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Hemodialysis Vascular Access

What are the objectives of hemodialysis vascular access?
-List the two types of internal vascular access and the two type of CVC's
-Discuss how an AVF is created and what is required for successful maturation
-List the advantages of the AVF, AVG and CVC and things to consider with each access.
-Discuss the steps in a complete access assessment
-Discuss the considerations prior to cannulation of an AVF or AVG
-Describe the KDOQI rule of 6's
-Describe possible AV access complications, the cause and prevention
-Describe the process of AV access site selection, preparation, and cannulation.
-List the risks associated with a CVC
-Describe the process for pre-dialysis care of the CVC and treatment initiation
-List the steps in a CVC dressing change
-Discuss the patient education to be given to patients with AVF, AVG and CVC.

What are the internal vascular access types?

Arterio-venous fistula and artery-venous graft

What are the fistula configurations?

There is side to side, Side to end, end to side, end to end.

What should we know about EndoAVF system?

-No incision and minimal vessel trauma at creation site.
-Surgeon to provide cannulation diagram.
-Ultrasound used to confirm identification of cannulation sites.

What are the advantages of AVF?

-lowest death rate
-least clotting
-least infections
-longest lasting
-least hospitalizations
-least activity restrictions
-no chance for allergic reaction
-cannot become dislodged

What are the considerations of AVF?

-Requires time to mature
-requires vessel mapping
-requires surgery
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-may be visible under skin

-two needles are inserted each treatment
-not suitable for all patients

What is the rule of 6's for daily access check?

Depth below skin less then 0.6 cm, 6-8 week post check, access blood flow >600 ml/min, diameter of
vessel >0.6cm.

We should always listen, look, feel at a fistula.

What should we know about an outflow stenosis?

We should know that this occurs when blood is being recirculated within the fistula so not very much
new blood is recirculating there. This causes a whistle sound when you listen to it.

What should we know about an inflow stenosis?

We should know that this occurs when poor development of a new fistula or clotting has occurred or
about to occur. This usually sounds like a water hammer pulse when you listen to it.

What should we know about arteriovenous graft?

We should know that these are for people;e with poor vascular health like diabetes or even long term
smokers.

What are the advantages of AVG?

-can be used sooner than fistula
-blood flow not dependent on vein maturation
-less activity restrictions
-cannot become dislodged

What are considerations of AVG?

-Higher incidence of clotting
-two needles
-venous stenosis
-infections
-increased risk of mortality
-not suitable for all patients

What is a HERO graft?

This is a hybrid CVC/Graft. The advantages are no external parts, similar cannulation. The
considerations are monitoring look, listen, feel.
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What is a VWing?
The venous window needle guide is indicated for use as an access device accessory on arteriovenous
fistulas for hemodialysis procedures using a constant site or buttonhole method of needle insertion.

What are the considerations for cannulation?

Newly mature fistula: This is for experts only. People that have a lot of cannulates under their belt.
Mature fistula: Is someone who is moderate at cannulating and has a decent amount of cannulation
under their belt.
Established fistula: Anybody can cannulate this.

What should we know about site preparation?

Use clean barrier, assess for signs/symptoms of infection, assess patency, assess access blood flow
direction.

What should we know about access disinfection timing?

-Proper per policy timing requires a clock or wrist watch for accuracy.
-follow manufacturers recommended contact time
-disinfectants kill microorganisms as they dry
-if contact time is inadequate, the access surface is not completely sterilized.

What should we know about site preparation and rotation?

We select the site by goin at a new place every time. We clean the site to make sure that we are not
causing infection. We clean with alcohol for 60 seconds each point of entry. We should also know that
the rope/ladder method is crucially important for access longevity. Every treatment cannulate in a
different spot. 14 days before cannulation same site again. we must make sure to educate patient.

What should we do prior to cannulating?

Inject or apply local anesthesia as prescribed, apply tourniquet to AVF, remove cap from cannulation
needle, stabilize access without touching site.

