Vascular Access Formation Care Pre/Post Vascular Access Formation Care ปิ่นแก้ว กล้ายประยงค์ สาขาวิชาโรคไต ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี

VASCULAR ACCESS for HEMODIALYSIS Temporary Vascular Access 1. Noncuffed Catheter 2. Long-term Catheter 2.1 Tunneled cuffed catheter 2.2 Port catheter system Permanent Vascular Access 1. Native AV Fistula 2. Synthetic AV Graft

K/DOQI Guidelines for Vascular access • Published guidelines in 1997 Updated in 2000, 2006 • Creation of AVF’s in 50% of all incident and 65% of prevalent patents. • Less than 10% of chronic hemodialysis patients should be maintained on catheters. • 6 Headings • 38 Guidelines

K/DOQI Guidelines I. Patient Evaluation Prior to Access Placement Monitoring, Surveillance, and Diagnostic testing II. Selection and Placement Select Areas of Most importance III. Prevention of Complications: Infections IV. Management of Complications: When to intervene V. Management of Complications: Optimal Approaches for Testing Complications VI. Potential Quality of Care Standards.

Objectives Provide an overview purpose of the KDOQI guidelines 2006 Review pre-post operative methods to maximize maturation of AV Fistula Describe how to the access formation, and identify ways that the patients can be prepared

Vascular Access – KDOQI 2006 Fistula First Change Package Clinical and organizational recommendations based on best practices for increasing AV fistula use and improving hemodialysis patient outcomes - Lasts longer than other access types - Has fewer infections than grafts or catheters - Needs fewer follow-up procedures to keep it working, which means fewer hospital visits fistulafirst.org

Which is Closest to the Ideal Access? + = close to ideal, - = far from ideal Lynch P. What is it? Where are we now? Where do we need to go? How are we going to achieve the fistula first goals?

Fistula First Change Package 1. Routine CQI review of vascular access 2. Timely referral to nephrologist 3. Early referral to surgeon for “AVF only” 4. Surgeon selection 5. Full range of appropriate surgical approaches 6. Secondary AVFs in AVG patients 7. AVF evaluation/placement in catheter patients 8. Cannulation training 9. Monitoring and Maintenance 10. Continuing education 11. Outcomes feedback fistulafirst.org

Vascular Access – KDOQI 2006 of Access Routine CQI review of vascular access Timely referral to nephrologist CPG 1: Preparation & Evaluation for Permanent Access - Patients with a GFR of < 30 ml/min/1.73m2 (CKD stage IV) should be educated on all modalities of RRT including transplantation and placement of a permanent dialysis access if necessary (A)

Kigney Transplantation Counseling for RRT modalities Kigney Transplantation CAPD Hemodialysis

Vein Preservation and Hemodialysis Fistula Protection If the patient has CKD or is at risk for CKD, whether or not he/she is on dialysis: DO use the dorsum of the hand for venipuncture and IV infusions DO rotate venipuncture sites DO use a manual blood pressure device DO NOT use the cephalic veins of either arm for blood draws, IV fluid therapy, or drug infusions DO NOT place a subclavian catheter or a PICC line (place an internal jugular line, instead)

Vascular Access – KDOQI 2006 of Access Early referral to surgeon for “AVF only” evaluation and timely placement - 6 months prior to initiation Surgeon selection based on best outcomes, willingness, and ability to provide access services Full range of appropriate surgical approaches to AVF evaluation and placement fistulafirst.org

Vascular Access – KDOQI 2006 of Access CPG 2. Selection and Placement Select Areas of Most importance Reducing Catheter Use -- Strategies Role of vein imaging (mapping) in fostering the AV fistula initiative Major Focus Areas 􀂃 Pre-op venous imaging/mapping for planning AVF construction

AV Fistula Maturation Pre-Op Assessment Vascular mapping – Caliber – Patency – Phlebitic changes – Neutralizes demographic impact Venogram Access history Physical exam – Pulses – Vein pattern

Pre-operative preparation Patient : Informed consent Non-dominant arm Reduction of non-maturing (FTM) AVF via mapping /optimal vessel selection Arterial requirements Pressure differential < 20 mmHg between arms Patient palmar arch has to be good Allen test Arterial lumen diameter ≥ 2.0 mm at point of anastomosis

Pre-operative preparation Venous requirements Luminal diameter ≥ 2.5 mm or greater at anastomosis point Absence of obstruction, calcifications Straight segment for cannulation Within 1 cm of surface Continuity with patent central veins Doppler USG

Pre-operative preparation Davis J, People like us: The NKF’s patient empowerment program, 14; 1: 2005

Chronic AV Access Algorithm CPG 2. Selection of Access AV fistula :Preferred (B+) A wrist: radiocephalic (forearm) primary fistula (A) An elbow: brachiocephalic (upper arm) primary fistula (A) A transposed: brachiobasilic vein fistula (upper arm) (B) Primary failure –forearm > upper arm AV graft acceptable: AVG of synthetic or biological material, such as: (B) : 3-6 wks prior to initiation Forearm loop graft Brachio-axillary AVG Femoral loop AVG Avoid if possible: Long-term catheters (B)

