ANNA Jersey North Chapter 126 Patient Care Technician Certification Review Dialysis Access September...

ANNA Jersey North ANNA Jersey North Chapter 126Chapter 126

Patient Care Technician Patient Care Technician Certification ReviewCertification Review

Dialysis AccessDialysis AccessSeptember 13, 2009September 13, 2009

Alice Hellebrand MSN, RN, CNN, CURNAlice Hellebrand MSN, RN, CNN, CURNANNA Northeast Chapter Coordinator ANNA Northeast Chapter Coordinator Renal Educator-Holy Name HospitalRenal Educator-Holy Name Hospital

Access for HemodialysisAccess for Hemodialysis

AVF-arterio-venous fistulaAVF-arterio-venous fistula AVG-arterio-venous graftAVG-arterio-venous graft Catheter-temporary or permanentCatheter-temporary or permanent

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Dialysis AccessesDialysis Accesses The Fistula is the The Fistula is the

patient’s own natural vein patient’s own natural vein that has been attached to that has been attached to a near-by artery via an a near-by artery via an anastomosis.anastomosis.

It takes 1-3 months for an It takes 1-3 months for an AVF to mature and AVF to mature and become strong enough to become strong enough to use a large gauge needle use a large gauge needle and achieve quality and achieve quality BFRs.BFRs.

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Dialysis AccessesDialysis Accesses

An anastomosis is a surgical An anastomosis is a surgical connection. In a vascular access, the connection. In a vascular access, the anastomosis is the spot where a vein anastomosis is the spot where a vein and artery are joined to form a fistula, and artery are joined to form a fistula, or where the artificial vein is joined to or where the artificial vein is joined to the patient’s artery and vein for a the patient’s artery and vein for a graft. Dialysis needles should not be graft. Dialysis needles should not be inserted into the area of the inserted into the area of the anastomosisanastomosis..

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ProsPros The AVF is the ‘GOLD Standard’ for The AVF is the ‘GOLD Standard’ for

hemodialysis accesses.hemodialysis accesses. It lasts longerIt lasts longer Has fewer infectionsHas fewer infections Has fewer complications like rejection, Has fewer complications like rejection,

stenosis, and clotting.stenosis, and clotting.

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ConsCons The main disadvantage is that the AVF takes The main disadvantage is that the AVF takes

4-6 weeks to mature and sometimes longer.4-6 weeks to mature and sometimes longer. Some fistula fail to mature at all, but it is not Some fistula fail to mature at all, but it is not

often.often. Side veins off of the AVF (accessory veins) Side veins off of the AVF (accessory veins)

can reduce pressure in the fistula causing it to can reduce pressure in the fistula causing it to fail.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.66

Assessing a FistulaAssessing a Fistula

Look for signs of infectionLook for signs of infection Look for signs that the surgical Look for signs that the surgical

wound/suture line has healedwound/suture line has healed Feel the thrillFeel the thrill Listen for the bruitListen for the bruit Feel the diameter of the vesselFeel the diameter of the vessel After one week, apply a tourniquet and After one week, apply a tourniquet and

feel for firmness..can I get a needle in feel for firmness..can I get a needle in therethere

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Assessing the FistulaAssessing the Fistula

Assess for signs of infectionAssess for signs of infection RednessRedness DrainageDrainage Increased warmthIncreased warmth

Bleeding from venipuncture siteBleeding from venipuncture site

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Always start with a 17 Always start with a 17 gauge fistula needle.gauge fistula needle.

The fistula needle The fistula needle gauge can decrease gauge can decrease (as needle gauges (as needle gauges get smaller-the get smaller-the diameter of the diameter of the needle shaft gets needle shaft gets larger) after the fistula larger) after the fistula becomes fully mature.becomes fully mature.

This allows for This allows for increases BFRs.increases BFRs.

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I’m going to cannulateI’m going to cannulate

WASH HANDS!! WEAR PPE!!!WASH HANDS!! WEAR PPE!!! Prepare the patients sitePrepare the patients site

AlcoholAlcohol Betadine (providone iodine)Betadine (providone iodine) Chlora-prep (chlorhexidine gluconateChlora-prep (chlorhexidine gluconate Exsept (sodium hypochloriteExsept (sodium hypochlorite

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How far must you stick away from an How far must you stick away from an anastomosis?anastomosis?