Needle size and blood flow rates!

-17 gauge needles require 200-250 blood flow rate. The AP pressure should not go more negative then -
150.
-16 gauge needles require 250-350 blood flow rate. The AP pressure should not go more negative than -
200.
-15 gauge needles require 350-450 blood flow rate. the AP pressure should not go more negative than -
220.
-14 gauge needles require 450 or higher blood flow rate. the AP pressure should not go more negative
then -260.
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What are the angles that we should insert the needles for a fistula and a graft?
For a fistula we should go in at a 25 degree angle. and for a graft we should go in at a 45 degree angle.
different fistulas very so they may be a little different. We should remember to not advance needle hub
all the way to the end. Unless medisystem then you can advance.

What are the cannulation rules?

-Always place the venous needle with the flow of blood.
-Always keep the tips of the needles at least 1.5 inches apart to prevent recirculation
-Always keep the needles at least 1.5 inches away from the anastomosis site.
-Always rotate the puncture site allowing 14 days for healing.
-Aways determine the flow pattern of the access prior to needle placement.
-always assess for patency
-never place a needle in a hematoma
-never place a needle in a infected area
-never place a needle in a aneurysm or pseudo aneurysm.

What should we know about access complications "BESTIPS"

Bleeding, erosion, stenosis, thrombosis, infection, pseudo-aneurysms/aneurysms, steal syndrome

What are some of the complications that occur with fistulas or grafts?
-Bleeding during dialysis. This is from too much flipping of needles or going in at the same site all the
time.
-Recirculation occurs when there is recirculation of blood. we should get this checked.
-Thrombosis can be heard with inflow stenosis. this needs to be addressed right away so that we don't
potentially lose the fistula or graft.
-Infections can occur we should rotate locations. make sure to clean site right.
-Aneurysms occur when we don't rotate locations
-pseudoaneurysms occur with grafts only pretty much.
-steal syndrome is when we are not getting enough oxygenated blood to the fingers. this is bad for
tissue recovery and bad in general.

What should we do when infiltration occurs?

We should remove needle and wait for bleeding to stop. you then look for another place to stick but
above the infiltration site. During dialysis do not remove old needle unless painful for patient or
hematoma continues to enlarge. May need recirculate blood while inserting new needle. apply ice to
hematoma.

How to remove needle?

We remove needles at same angle needle was inserted. Flip to original position only if needle was
flipped at initiation of treatment.
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What is the needle removal procedure?

Terminate treatment, clamp needles, remove tape, cover site with sterile gauze, remove needle, engage
safety device, no pressure until needle is removed.

What should we know about buttonholes?

We should know that a physician order is required. Only for patients with AV fistulas can use
buttonhole technique. Teammates must be trained prior to performing this procedure. includes class,
skills checklist, exam.

What should we know about access clamps?

Require an MD order, use spring-loaded clamps only, one clamp at a time, check for blood flow
above/below clamp, check hemostasis.

What should we know about hemostatic sponges?

Requires physical order, evaluate reason for prolonged bleeding, remove hemostatic sponges prior to
discharging patient.

What should we teach the patients about fistulas and grafts?

-No heavy pressure or tight clothing, bags or jewelry on access extremity
-avoid sleeping on access extremity
-no blood pressures to be taken on access extremity
-no venipuncture IV's or labs drawn in access extremity by non dialysis personnel.
-Avoid lifting or pulling heavy loads with access extremity
-check access daily
-wash access extremity before treatment
-wash hands before and after treatment
-wear gloves when holding sites
-when to remove bandage (Later that afternoon)
-What to do if breakthrough bleeding occurs. We put pressure on the access and hold tell stops bleeding
and replace gauze.

What should we know about external vascular devices?

Placed in large vein. Catheter limbs are located outside the body. Recommended as a temporary
measure.

What are the two types of external devices?