Vascular Access – KDOQI 2006 of Access Secondary AVF placement in patients with AV graft AVF placement in patients with catheters where indicated Cannulation training for AV fistulas Monitoring and maintenance to ensure adequate access function fistulafirst.org

CPG 3. Cannulation & Access Care AVF dysfunction/failure-to-mature: - Early recognition of F-T-M AVF by evaluation - Monitoring & Timely Intervention for late AVF failure /aggressive Salvage Maturation - Fistula hand-arm exercise (B) If a fistula has not matured, a fistulogram or other imaging study should be obtained to determine the cause of the problem (B+)

CPG 3. Access Care: Patient Education Teach patients fistula exercise Isometric exercise should help develop both enlarge the vein by increasing flow and build the muscle below to make the vein more prominent Have the patient use a light tourniquet or opposite hand to help engorge the veins with exercise Have the patient exercise 4 times a day for 5-10 minutes a day or more

CPG 3. Access Care: Patient Education Fistula hand arm exercise: before a fistula is placed and help the fistula mature after placement .

Pre-operative Teaching About the surgery: Will be done as a day or short stay surgery; non-dominant arm preferred After the surgery: Keep arm straight & raised on a pillow, even while sleeping Monitor discomfort: If mild to moderate, take pain medication regularly Follow-up appointments in 2 weeks

CPG 3. Access Care: Patient Education Post-op care: Keep dressing clean and dry Rest and take medicine as prescribed Notify the surgeon’s office or go to ER if dressing becomes satuated with blood or fluid Monitor colour & warmth of fingers on fistula hand should be the same as other hand Experience a rise in temperature, numbness of the hand, or and increase in pain

CPG 3. Access Care: Patient Education Post-op care: Keep fingers moving, squeeze soft ball to encourage vein development Check fistula every morning & evening for thrill (feel for buzzing sensation) & bruit (hold anastomosis site to the ear & listen for bruit)

Patient Education Have the patient demonstrate the proper exercise procedure while at dialysis for review by the dialysis staff Ask the patient every treatment if they are still exercising daily Examine the fistula weekly for signs of proper maturation

When is an AVF mature? Maturity Characteristics 􀁹Goes from soft and pliable to springy and firm : adequate dilation 􀁹Diameter of vessel is increasing (2mm →→ 4mm →→ 6mm) 􀁹Thrill is stronger 􀁹Bruit is continuous and low pitch 􀁹 No accessory veins detracting form the main conduit Causes of Non-Development 􀁹 Location 􀁹 Diseased vessels 􀁹 Poor cardiac output 􀁹 Accessory veins 􀁹Juxta-anastomotic stenosis

AV Fistula Maturation Adequate flow –Access flow 100 mL/min > dialysis flow rate –International variation USA –400 cc/min Europe –300 cc/min Japan –200 cc/min Adequate wall thickening Adequate location

Rule of 6s for the Fistula Maturation Greater than 600mL / min flow Greater than 6 mms in diameter Less than 6mms below skin surface AND all fistulae should be thoroughly examined no later than 6 weeks post op Is there at least 6 cms of vein to cannulate? (>6 cm long)

All Patient should be taught how to: Compress a bleeding access Wash skin over access with soap and water daily and before HD Recognize s/s of infection: redness, warmth or pain in fistula arm, oozing or drainage Select proper methods for exercising fistula arm with some resistance to venous flow Palpate for thrill /pulse daily Listen for bruit with ear opposite access if can’t palpate for any reason Call your health care provider or dialysis center immediately if you can't feel a thrill

All patients should know to: Avoid heavy lifting Avoid putting pressure on fistula - Avoid sleeping on the access arm - Avoid tight clothing on the access - Do not wear restrictive jewelry wearing occlusive closing over access Stay active, but avoid contact sports Save fistula arm for dialysis & let others know this - No BP, blood work or IV - Wear medical alert bracelet

All patients should know to: Apply pressure for stop bleeding post dialysis: with 2 fingers – Strong enough to prevent bleeding – Not so strong as to occlude flow Noticeable swelling or itching in fistula arm Be aware of site rotation (unless buttonhole cannulation method is used) Be aware of proper skin preparation and importance of staff wearing masks Report and s/s of infection and absence of bruit /thrill to staff immediately

AV Fistula Immaturation Causes of early fistula failure – Inflow problem • Pre-existing arterial anomalies – Anatomically small – Atherosclerosis • Acquired – Anastomotic stenosis – Outflow problems • Pre-existing venous anomalies – Anatomically small – Fibrosis – Accessory veins (side branches)

Goals for Access Placement Each center should establish a database and CQI process to track the types of accesses created and the complication rates for these accesses The goals for incident hemodialysis access placement should include: - fistula >65%, catheters <10%. - The primary access failure rates of hemodialysis accesses (grafts and catheters) : Forearm straight grafts < 15 % : Forearm loop grafts < 10% : Upper-arm grafts < 5 %

Conclusion Reported Barriers – No vascular access counseling • Lack of pre-dialysis care / delayed nephrology referral – No vascular access counseling – Patients discharged from hospital with no plan for permanent access • Lack of timely surgical placement of permanent access – Low rate of pre-dialysis access surgery despite referral – Incomplete AVF maturity • Patient refusal of permanent access surgery – Fear of pain, cosmetic concerns

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