Dialysis Access 1 Vascular System Superior Vena Cava

Dialysis Access 1

Vascular System Superior Vena Cava Internal Jugular Vein External Jugular Vein Brachlocephalic Vein Subclavian Vein Cephalic Vein Axillary Vein Brachial Vein Inferior Vena Cava 2

What is Kidney Failure? Less than 10% kidney function Sudden condition Acute Often temporary Slower onset Chronic Not reversible 3

What causes Kidney Failure? Diabetes High blood pressure Inflammation Blockage Chronic infection Heriditary Other 4

How do you treat Kidney Failure? Kidney transplant Haemodialysis Continuous ambulatory peritoneal dialysis Automated peritoneal dialysis 5

What happens during a Haemodialysis Session? Blood with waste to dialyser Access Cleaned blood back to the body 6

Fistula Access Arterial line Venous line Fistula Vein Artery Vein Radial artery 7

Jugular Catheter 8

What is Peritoneal Dialysis? New solution Tubing set Used solution 9

Peritoneal Dialysis Catheter 10

What is CAPD? Constant dialysis 24 hours a day Continuous Ambulatory You can walk around while it’s happening Peritoneal Dialysis Peritoneal membrane works as a filter 11

CAPD exchange Drai n Used solution Dwel l Fill New solution Remove tubing set 12

8 French Single Lumen Catheter Recommend ed for acute hemodialysis • Acute haemodialysis • low-cost • 8 French • Single Lumen • choice of straight or curved extension, • singles and kits, and • radiopaque polyurethane • Five outflow holes spiral near the tapered tip to help prevent occlusion against the vessel wall. • rotatable suture wing facilitates suturin • luer-lock adapter optimises connections. • Priming volumes are conveniently printed on the extensions to aid in accurate heparinization. 13

Quinton Haemodialysis Catheters Recommend ed for acute hemodialysis • Acute or Chronic haemodialysis • single, double, or triple lumen catheters • Mahurkar design = optimal flow UNIQUE • silicone extensions • unbreakable clamps • Priming volumes printed on extensions • choice of straight or curved extension, • singles and kits • Luer lock adapters • Polyurethane acute • Silicone chronic • tapered atraumatic tip • rotatable suture wing facilitates suturin • luer-lock adapter optimises connections. • subclavian, jugular, femoral placement 14

8 French Single Lumen Catheter Adaptable Recommend ed for acute hemodialysis An optional, disposable Y-adapter lets you convert the single extension catheter to a dual. Percutaneous Insertion The catheter can be inserted percutaneously into the subclavian, femoral, or jugular vein. Catheter Kit 8 French Single Lumen Catheters are available in time-saving, cost-efficient Catheter Kits. 15

Mahurkar Dual Lumen Catheter Recommend ed for acute hemodialysis & apheresis • 8, 10 or 11. 5 Fr. diameter, • curved or straight extensions • Singles and Kits Patented Design Made of flexible polyurethane, Quick insertion patented double-D lumina = high flow rates (300 to 350 ml/ min) tip design helps minimize recirculation. Rotatable Suture Wing helps stabilize the catheter enables the tip to be rotated after implant without removing sutures transparent angled away from the exit site Easy to see exit site Easy to clean area 16

Mahurkar Dual Lumen Catheter Imprinted Extensions Recommend ed for acute hemodialysis & apheresis catheter’s name Length priming volumes Optional Curved Extensions patented curved extensions (jugular placements) Catheter Kit time-saving cost-efficient convenient 17

Perm. Cath Dual Lumen Catheter short- and long-term Efficient Recommend ed for hemodialysis , apheresis & infusion 2. 5 cm separation between the arterial lumen and the venous tip helps reduce recirculation Priming volumes are printed on the clear extensions. Comfortable silicone felt cuff anchors the catheter subcutaneously helps establish a natural infection barrier. 18