1: Non-tunneled, non cuffed CVC. These are temporary only last 14 days and need to get replaced or
just taken out. This is a high risk for infection.
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2: Tunneled, cuffed CVC. This is more of a permeant catheter but we don't like using them for that
long.
They are both double lumen catheters.

What are the risk of CVC's

Highest rate of death, infection, clotting, and hospitalization. Lower blood flow rates, longer treatment
times, increased risk of stenosis in the veins leading to the heart.

What should we know about CVC insertion sites?

We should know that they go in the right internal jugular vein which is preferred, subclavian vein
should not be used, tunneled vs non tunneled cvc''s. Femoral vein has higher infection rates and
mobility problems.

What are the advantages of CVC?

Can be used immediately after placement, used temporarily when there are complications of internal
access, used when all extremity vessels are visualized as inadequate by vessel mapping/documented.

What are the considerations of CVC?

Clotting, infection, stenosis, recirculation, inadequate blood flows, self image alterations, dislodgment,
hemorrhage, air embolus.

What is the care of a CVC?

Check local regulations regarding PCT/LPN's/LVN's scope of practice related to CVC. Inspect exit site
for s/s of infection prior to treatment initiation: redness, pain, drainage, warmth. Inspect CVC for
integrity and stability, dressing changes and exit care every treatment, device is to be used for dialysis
only.

What should we know about healthy CVC exit site?

We should know that surrounding skin color may be darkened, light pink, dark purplish discoloration.
No blood or pus, skin like tissue is visible at exit site, visible area is dry, no bruising, swelling, or
tenderness at exit site. Cuff is seeded into the skin and does not move when gently pulled on.

What is an unhealthy CVC site?

Redness and or tenderness, purulent drainage within 2cm of the skin at the exit site of catheter.
Reminder all signs and symptoms of an infection should be documented in a patient medical record.

What is the pre dialysis cvc exit site care?

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Hand hygiene, PPE, aseptic technique, supine position and face mask, teammate position, evaluation of
CVC and CVC exit site, antiseptic/disinfectant solution, antibiotics ointment if prescribed, new
dressing, anti microbial patch, labeling of dressing.

What should we know about scrubbing the hub?

Hand hygiene, check CVC limbs are clamped, scrubbing end caps, sterile surfaces, scrubbing the hubs,
allow hubs to air dry, attach 10 ml sterile syringes to each CVC limb.

What should we know about treatment initiation?

Swab each catheter end with alcohol prep pad before attaching sterile syringes. Apsirate CVC locking
solution 5ml from each limb. Draw labs as indicated, flush each limb with normal saline, administer
loading dose of heparin. After heparin we must wait 3-5 minutes before attaching blood lines and
initiating treatment.

What do we do if we have an inadequate blood flow with CVC's during treatment initiation.
Check for kinks in CVC limbs, move arterial and venous clamps to new positions, flush catheter limbs
with saline, reverse lines as last resort, administer cathflo activate per MD order.

Inadequate blood flow during treatment?

Check for kinks, ask patient cough, take deep breath, reposition patient, lay back, turn to side, reverse
lines as last resort, document if ordered BFR is decreased.

Post dialysis CVC care

Hand hygiene, patient position face mask, disconnecting CVC limbs from blood lines, CVC end caps
or clear guard HD caps, saline flushes and locking solution, scrub the hub. labeling of CVC limbs.

Importance pf access management

Vascular access is the patients lifeline. During the first year of dialysis 50% of patients dependent on
CVC's die. At 3 years 70% of all AV grafts fail. At 3 years 75% of AV fistulas are still patent. Tunneled
CVC's are infected 16 times more often than AV graft and 35 times more often than AV fistula.

What are the goals with vascular access?

-Decrease number of CVC's
-Increase number of AVF's
-Reduce clotted accesses
-Decrease access-related hospitalizations
-decrease access-related missed treatments
-increase access longevity