Transcript Slide 1

ANNA Jersey North
Chapter 126
Patient Care Technician
Certification Review
Dialysis Access
September 13, 2009
Alice Hellebrand MSN, RN, CNN, CURN
ANNA Northeast Chapter Coordinator
Renal Educator-Holy Name Hospital
Access for Hemodialysis
 AVF-arterio-venous
fistula
 AVG-arterio-venous graft
 Catheter-temporary or permanent
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Dialysis Accesses

The Fistula is the
patient’s own natural vein
that has been attached to
a near-by artery via an
anastomosis.

It takes 1-3 months for an
AVF to mature and
become strong enough to
use a large gauge needle
and achieve quality
BFRs.
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Dialysis Accesses
 An
anastomosis is a surgical
connection. In a vascular access, the
anastomosis is the spot where a vein
and artery are joined to form a fistula,
or where the artificial vein is joined to
the patient’s artery and vein for a
graft. Dialysis needles should not be
inserted into the area of the
anastomosis.
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Dialysis Accesses
 Pros

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The AVF is the ‘GOLD Standard’ for
hemodialysis accesses.
It lasts longer
Has fewer infections
Has fewer complications like rejection,
stenosis, and clotting.
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Dialysis Accesses
 Cons


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The main disadvantage is that the AVF takes
4-6 weeks to mature and sometimes longer.
Some fistula fail to mature at all, but it is not
often.
Side veins off of the AVF (accessory veins)
can reduce pressure in the fistula causing it to
fail.
The chosen vessel may be too small (<2mm)
and unable to develop.
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Assessing a Fistula
 Look
for signs of infection
 Look for signs that the surgical
wound/suture line has healed
 Feel the thrill
 Listen for the bruit
 Feel the diameter of the vessel
 After one week, apply a tourniquet and
feel for firmness..can I get a needle in
there
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Assessing the Fistula
 Assess



for signs of infection
Redness
Drainage
Increased warmth
 Bleeding
from venipuncture site
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Dialysis Accesses

Always start with a 17
gauge fistula needle.
 The fistula needle
gauge can decrease
(as needle gauges
get smaller-the
diameter of the
needle shaft gets
larger) after the fistula
becomes fully mature.
 This allows for
increases BFRs.
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I’m going to cannulate
 WASH
HANDS!! WEAR PPE!!!
 Prepare the patients site




Alcohol
Betadine (providone iodine)
Chlora-prep (chlorhexidine gluconate
Exsept (sodium hypochlorite
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Dialysis Accesses
 How
far must you stick away from an
anastomosis?
 Two
finger breadths from the anastomosis
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Dialysis Accesses
 When
might you need to use a tourniquet
on a fistula?
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Apply a Tourniquet




ALWAYS
Allows you to see the fistula
Holds it in place
Gives you a better “feel”

Apply tourniquet as far away from site as you
can
 They should not be so tight that they cause pain,
tingling or cut off blood flow to fingers
 ONLY USED FOR CANNULATION!!
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Dialysis Accesses
 What
is the correct angle for needle
insertion of a fistula?
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Dialysis Accesses
 25-30
degree angle.
 Why
do we need to use a different needle
insertion degree angle from what is used
on a graft?
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Dialysis Accesses
 The
25-30 degree angle is a more shallow
cannulation entry into the fistula.
 This technique is performed to prevent
cannulating through the Fistula causing an
infiltration.
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Cannulation Techniques
 Rope


ladder
Also called rotating sites
Sites are rotated to prevent aneurysms or
weak spots in the wall of the vessel
 Buttonhole
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or constant site
Remove scabs
Dull needles after site is established
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Easing the Pain
 Tighten
the skin during cannulation= less
pain
 Lidocaine injection
 Ethyl chloride spray- feels cold on skin
 Topical Anesthetics


EMLA cream
Less-n-pain (over the counter)
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Fistula Complications

Infection

Never cannulate
• Drainage, redness

Line separation


Tape needles securely
Fasten the blood lines

Set arterial and venous pressure monitor limits
 TURN OFF BLOODPUMP and CLAMP THE
BLOODLINES
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Recirculation
 Arterial

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and venous blood mixes
Blood flows within the AVF is lower than that
in the dialyzer
Needles placed to close together
Lines are reversed
Stenosis is present
 Place
needles in the correct position
 Keep the tips of the arterial and venous
needle at least 1.5 inches apart
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Fistula Complications
 Air
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Embolism
Can cause cardiac arrest
Signs and symptoms
•
•
•
•
•
•
Anxious feeling
Trouble breathing
Cyanotic
Vision problems
Low blood pressure
Confused, paralyzed or unconscious
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Fistula Complications

Most common complication
 Infiltration/Hematoma

Tip of needle goes into the vein, out the other side or
nick the side of the vessel

Causes pain, bruising, additional cannulation
and lack of trust in staff
 Infiltrated arterial needle-arterial pressure
becomes more negative
 Infiltrated venous needle-raise in venous
pressure and will stop the blood pump
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Fistula Complications
 Thrombosis

Formation of blood clots
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Dialysis Accesses
 High
Output Cardiac Failure
 What
causes this condition to occur in a
patient with an AVF?
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Dialysis Accesses

The fistula brings more blood to the heart.

