Access for Renal Replacement Therapy Clinical … · Web viewAccess for Renal Replacement Therapy...
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CHHS15/095 Canberra Hospital and Health Services Clinical Guideline Access for Renal Replacement Therapy Contents Contents..................................................... 1 Introduction................................................. 2 Scope........................................................ 2 Background................................................... 2 Key Objectives............................................... 2 Section 1 – Arteriovenous Fistulas (AVF) and Grafts (AVG) – Pre and Post Operative Patient Management....................3 Section 2 – Surveillance of a new AVF or AVG – Patients not receiving haemodialysis......................................4 Section 3 – Surveillance of a new vascular access that has not been cannulated for patients on haemodialysis................5 Section 4– Surveillance of an established vascular access being routinely cannulated by haemodialysis staff............6 Section 5 – Removal of Tunnelled Haemodialysis Central Venous Catheters.................................................... 7 Section 6 – Tenckhoff Peritoneal Dialysis Catheter Insertion - Pre-Post Operative Patient management........................8 Implementation............................................... 9 Evaluation................................................... 9 Related Policies, Procedures, Guidelines and Legislation....10 References.................................................. 10 Definition of Terms (if applicable).........................11 Search Terms................................................ 11 Consultation................................................ 12 Attachments................................................. 12 Doc Number Version Issued Review Date Area Responsible Page CHHS15/095 1.1 28/04/15 21/04/2019 Medicine 1 of 22 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript of Access for Renal Replacement Therapy Clinical … · Web viewAccess for Renal Replacement Therapy...
CHHS15/095
Canberra Hospital and Health ServicesClinical GuidelineAccess for Renal Replacement TherapyContents
Contents....................................................................................................................................1
Introduction..............................................................................................................................2
Scope........................................................................................................................................ 2
Background............................................................................................................................... 2
Key Objectives...........................................................................................................................2
Section 1 – Arteriovenous Fistulas (AVF) and Grafts (AVG) – Pre and Post Operative Patient Management.............................................................................................................................3
Section 2 – Surveillance of a new AVF or AVG – Patients not receiving haemodialysis............4
Section 3 – Surveillance of a new vascular access that has not been cannulated for patients on haemodialysis...................................................................................................................... 5
Section 4– Surveillance of an established vascular access being routinely cannulated by haemodialysis staff................................................................................................................... 6
Section 5 – Removal of Tunnelled Haemodialysis Central Venous Catheters...........................7
Section 6 – Tenckhoff Peritoneal Dialysis Catheter Insertion - Pre-Post Operative Patient management.............................................................................................................................8
Implementation........................................................................................................................ 9
Evaluation................................................................................................................................. 9
Related Policies, Procedures, Guidelines and Legislation.......................................................10
References.............................................................................................................................. 10
Definition of Terms (if applicable)...........................................................................................11
Search Terms.......................................................................................................................... 11
Consultation............................................................................................................................12
Attachments............................................................................................................................12
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Introduction
Access for Renal Replacement Therapy (RRT) in adult consumers is important in the ongoing care of consumers with Acute Kidney Injury and Chronic Kidney Disease (CKD).
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Scope
The Clinical Guideline – Access for Renal Replacement Therapy applies to nursing and medical staff under the clinical governance of the Canberra Hospital and Health Service (CHHS) Renal Network.
For the purposes of this document, the term Access refers to any device or arteriovenous formation that may be used for Renal Replacement Therapy both peritoneal dialysis (PD) and haemodialysis (HD) and includes:
Peritoneal Tenchkoff Catheters Central Venous Catheters (Tunnelled or non tunnelled) Arteriovenous Fistulas and Grafts
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Key Objectives
To guide the care of patients requiring access procedures for renal replacement therapy.
To ensure that patients with Chronic Kidney Disease (CKD) approaching dialysis or already on dialysis, with an arteriovenous fistula (AVF) or arteriovenous graft (AVG), undergo routine surveillance to identify access problems or other complications. PD catheters are routinely under the care of the Home Therapies Unit post insertion.
