal placement, the cathe-
ter should have a gentle, curved downward-facing exit-site.
WARNING: Check catheter at primary site and exit-site to ensure
the catheter is not twisted or kinked.
2. After the catheter has been tunneled to the exit-site, verify
catheter patency by infusing and draining a minimum of 1.0 L of
sterile saline.
3. Attach the catheter connector and cap, or alternatively, a
connector and transfer set. See below, “Catheter Connector
Instructions”, for details.
4. Close the primary and secondary incision sites, appropriate
to the implantation technique used.
NOTE:
a. Do not suture the exit-site.
b. Do not use anchoring stitches to secure the catheter to the
skin. Instead, use sterile adhesive strips to immobilize the
catheter on the skin adjacent to the exit-site.
c. Apply appropriate dressings to all incision sites and to the
catheter itself.
Supplemental Information
• The external catheter limb can be embedded at this point, if
desired. An Embedding™ Tool is available from Merit Medical.
• Urgent or supportive dialysis can begin immediately with re-
duced volumes (1 liter maximum) and the patient in a supine
position. If possible, the abdomen should be continuously
dry (nocturnally) for 8-12 hours within each 24 hour period
after catheter placement for the rst full week of dialysis. If
the patient assumes an upright position, there should be no
uid in the abdomen for the rst 7 days or until the catheter
sites are healed.
• Catheter immobilization is important to allow for proper
tissue in-growth.
• The catheter should be ushed with heparinized saline with-
in 24 to 72 hours and a minimum of every 7 days thereafter.
Section D
INSTRUCTIONS FOR IMPLANTING UPPER CHEST
CATHETER: SIZING, CONNECTING AND PLACEMENT
Measurement Locations for Sizing the Upper Chest Catheter
Measurements are based on three locations: 1) the Primary
Incision Site, T-bar, where the rectus cu is located and the
Lower Catheter is temporarily exiting the abdomen; 2) the
Secondary Incision Site, as indicated by the Rectangle and 3) the
location where the two catheters will be joined together. These
instructions presume that the primary and secondary incision
sites were marked during patient preparation prior to surgery.