The heart works harder, reducing resistance in
the arteries.

Arterial blood pressure falls.

The drop in arterial blood pressure triggers the
renin-angiotension system.
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Dialysis Accesses
 Patients
with High Output Cardiac Failure
may have rapid pulses as their hearts try
to make up for the extra blood flow (20%
or >) caused by the AVF access.
 They may be SOB, have swelling in their
hands and feet (because return circulation
to the heart is poor).
 Some patients may have chest pain if the
BFR is too high during their treatment.
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Dialysis Accesses
 What
is an arteriovenous graft (AVG) ?
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Dialysis Accesses
 An
AVG is an artificial blood vessel used
to connect an artery and a vein.
 There
are many types of materials that
can be used for AVGs.
 These
materials can be divided into
biologic and synthetic materials.
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Dialysis Accesses
 Biologic
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Materials
Human and animal materials have been used
for AVGs, but are rarely used today
Human AVGs were made from a vein from the
patient's leg
Veins from the umbilical cords of newborn
infants were also used, but had a high rate of
infection and aneurysms
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Dialysis Accesses

Examples of a human
graft materials that
have been used for
AVGs.
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Dialysis Accesses
 Bovine
(cow) and Ovine (sheep) carotid
arteries are also used for grafts and must
be treated to remove proteins that would
cause the human body to reject them.
 These
biologic grafts can also have a high
rate of infection and aneurysms.
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Dialysis Accesses
 Can
you name any of the synthetic types
of materials used for AVGs?
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Dialysis Accesses
 ePTFE
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(polytetrafluoroethylene) Grafts
Venaflo – combines the ePTFE material with
the well known material properties of IMPRA
Carboflo vascular graft to reduce platelet
adhesion (clotting).
Carboflo – In pre-clinic studies, Carboflo’s are
Carbon lined to significantly decreases
platelet accumulation by as much as 6 times
greater than standard ePTFE grafts.
Distaflo – Used mainly for arterial bypass
grafts and is shown to improve patency of the
graft over other materials.
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Dialysis Accesses

Examples of ePTFE
grafts
 Distaflo - upper left
 Venaflo – right
 Impra Carboflo – lower
left
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Dialysis Accesses

The AVG is has two
anastomosis’ because
it is surgically attached
to both the artery and
vein.
 The Graft can be
straight, looped, or
curved.
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Dialysis Accesses
 What
is the correct angel degree for
cannulating an AVG?
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Dialysis Accesses
 Cannulate
AVGs at a 45 degree angle.
 Why
does it matter what angel we
cannulate an AVG and an AVF?
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Dialysis Accesses
AVG’s cannulation insertion is a steeper angle to
prevent unnecessary increased puncture size
and tearing of the graft material during needle
insertion.
 AVF’s on the other hand, need a lower angle to
prevent the needle tip from puncturing through
the other side of the fistula which could cause a
serious infiltration and potential damage to the
fistula.

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Dialysis Accesses
 Pros

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The AVG takes about 2 weeks to heal and be
ready for cannulation.
Graft size and blood flows don’t depend on
maturation.
Grafts can start out with larger gauge needles
and obtain better BFRs sooner.
The AVG is a good access for those patients
who cannot maintain a fistula.
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Dialysis Accesses
 Cons

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The biggest problems with all grafts are
infection and thrombosis.
Grafts are more likely to develop stenosis
than AVFs.
Grafts are more likely to clot than AVFs.
Grafts have an increased risk of infection over
the AVF.
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Central Venous Catheters
 Long

Tunneled, cuffed catheter
 Short

term
term
Urgent dialysis
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Catheters
 Pros

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Can be used immediately
Hidden under clothing
Hands and arms can be moved freely
No needles
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Catheters
 Cons

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Increase risk of infection
Foreign body can cause inflammation and
clotting
Lower blood flows decreased adequacy
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Care of the patient with a catheter
 Assess

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Site
Patient
Catheter limbs
 First
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
choice
Chlorahexidine
Betadine
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Continuous Quality
Improvement (CQI)
 Identify
Improvement is Needed
 Analyze the Process
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Choose a team
Review the data
Find the reason the problem occurred
Identify trends
 Identify
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the root causes
What is the exact cause of the problem
Define the problem
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Implement PDCA Cycle
PLAN
DO
CHECK
ACT
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Questions????
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