Perm. Cath Dual Lumen Catheter Choice of Insertion Sites Recommend ed for hemodialysis , apheresis & infusion jugular, subclavian, or femoral vein. 40 cm and 45 cm catheters permit access to the right atrium from the patient’s left side. They are particularl useful for larger patients, when the right side is thrombosed, or for a thoracic approach. Catheter Kit patented Oval Pull-Apart. TM sheath/dilator Oval Pull-Apart. TM Introducer Set conforms to catheter shape = reduces risk of air embolism during insertion. 19

Perm. Cath Dual Lumen Catheter Oval Pull-Apart Introducer Extra Oval Pull-Apart sheath/dilators are available. Catheter Repair Kit Recommend ed for hemodialysis , apheresis & infusion Catheter Repair Kits eliminate the need to replace a catheter due to external damage. Repair Kits are available in all Perm. Cath sizes. 20

Mahurkar 13. 5 Fr Cuffed Catheter Efficient Recommend ed for hemodialysis 2. 5 cm separation between the arterial lumen and the venous tip helps reduce recirculation Priming volumes are printed on the clear extensions. Choice of Insertion Sites jugular, subclavian or femoral vein. 40 cm, 45 cm and 50 cm catheters permit access to the right atrium from the patient’s left side. useful for larger patients, when the right side is thrombosed, or for a thoracic approach. 21

Mahurkar 13. 5 Fr Cuffed Catheter Comfortable Recommend ed for hemodialysis silicone rubber, the catheter does not abrade the skin at the exit site or interfere with patient mobility. The flexible silicone suture wings anchor the catheter while tissue ingrowth occurs. A felt cuff anchors the catheter subcutaneously and helps establish a natural infection barrier Catheter Kit The catheters are available in time-saving, cost-efficient Kits. They contain the basic items needed for percutaneous insertion and a convenient tunnelling stylet. Catheter Repair Kits eliminate the need to replace catheters, due to external damage. Repair Kits are available in all catheter lengths. 22

MAHURKAR Acute Triple Lumen Catheter Safety • Soft Atraumatic Tip designed to reduce vessel trauma during insertion Recommend ed for hemodialysis , apheresis and infusion • Laser Cut Arterial Slot reduces positional occlusion, maintains high flows and retains heparin lock • Imprinted Primimg Volumes on catheter extensions quickly identify heparin loading volumes • Straight Infusion Lumen differentiates it from the dialysis ports to prevent accitental infusion of heparin or Urokinase 23

MAHURKAR Acute Triple Lumen Catheter Ease of use • 180° Curved Extensions help stabilize the catheter and aid in patient comfort Recommend ed for hemodialysis , apheresis and infusion • Rotatable Suture Wings enable the tip to be rotated after implantation and stabilize the catheter Selection • The 12 Fr. Mahurkar Acute Triple Lumen Catheter is available in four lengths: 13 cm, 16 cm, 20 cm and 24 cm to accommodate varying body types and insertion sites • Catheters are available individually or in kits 24

MAHURKAR Acute Triple Lumen Catheter Recommend ed for hemodialysis , apheresis and infusion 25

Tenckhoff Peritoneal Catheters Broad Selection Recommend ed for peritoneal dialysis or intraperitone al chemotherap y Choose from a variety of catheter lengths and cuff placements, or choose Quinton’s Universal Tenckhoff- a unique catheter that can be trimmed to fit most patient sizes. Quinton offers the Tenckhoff in four cuff configurations: two attached cuffs - one subcutaneous and one preperitoneal, one attached cuff - in either the subcutaneous or preperitoneal position, and two loose cuffs - catheter can be customized to fit the needs of the patient. Cost-Efficient For your convenience, Quinton packages Tenckhoff catheters one per carton, enabling you to stock multiple configurations at minimal cost. Catheters are also available in time-saving, cost-efficient Kits. They contain the basic items needed for percutaneous insertion, featuring the Pull-Apart. TM sheath/dilator and tunnelling stylet. 26