Two finger breadths from the anastomosisTwo finger breadths from the anastomosis

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When might you need to use a tourniquet When might you need to use a tourniquet on a fistula?on a fistula?

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Apply a TourniquetApply a Tourniquet

ALWAYSALWAYS Allows you to see the fistulaAllows you to see the fistula Holds it in placeHolds it in place Gives you a better “feel”Gives you a better “feel”

Apply tourniquet as far away from site as you Apply tourniquet as far away from site as you cancan

They should not be so tight that they cause pain, They should not be so tight that they cause pain, tingling or cut off blood flow to fingerstingling or cut off blood flow to fingers

ONLY USED FOR CANNULATION!! ONLY USED FOR CANNULATION!!

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What is the correct angle for needle What is the correct angle for needle insertion of a fistula?insertion of a fistula?

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25-30 degree angle.25-30 degree angle.

Why do we need to use a different needle Why do we need to use a different needle insertion degree angle from what is used insertion degree angle from what is used on a graft?on a graft?

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Dialysis AccessesDialysis Accesses The 25-30 degree angle is a more shallow The 25-30 degree angle is a more shallow

cannulation entry into the fistula. cannulation entry into the fistula. This technique is performed to prevent This technique is performed to prevent

cannulating through the Fistula causing an cannulating through the Fistula causing an infiltration.infiltration.

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Cannulation TechniquesCannulation Techniques

Rope ladderRope ladder Also called rotating sitesAlso called rotating sites Sites are rotated to prevent aneurysms or Sites are rotated to prevent aneurysms or

weak spots in the wall of the vesselweak spots in the wall of the vessel Buttonhole or constant siteButtonhole or constant site

Remove scabsRemove scabs Dull needles after site is establishedDull needles after site is established

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Easing the PainEasing the Pain

Tighten the skin during cannulation= less Tighten the skin during cannulation= less painpain

Lidocaine injectionLidocaine injection Ethyl chloride spray- feels cold on skinEthyl chloride spray- feels cold on skin Topical AnestheticsTopical Anesthetics

EMLA cream EMLA cream Less-n-pain (over the counter) Less-n-pain (over the counter)

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Fistula ComplicationsFistula Complications

InfectionInfection Never cannulateNever cannulate

• Drainage, rednessDrainage, redness

Line separationLine separation Tape needles securelyTape needles securely Fasten the blood lines Fasten the blood lines

Set arterial and venous pressure monitor limits Set arterial and venous pressure monitor limits TURN OFF BLOODPUMP and CLAMP THE TURN OFF BLOODPUMP and CLAMP THE

BLOODLINES BLOODLINES

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RecirculationRecirculation

Arterial and venous blood mixesArterial and venous blood mixes Blood flows within the AVF is lower than that Blood flows within the AVF is lower than that

in the dialyzerin the dialyzer Needles placed to close togetherNeedles placed to close together Lines are reversedLines are reversed Stenosis is presentStenosis is present

Place needles in the correct positionPlace needles in the correct position Keep the tips of the arterial and venous Keep the tips of the arterial and venous

needle at least 1.5 inches apartneedle at least 1.5 inches apart

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Air EmbolismAir Embolism Can cause cardiac arrestCan cause cardiac arrest Signs and symptomsSigns and symptoms

• Anxious feelingAnxious feeling• Trouble breathingTrouble breathing• CyanoticCyanotic• Vision problemsVision problems• Low blood pressureLow blood pressure• Confused, paralyzed or unconsciousConfused, paralyzed or unconscious

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Most common complicationMost common complication Infiltration/HematomaInfiltration/Hematoma

Tip of needle goes into the vein, out the other side or Tip of needle goes into the vein, out the other side or nick the side of the vesselnick the side of the vessel

Causes pain, bruising, additional cannulation Causes pain, bruising, additional cannulation and lack of trust in staffand lack of trust in staff

Infiltrated arterial needle-arterial pressure Infiltrated arterial needle-arterial pressure becomes more negativebecomes more negative

Infiltrated venous needle-raise in venous Infiltrated venous needle-raise in venous pressure and will stop the blood pumppressure and will stop the blood pump

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ThrombosisThrombosis Formation of blood clotsFormation of blood clots

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High Output Cardiac FailureHigh Output Cardiac Failure

What causes this condition to occur in a What causes this condition to occur in a patient with an AVF?patient with an AVF?

