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 2

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. 3

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. 4

Dialysis Accesses  Pros The AVF is the ‘GOLD Standard’ for hemodialysis accesses. The AVF is the ‘GOLD Standard’ for hemodialysis accesses. It lasts longer It lasts longer Has fewer infections Has fewer infections Has fewer complications like rejection, stenosis, and clotting. Has fewer complications like rejection, stenosis, and clotting. 5

Dialysis Accesses  Cons The main disadvantage is that the AVF takes 4-6 weeks to mature and sometimes longer. 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. 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. 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) The chosen vessel may be too small (<2mm) and unable to develop. and unable to develop. 6

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 7

Assessing the Fistula  Assess for signs of infection Redness Redness Drainage Drainage Increased warmth Increased warmth  Bleeding from venipuncture site 8

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. 9

I’m going to cannulate  WASH HANDS!! WEAR PPE!!!  Prepare the patients site Alcohol Alcohol Betadine (providone iodine) Betadine (providone iodine) Chlora-prep (chlorhexidine gluconate Chlora-prep (chlorhexidine gluconate Exsept (sodium hypochlorite Exsept (sodium hypochlorite 10

Dialysis Accesses  How far must you stick away from an anastomosis?  Two finger breadths from the anastomosis 11

Dialysis Accesses  When might you need to use a tourniquet on a fistula? 12

Apply a Tourniquet  ALWAYS Allows you to see the fistula Allows you to see the fistula Holds it in place Holds it in place Gives you a better “feel” 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!! 13

Dialysis Accesses  What is the correct angle for needle insertion of a fistula? 14

Dialysis Accesses  degree angle.  Why do we need to use a different needle insertion degree angle from what is used on a graft? 15

Dialysis Accesses  The degree angle is a more shallow cannulation entry into the fistula.  This technique is performed to prevent cannulating through the Fistula causing an infiltration. 16

Cannulation Techniques  Rope ladder Also called rotating sites Also called rotating sites Sites are rotated to prevent aneurysms or weak spots in the wall of the vessel Sites are rotated to prevent aneurysms or weak spots in the wall of the vessel  Buttonhole or constant site Remove scabs Remove scabs Dull needles after site is established Dull needles after site is established 17

Easing the Pain  Tighten the skin during cannulation= less pain  Lidocaine injection  Ethyl chloride spray- feels cold on skin  Topical Anesthetics EMLA cream EMLA cream Less-n-pain (over the counter) Less-n-pain (over the counter) 18

Fistula Complications  Infection Never cannulate Never cannulate Drainage, rednessDrainage, redness  Line separation Tape needles securely Tape needles securely Fasten the blood lines Fasten the blood lines  Set arterial and venous pressure monitor limits  TURN OFF BLOODPUMP and CLAMP THE BLOODLINES 19

Recirculation  Arterial and venous blood mixes Blood flows within the AVF is lower than that in the dialyzer Blood flows within the AVF is lower than that in the dialyzer Needles placed to close together Needles placed to close together Lines are reversed Lines are reversed Stenosis is present Stenosis is present  Place needles in the correct position  Keep the tips of the arterial and venous needle at least 1.5 inches apart 20

Fistula Complications  Air Embolism Can cause cardiac arrest Can cause cardiac arrest Signs and symptoms Signs and symptoms Anxious feelingAnxious feeling Trouble breathingTrouble breathing CyanoticCyanotic Vision problemsVision problems Low blood pressureLow blood pressure Confused, paralyzed or unconsciousConfused, paralyzed or unconscious 21

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 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 22

Fistula Complications  Thrombosis Formation of blood clots Formation of blood clots 23

Dialysis Accesses  High Output Cardiac Failure  What causes this condition to occur in a patient with an AVF? 24

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. 25

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. 26

Dialysis Accesses  What is an arteriovenous graft (AVG) ? 27

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. 28

Dialysis Accesses  Biologic Materials Human and animal materials have been used for AVGs, but are rarely used today 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 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 Veins from the umbilical cords of newborn infants were also used, but had a high rate of infection and aneurysms 29

Dialysis Accesses  Examples of a human graft materials that have been used for AVGs. 30

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. 31

Dialysis Accesses  Can you name any of the synthetic types of materials used for AVGs? 32

Dialysis Accesses  ePTFE (polytetrafluoroethylene) Grafts Venaflo – combines the ePTFE material with the well known material properties of IMPRA Carboflo vascular graft to reduce platelet adhesion (clotting). 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. 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. Distaflo – Used mainly for arterial bypass grafts and is shown to improve patency of the graft over other materials. 33

Dialysis Accesses  Examples of ePTFE grafts Distaflo - upper left Distaflo - upper left Venaflo – right Venaflo – right Impra Carboflo – lower left Impra Carboflo – lower left 34

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. 35

Dialysis Accesses  What is the correct angel degree for cannulating an AVG? 36

Dialysis Accesses  Cannulate AVGs at a 45 degree angle.  Why does it matter what angel we cannulate an AVG and an AVF? 37

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. 38

Dialysis Accesses  Pros The AVG takes about 2 weeks to heal and be ready for cannulation. The AVG takes about 2 weeks to heal and be ready for cannulation. Graft size and blood flows don’t depend on maturation. Graft size and blood flows don’t depend on maturation. Grafts can start out with larger gauge needles and obtain better BFRs sooner. 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. The AVG is a good access for those patients who cannot maintain a fistula. 39

Dialysis Accesses  Cons The biggest problems with all grafts are infection and thrombosis. The biggest problems with all grafts are infection and thrombosis. Grafts are more likely to develop stenosis than AVFs. Grafts are more likely to develop stenosis than AVFs. Grafts are more likely to clot than AVFs. Grafts are more likely to clot than AVFs. Grafts have an increased risk of infection over the AVF. Grafts have an increased risk of infection over the AVF. 40

Central Venous Catheters  Long term Tunneled, cuffed catheter Tunneled, cuffed catheter  Short term Urgent dialysis Urgent dialysis 41

Catheters  Pros Can be used immediately Can be used immediately Hidden under clothing Hidden under clothing Hands and arms can be moved freely Hands and arms can be moved freely No needles No needles 42

Catheters  Cons Increase risk of infection Increase risk of infection Foreign body can cause inflammation and clotting Foreign body can cause inflammation and clotting Lower blood flows decreased adequacy Lower blood flows decreased adequacy 43

Care of the patient with a catheter  Assess Site Site Patient Patient Catheter limbs Catheter limbs  First choice Chlorahexidine Chlorahexidine Betadine Betadine 44

Continuous Quality Improvement (CQI)  Identify Improvement is Needed  Analyze the Process Choose a team Choose a team Review the data Review the data Find the reason the problem occurred Find the reason the problem occurred Identify trends Identify trends  Identify the root causes What is the exact cause of the problem What is the exact cause of the problem Define the problem Define the problem 45

Implement PDCA Cycle PLAN DO CHECK ACT 46

 Questions???? 47