Communication between the CHHS Renal Vascular Access Nurse (VAN) and the Renal Network is undertaken by Renal Network Electronic Medical Record (CV5) when available and by VAN Referral Form if CV5 unavailable. Attachment 1 Vascular Access Referral Form
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Section 1 – Arteriovenous Fistulas (AVF) and Grafts (AVG) – Pre and Post Operative Patient Management
Preoperative ManagementMost patients are admitted via Day Surgery Admissions for this procedure and arrive on the ward post operatively. Ward inpatient prior to surgery:
Confirm the procedure time with the Perioperative Unit and ensure the patient is nil by mouth for four hours prior to the procedure.
Protect the identified site for Arteriovenous (AV) access by not allowing venepuncture or cannulation. Clearly indicate on the patient’s bed with an alert
Confirm Renal Unit Profile (RUP) Full Blood Count (FBC) and Full Coagulation Profile (FCP) blood results are available and reviewed by the Renal Advanced Trainee.
Ensure Serum Potassium is within normal range. If outside normal range, contact admitting team who may seek renal input pre-op.
Prepare the patient as per Canberra Hospital and Health Service (CHHS) Pre Operative Care (TCH 11:051) and Patient Identification (CED11:27 and CED11:29) Standard Operating Procedures.
Post operative Management – On return to ward
No blood pressure measurement or venepuncture to be attended on the arm with the new access. Place a “No venepuncture or BP on specific area” alert on the patient’s bed head.
Attend to general post operative and neurovascular observations as per CHHS SOPs TCH11: 011 and TCH 11:010)
Observation Schedule for access patency:Frequency of Observations:
15 minutely for 1 hour (usually completed whilst in Post Anaesthetic Care Unit) 30 minutely for 6 hours 1 hourly for 24 hours 4 hourly until discharge.
How to access for patency Check for swelling, redness, finger movement, colour, sensation, radial pulse, capillary refill,
bleeding and ooze. For leg grafts check for popliteal and pedal pulse. Check access for patency by placing a stethoscope lightly over the incision. A
‘whooshing” sound should be heard. This is called the ‘Bruit’. The bruit should be the loudest near the incision and it gradually becomes softer as the stethoscope is moved further up the vessel.
Placing a hand lightly over the incision site, a ‘buzzing’ sensation should be felt. This is called the ‘Thrill’.
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A Bruit will usually be present post op if the AV Fistula or Loop is patent. A Thrill will not always be palpable until days post operatively.
Check the dressing and monitor the wound. Support the arm or thigh on a pillow and elevate (to heart level only) and keep warm and well
supported to help peripheral circulation. Advise patient not to lie on the arm with the new access.
Patient to rest in bed if they have a thigh graft, to toilet with full assist. Educate the patient about the complications post access creation. Provide patient
with educational handout titled ‘Post surgery care of an AVF’ or ‘Postoperative surgery care of an AVL’.
Notify RMO if :
Bruit or thrill is not present. Patient complains of severe pain, oedema, coldness, numbness, pins and
needles. Report hypotension promptly as a drop in blood pressure can compromise patency
of access.
Post operative Management – Day 1
Continue to monitor bruit and thrill 4 hourly. Monitor neuro-vascular observations 4 hourly. Assess tegaderm dressing and wound. Dressing may be attended if oozing
and the arm has become swollen (SEEK advice from Team Leader) using strict aseptic technique as per CHHS SOP CHHS 14/ 011.
Cover new access with plastic when showering, area should not get wet. It is normal for an AV Graft to cause minimal to significant swelling in arm/leg.
Significant swelling can cause bruising under the tegaderm. This is to be expected as the AV Graft is a foreign body.
Post operative Management – Discharge Planning
The patient is usually discharged the day following the creation of the AV Fistula. AV Grafts require a 3-4 day stay due to swelling at the operation site. If an AV Graft is inserted in a thigh, the patient is to rest in bed for 1-2 days.
Advise patient that the Vascular Access Nurse (VAN) will review them prior to discharge and organize subsequent follow up.
Continue patient support, education and provide leaflet “Post surgery care of an Arteriovenous Fistula” (Attachment 2) or “Post surgery care of an Arteriovenous Graft” (Attachment 3).
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Section 2 – Surveillance of a new AVF or AVG – Patients not receiving haemodialysis
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Vascular access assessed by the Vascular Access Nurse (VAN) clinic in Renal Outpatients. For Southern New South Wales Local Health District (SNSWLHD) renal patients who attend SNSWLHD outreach renal clinics, the Renal Outreach Nurse/Renal Physician at clinic or GP would be the person who would be reviewing the access. Any concerns identified are to be referred to the VAN.