Tenckhoff Peritoneal Catheters Complete System Recommend ed for peritoneal dialysis or intraperitone al chemotherap y Each Tenckhoff catheter comes with an adapter, cap, and clamp. The Ultem® adapter forms a tight closure with standard CAPD transfer sets and eliminates the need for expensive titanium adapters. In Addition Quinton makes Curled Peritoneal Catheters, Peritoneal Catheter Kits, and catheter accessories. Catheter Repair Kit The Peri-Patch® and Peritoneal Catheter Repair Kits provide the components for fast, convenient Tenckhoff repair. Unlike polyurethane catheters, the silicone-rubber Tenckhoff can be extended or repaired, thereby eliminating the need for costly replacement due to external damage. To calculate the internal volume of the catheter, multiply. 058 by the length of the catheter. 27

Tenckhoff Peritoneal Catheters Recommend ed for peritoneal dialysis or intraperitone al chemotherap y 28

Curl Cath Peritoneal Catheters Features Recommend ed for peritoneal dialysis or intraperitone al chemotherap y The Curl Catheter, a modified Tenckhoff, is suitable for acute or chronic peritoneal dialysis and intraperitoneal chemotherapy. It can be inserted either percutaneously or surgically. The additional mass of the Curl Cath keeps the catheter low in the pelvic gutter, resulting in fewer dislodgements and less catheter migration. The catheter’s curled tubing and numerous inflow/outflow holes diffuse dialysate gently into the patient. The Curl Cath is made of translucent, medical-grade silicone rubber with a radiopaque stripe. It has a 4. 9 mm OD. , and a 2. 6 mm ID. , and comes in adult or pediatric lengths. Unlike polyurethane catheters, the Curl Cath can be extended or repaired if necessary, eliminating the need for costly catheter replacement due to external damage. 29

Curl Cath Peritoneal Catheters Recommend ed for peritoneal dialysis or intraperitone al chemotherap y Felt cuffs anchor the catheter subcutaneously and help establish a natural infection barrier through tissue ingrowth. To meet the varying needs of patient and physician, Quinton offers four cuff configurations: • two attached cuffs - one subcutaneous and one preperitoneal, • one attached cuff - in the preperitoneal position, and • two loose cuffs - the clinician customize cuff placement on the catheter to meet the needs of the patient. The adapter provides a tight closure with standard CAPD transfer sets and eliminates the need for expensive titanium adapters. Curl Catheters are also available in convenient Kits, which provide the necessary components for inserting the catheter by modified Seldinger technique. Each Kit features a Pull-Apart. TM Introducer and Peritoneal Catheter Tunnelling Stylet. Accessories Quinton offers a full line of accessory items for Curl Cath catheters, including repair kits, and stylets. See our Peritoneal Catheter Accessories and Peri-Patch® data sheets for ancillary and replacement components. 30

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis Swan Neck Specialty Peritoneal Catheters give you the options and features you need to simplify access for peritoneal dialysis. • • Broad Selection Choose from a Variety of Catheter Options: Tenckhoff Curl Cath Missouri (Available in Tenckhoff and Curl Cath) Oreopoulos-Zellerman or Toronto Western (Available in Tenckhoff and Missouri) Presternal (Available in Curl Cath) Some are available in pediatric 31

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis 32

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis 33

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis 34

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis 35

Swan Neck Peritoneal Catheters Recommend ed for peritoneal dialysis 36

Peritoneal Catheter Kit Recommend ed for percutaneou s placement of Peritoneal Catheters 37

Peritoneal Catheter Kit Percutaneous Insertion Recommend ed for percutaneou s placement of Peritoneal Catheters The Peritoneal Catheter Kit provides an ideal alternative to catheter placement by laparotomy. Each Kit features a Pull-Apart Introducer used to insert the catheter percutaneously using modified Seldinger technique. This technique involves a smaller incision, helping to minimize the risk of post-operative dialysate leakage, and often enabling the catheter to be used sooner. In general, percutaneous insertion means faster insertion and greater patient comfort. 38