Assess access at:o 4 weeks post creationo 8 weeks post creation, ultrasound if not maturingo 12 weeks post creationo Then 3 monthly or 6 monthly depending on the maturation development
Assess and document :o Gain consent from patient to expose the entire arm or leg with the patient’s
accesso Look for evidence of bruising and swellingo Look at the incision site for healing o Check for signs of cyanosis of the finger tips and delayed capillary refill of the nail
bedo Check patency by auscultation using stethoscope, listen for bruit at the
arteriovenous anastomosis; note changes in pitch and amplitude of bruit along the vascular access path
o Check calibre of the access by palpating the entire length of the AVF using fingers to determine width and length: a strong thrill should be palpable at the anastomosis, decreasing as you move further away from the anastomosis
o Check calibre of AVF by applying tourniquet enabling for easier palpation ( not tight enough to occlude blood flow ) and repeat above palpation
o Look for signs of infection ( redness, discharge and swelling ) o Check for evidence of Steal Syndrome by comparing temperature of comparative
non access limb and digits. Check for popliteal and pedal pulses in leg AVG’s
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Section 3 – Surveillance of a new vascular access that has not been cannulated for patients on haemodialysis
New vascular access assessed by haemodialysis staff at each haemodialysis session for the first few weeks then weekly.
Assess and document:o Gain consent from patient to expose the entire arm or leg with the patient’s
accesso Look for evidence of bruising and swellingo Look at the incision site for healing
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o Check for signs of cyanosis of the finger tips and delayed capillary refill of the nail bed
o Check patency by auscultation using stethoscope, listen for bruit at the arteriovenous anastomosis; note changes in pitch and amplitude of bruit along the vascular access path
o Check calibre of the access by palpating the entire length of the AVF using fingers to determine width and length: a strong thrill should be palpable at the anastomosis, decreasing as you move further away from the anastomosis
o Check calibre of AVF by applying tourniquet enabling for easier palpation ( not tight enough to occlude blood flow ) and repeat above palpation
o Look for signs of infection ( redness, discharge and swelling ) o Check for evidence of Steal Syndrome by comparing temperature of comparative
non access limb and digits. Check for popliteal and pedal pulses in leg AVG’s
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Section 4– Surveillance of an established vascular access being routinely cannulated by haemodialysis staff
Check and document at each dialysis:o Physical examination to evaluate for findings of persistent swelling of the arm,
presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in the outflow vein.
o Dialysis clearances as per unit protocolo Frequent clotting of cannula during cannulationo Low blood pressure periods can put the access at risk and trigger increased
surveillanceo Increased positive venous pressure and negative arterial can indicate
deterioration and should trigger increased surveillance and need for further investigation
Attend regular access flow measurements as per unit protocol
ACT: Transonic machine (Ultrasound saline dilution protocol)SNSWLHD: using Fresenius BTM (Thermo dilution technique) in conjunction with the VAM software program.
Access flow on dialysis Recirculation rate
Direct access flow measurements:New accesses need to have an access flow reading 1 to 2 weeks after successful cannulation to establish a baseline reading.
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When access has been cannulated
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Where normal access flow measurements are recorded, (AVF >500mls per minute, AVG >600mls per minute), repeat the access flow measurement every three months or as per unit protocol.
Abnormal access flow measurements requiring intervention are decided by any of the following:
AVF < 500mls per minute AVG < 600mls per minute 25% decrease in access flows from previous reading Recirculation measurement of >0% using the transonic flow measurements Two abnormal access flow readings At the Medical Officers discretion
All access problems e.g.: cannulation problems, concern with aneurysms, lesions on the access arm, symptoms of Steal Syndrome causing pain, infections and abnormal access flow measurements please:
Consult with Clinical Nurse Consultant/Nurse Unit Manager Refer to the VAN who will consult the patient’s nephrologist VAN organises surgical reviews, interventional radiology procedures, duplex
ultrasound when needed and organises dialysis post procedure if required VAN communicates details of interventions time and place to haemodialysis unit
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Section 5 – Removal of Tunnelled Haemodialysis Central Venous Catheters
Tunnelled CVC Removal is to occur at the tertiary hospital or at an appropriate SNSWLHD facility (if available) in consultation with the Renal NUM
Equipment required: 70% Alcohol with Chlorhexidine 2% Suture Tray set Disposable scalpel blade with handle Sterile gown x 1 Sterile curved mosquito forceps Two sterile drapes Sterile gloves 4/0 Prolene sutures Gauze x 3 and a combine 5ml syringe Drawing up needle and 25G needle Xylocaine 1% with adrenaline 1:100,000 Yellow top jar/Labelled path form for MC&S and Progress Note, & Consent Form Tegaderm dressing
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Process:1. Nurse identifies the patient; prepare patient in a gown, takes observations.