Peritoneal Catheter Kit Convenience Recommend ed for percutaneou s placement of Peritoneal Catheters Cost-efficient Kits simplify inventory and save staff time required for assembling supplies needed for catheter insertion. Each Kit contains the following components: • peritoneal catheter, • Beta. Cap adapter, cap and clamp, • 1 6 Fr. Pull-Apart sheath/dilator, • 18 gage introducer needle, • J/straight guide wire, • 10 cc syringe, • #11 scalpel, • tunnelling stylet, and • gauze sponges. 39

Peritoneal Catheter Kit Complete System Recommend ed for percutaneou s placement of Peritoneal Catheters Each catheter comes with a Beta-Cap adapter, cap, and clamp. The Ultem adapter forms a tight closure with standard CAPD transfer sets. Choices • • • variety of lengths (42, 57, 60 and 62 cm) styles (straight, curled, and universal) cuffed positions (single, dual, preperitoneal, or subcutaneous) styles (straight or curled, universal and straight or curled Swan Neck) catheter stencils (Available for Swan Neck) 40

Peri-Patch Repair Kit The Peri-Patch® Repair Kit contains: • 15 cm silicone rubber catheter extension (2. 6 mm ID. , 4. 9 mm CD. ) with Recommend ed for lengthening and repair of the external portion of Peritoneal Catheters • • • double-barbed connector; Beta-Cap® adapter, cap, and clamp; medical-grade silicone adhesive, Type A; and glue mold. The hinged glue mold with locking ring is approximately 5 cm long. Used with the adhesive, the mold forms a permanent silicone seal over the connection between the indwelling catheter and the extension. NOTE: To be repaired, the indwelling catheter needs to have at least 3 cm external tubing at the exit site. All components, including silicone adhesive are supplied sterile. Kits are double packaged; the inner package can be placed directly on a sterile field. Due to the expiration date, the adhesive is packaged separately in a sterile pouch. 41

Peritoneal Catheter Accessories Peritoneal Catheter Straightening Stylet Tyco Healtcare offers top quality accessories for its peritoneal catheters The stainless steel stylet is 62 cm long, helping to keep the catheter straight and manoeuvrable during insertion into the peritoneum. Peritoneal Tunnelling Stylet The Stylet penetrates tissue cleanly, creating a subcutaneous tunnel with minimal bleeding and tissue trauma. As the stylet dilates the tissue, the practitioner simultaneously pulls the catheter through the tunnel. Made of pliable stainless steel, it can be bent to create a customized, curved tunnel. The stylet is 5 Fr. x 23 cm (9”). Felt Cuffs enable the practitioner to custom fit Quinton® Peritoneal Catheters. They anchor the catheter and help establish a natural infection barrier. Each cuff is one centimetre long. 42

Peritoneal Catheter Accessories Medical Grade Silicone Adhesive Type A Tyco Healtcare offers top quality accessories for its peritoneal catheters The sterile adhesive is used to bond felt cuffs to the catheter. It is also used with Quinton® Repair Kits to extend or repair catheters. Injection Sealing Caps provide self-sealing injection sites for administering medications. Beta-Cap® Adapter The Beta-Cap adapter is made of Ultem® resin and can be used with all Quinton® Peritoneal Catheters. It forms a tight closure with standard CAPD transfer sets and eliminates the need for expensive titanium adapters. Beta-Cap® Clamp The Beta-Cap Clamp is compatible with all Quinton® Peritoneal Catheters. 43

Single Lumen Right Atrial Catheter Advantages Recommend ed for long term infusion and blood sampling Single Lumen Right Atrial Catheters provide long-term vascular access with minimal trauma to the system. Made of soft, biocompatible silicone rubber, these radiopaque catheters are ideal for immunosuppressed, thrombocytopenic patients needing: • • chemotherapy, total parenteral nutrition, blood sampling, or blood product administration. 44

Single Lumen Right Atrial Catheter Features Recommend ed for long term infusion and blood sampling • • reinforced tubing to protect the catheter when clamping felt cuff to anchor the catheter subcutaneously and help establish a natural infection barrier range of sizes catheter name and priming volume are imprinted on extensions for easy identification can be inserted percutaneously using a Pull-Apart. TM sheath/dilator or surgically implanted in-line clamp and luer-lock adapter atraumatic tunnelling stylet designed to minimize bleeding in the tunnel tract 45

Single Lumen Right Atrial Catheter Repair Kit Recommend ed for long term infusion and blood sampling Catheter Repair Kits eliminate the need to replace a catheter due to external damage. 46

Raaf Dual Lumen Right Atrial Catheter Advantages Recommend ed for long term infusion and blood sampling Single Lumen Right Atrial Catheters provide long-term vascular access with minimal trauma to the system. Made of soft, biocompatible silicone rubber, these radiopaque catheters are ideal for immuno suppressed, thrombocytopenic patients needing: • chemotherapy, • total parenteral nutrition, • blood sampling, or • blood product administration. 47

Raaf Dual Lumen Right Atrial Catheter Features Recommend ed for long term infusion and blood sampling • • reinforced tubing to protect the catheter when clamping felt cuff to anchor the catheter subcutaneously and help establish a natural infection barrier range of sizes catheter name and priming volume are imprinted on extensions for easy identification can be inserted percutaneously using a Pull-Apart. TM sheath/dilator or surgically implanted in-line clamp and luer-lock adapter atraumatic tunnelling stylet designed to minimize bleeding in the tunnel tract 48

Raaf Dual Lumen Right Atrial Catheter Repair Kit Recommend ed for long term infusion and blood sampling Catheter Repair Kits eliminate the need to replace a catheter due to external damage. 49

3. 9 mm Triple Lumen Catheter Recommend ed for chemotherap y, stem cell infusion, parenteral nutrition, incompatible therapeutic agents, blood sampling and transfusions Minimal Trauma Made of biocompatible, soft silicone rubber, the catheter minimizes internal trauma, making it ideal for immunosuppressed, thrombocytopenic patients. Percutaneous Insertion The catheter can be surgically implanted, or it can be introduced percutaneously through a 1 2 Fr. Pull-Apart. TM Introducer. A felt cuff anchors the catheter subcutaneously and helps create a natural infection barrier. Extras For your convenience, the catheter has clear extensions to enable you to see blood or air in the tube, in-line clamps, and color-coded, luer-lock adapters. The larger 1. 2 mm lumen, used for blood products, is conveniently identified by its red adapter. 50

3. 9 mm Triple Lumen Catheter Recommend ed for chemotherap y, stem cell infusion, parenteral nutrition, incompatible therapeutic agents, blood sampling and transfusions Catheter Repair Kit The Catheter Repair Kit eliminates the need to replace a catheter due to external damage. 51

Welcome to the Tyco test 1. What material are Acute Mahurkar Catheters made from? 2. What material are Permcath Catheters made from? 3. What are the extensions made of? 4. What material do our competitors use for the extensions? 5. Which catheters need a tunnel? 6. Which substance is used for priming? 7. Which substance is used for anti-clotting? 8. Please state three major placements in the body for HD catheters? 9. List the name of three competitors in your market 52

Welcome to the Tyco test continued 10. Quinton configurations on extensions: How many and their names? 11. How many cuffs on a PD catheter? 12. Which are the two major insertion methods of a HD catheter? 13. Describe the Seldinger technique in point form (step by step). 14. Where should the tip of the Permcatheter be placed? 15. Which Quinton catheter has suture wings? 16. What is the special benefit of the Quinton suture wing? 17. Where should the tip of a Mahurkar catheter be placed? 18. What are DOQI guidelines? 53

Your happy boss? 54