Medical Officer explains procedure and obtains written consent from patient2. Provide privacy, collect and set up equipment using aseptic technique3. Ask patient to keep head turned away from catheter side4. Remove old dressing5. Medical Officer washes hands and dons sterile gown and gloves6. Medical Officer cleans around the exit site and lumens with Alcohol
70%/Chlorhexidine 2%, allow to dry and then apply drapes7. Medical Officer assesses mobility of the catheter’s cuff. If resistance, the cuff
needs to be carefully dissected from the surrounding tissue8. Local anaesthetic is injected if dissection is needed9. Once the catheter and cuff are free following dissection, the catheter can be
pulled out. Pressure is applied on the internal jugular vein on the patient’s neck (as directed by the Medical Officer) for 20 minutes till bleeding has ceased.
10. The catheter is placed on the sterile field; the tip is cut off with sterile scissors and place in yellow top jar to be sent to pathology for culture and sensitivity. Ensure it is appropriately labelled
11. The incision site is then sutured, when bleeding has ceased an occlusive dressing is placed over the sutures
12. Make appointment to see patient in 7 to 10 days to remove sutures13. Dispose of equipment in appropriate manner14. Document in patients progress notes and record removal in CV515. Pathology results are followed up by the VAN
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Section 6 – Tenckhoff Peritoneal Dialysis Catheter Insertion - Pre-Post Operative Patient management
Preoperative ManagementMost patients are admitted for this procedure on day of surgery through the Day Surgery Admissions area.Ward inpatient prior to surgery:
• Confirm procedure time with the Perioperative Unit and fast the patient • Prepare the patient as per Canberra Hospital and Health Service (CHHS) Pre
Operative Care (TCH 11:051) and Patient Identification (CED 11:27, CED 11: 29) SOPs. • Confirm Blood Results: Renal Unit Profile (RUP),Full Blood Count (FBC) and Full
Coagulation Profile (FCP) are available and reviewed by the Renal Advanced Trainee• Ensure Serum Potassium is within normal range. If outside normal range, contact
admitting team who may seek renal input pre-op.• Check that an ECG and CXR have been attended • Ensure pre prescribed bowel prep has been effective. If not refer to RMO• Ensure patient showered using Triclosan or Chlorhexidine. Check umbilical area
clean.
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Post operative Management – On return to ward
• Attend to general post operative patient management as per TCH 11:011 Post Operative Handover and Observations Adult Patients – first 24 hours SOP.
• Check operation site for wound ooze (advise Team Leader or RMO)• Ensure catheter is appropriately secured (see PD RHT exit site clinical procedure).• Diet as per surgical team• Check the exit site and change dressing accordingly prior to discharge.
Post operative Management – Discharge Planning
• Following Tenckhoff insertion patients are advised "not to shower" until advised by Renal Home Therapies (RHT) nurse
• Post discharge follow up by RHT nurse or referral by the RHT nurse to the applicable SNSWLHD Renal Outreach Nurse
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Implementation
This guideline will be implemented and communicated to the Renal Network staff by incorporating it into the orientation programs for credentialing Renal Network staff and by inclusion on Policy Register.
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Evaluation
Outcome Measures
Patients with a new AVF or AVG will have monthly follow up of their access. Patients with a newly cannulated vascular access to have regular access flow
measurements conducted by the dialysis staff. Patients on haemodialysis will have access flow measurements by the dialysis staff
within two weeks of the first cannulation and then three monthly to measure the access flow on their AVF or AVG. Abnormalities will be reported to the VAN
Method
Statistics on Access flow measurement compliance will be kept to measure time frames are being adhered to.
VAN will collect data in CV5. SNSWLHD Renal Units will collect their own data and forward to the VAN on request ( if CV5 not available )
VAN will review this, at a minimum of six monthly, and report to the Director of Renal Services.
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The Director of Renal Services will review the results and determine changes to this Guideline.
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Related Policies, Procedures, Guidelines and Legislation
PoliciesNursing and Midwifery Continuing Competence Policy (DGD 12-050)Skin Preparation SOP (CHHS 12/187)Pre Operative Care SOP (TCH 11 : 051)Patient Identification SOPs (CED 11: 27 , CED 11: 29Post Operative Handover and Observations Adult Patients – first 24 hours SOP. TCH 11:011Procedures
Guidelines Operational Guideline- Access for Renal Replacement TherapyLegislation
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References
http://www.cari.org.au/dialysis_va_list_published.phphttp://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/index.htmhttp://www.ncbi.nlm.nih.gov/pubmed/21326504http://www.hindawi.com/journals/ijn/2012/649735/http://www.nwrenalnetwork.org/fist1st/AVFCare.pdfThomas Nicola, Renal Nursing. 4th ed.UK. John Wiley and Sons, Ltd.2014Scottish Renal Nursing Strategy Group (2007). Best Practice statement for the care of arteriovenous fistula and graft. Retrieved July17, 2014, from http://www.srr.scot.nhs.uk/SRNSG/AVFISTULA_BPS_SEP07.pdfTransplant, urology and nephrology directorate (2012). Guidelines on the management of arterio venous fistula and grafts. Retrieved July 17, 2014, from www.beaumont.ie/media/AVFguidelinefinalcopy1.pdfCrabtree, J.H., Firanek, C. A., Piraino, B., Abu-alfa, A. K., & Guest, S. (2012). Access Care Guide: Catheter Insertion and Care. Retrieved from http://www.qxmd.com/references/access-care-guide/access-care-guide-catheter-insertion-and-care ANNA Contemporary Nephrology Nursing: Principles and Practice, 2nd edition, chapter 24, 2006.Handbook of Dialysis, 4th edition, 2007.Oxford Handbook of Dialysis, 3rd edition, 2009.
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Definition of Terms (if applicable)
Arteriovenous fistula: The surgical creation of an anastomosis between an artery and a vein to allow arterial blood to flow through the vein causing venous engorgement and enlargement for chronic kidney patients requiring haemodialysis.Arteriovenous graft: a synthetic graft implanted subcutaneously and interposed between an artery and a vein allowing needles to be inserted in order to remove and return blood during haemodialysis for patient with inadequate vessels for creation of AV fistula. Bruit - Bruit (pronounced broo-ee), the sound blood makes as it moves through arteriesThrill -arterial thrill, which is a vibration that is felt over an artery and caused by turbulent blood flow.Steal Syndrome: refers to vascular insufficiency resulting from an arteriovenous fistula or synthetic vascular graft-AV fistula). Some of the symptoms of steal syndrome are cold extremity, decreased capillary refill, severe pain and absence of radial pulse.
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Search Terms
HaemodialysisArteriovenous fistulaArteriovenous graftVascular accessPeritoneal dialysisTenckhoff catheter
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Consultation
Name/position/Division of person(s) consulted
Feedback ReceivedYes/No
Feedback incorporatedYes/No
Comment
SNSWLHD Renal CNC and Dialysis Unit NUMs
Yes Yes Bring into line with equipment and processes in Dialysis Units in SNSWLHD
Dr Girish TalaulikarDirector Renal Service
Yes No changes
CHHS Renal Vascular Access Nurse and Renal Outpatient CNC
Yes Yes Merge feedback from SNSWLHD
CHHS Renal CNCs No
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CHHS Renal Consultants No
Dr R SingerNephrologist CHHS
Yes Yes Resonium recommendation removed
Dr Stephen BradshawVascular Surgeon
No
Dr Wendel NeilsonVascular Surgeon
No
Sandra Hruza and Shirynne CowanCNC and Ag CNC EDSU
No
Lorraine EriksonCNC 9A
No
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AttachmentsAttachment 1
Attachment 2
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Attachment 3
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Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Date Amended Section Amended Approved By
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