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Dialysis AccessesDialysis Accesses The fistula brings more blood to the heart.The fistula brings more blood to the heart.

The heart works harder, reducing resistance in The heart works harder, reducing resistance in the arteries.the arteries.

Arterial blood pressure falls.Arterial blood pressure falls.

The drop in arterial blood pressure triggers the The drop in arterial blood pressure triggers the renin-angiotension system.renin-angiotension system.

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Patients with High Output Cardiac Failure Patients with High Output Cardiac Failure may have rapid pulses as their hearts try may have rapid pulses as their hearts try to make up for the extra blood flow (20% to make up for the extra blood flow (20% or >) caused by the AVF access.or >) caused by the AVF access.

They may be SOB, have swelling in their They may be SOB, have swelling in their hands and feet (because return circulation hands and feet (because return circulation to the heart is poor).to the heart is poor).

Some patients may have chest pain if the Some patients may have chest pain if the BFR is too high during their treatment.BFR is too high during their treatment.

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What is an arteriovenous graft (AVG) ?What is an arteriovenous graft (AVG) ?

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An AVG is an artificial blood vessel used An AVG is an artificial blood vessel used to connect an artery and a vein.to connect an artery and a vein.

There are many types of materials that There are many types of materials that can be used for AVGs.can be used for AVGs.

These materials can be divided into These materials can be divided into biologic and synthetic materials.biologic and synthetic materials.

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Biologic MaterialsBiologic Materials Human and animal materials have been used Human and animal materials have been used

for AVGs, but are rarely used todayfor AVGs, but are rarely used today Human AVGs were made from a vein from the Human AVGs were made from a vein from the

patient's legpatient's leg Veins from the umbilical cords of newborn Veins from the umbilical cords of newborn

infants were also used, but had a high rate of infants were also used, but had a high rate of infection and aneurysmsinfection and aneurysms

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Examples of a human Examples of a human graft materials that graft materials that have been used for have been used for AVGs.AVGs.

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Bovine (cow) and Ovine (sheep) carotid Bovine (cow) and Ovine (sheep) carotid arteries are also used for grafts and must arteries are also used for grafts and must be treated to remove proteins that would be treated to remove proteins that would cause the human body to reject them.cause the human body to reject them.

These biologic grafts can also have a high These biologic grafts can also have a high rate of infection and aneurysms.rate of infection and aneurysms.

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Can you name any of the synthetic types Can you name any of the synthetic types of materials used for AVGs?of materials used for AVGs?

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Dialysis AccessesDialysis Accesses ePTFE (polytetrafluoroethylene) GraftsePTFE (polytetrafluoroethylene) Grafts

Venaflo – combines the ePTFE material with Venaflo – combines the ePTFE material with the well known material properties of IMPRA the well known material properties of IMPRA Carboflo vascular graft to reduce platelet Carboflo vascular graft to reduce platelet adhesion (clotting).adhesion (clotting).

Carboflo – In pre-clinic studies, Carboflo’s are Carboflo – In pre-clinic studies, Carboflo’s are Carbon lined to significantly decreases Carbon lined to significantly decreases platelet accumulation by as much as 6 times platelet accumulation by as much as 6 times greater than standard ePTFE grafts. greater than standard ePTFE grafts.

Distaflo – Used mainly for arterial bypass Distaflo – Used mainly for arterial bypass grafts and is shown to improve patency of the grafts and is shown to improve patency of the graft over other materials.graft over other materials.

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Examples of ePTFE Examples of ePTFE graftsgrafts Distaflo - upper leftDistaflo - upper left Venaflo – rightVenaflo – right Impra Carboflo – lower Impra Carboflo – lower

leftleft3434


The AVG is has two The AVG is has two anastomosis’ because anastomosis’ because it is surgically attached it is surgically attached to both the artery and to both the artery and vein.vein.

The Graft can be The Graft can be straight, looped, or straight, looped, or curved.curved.

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What is the correct angel degree for What is the correct angel degree for cannulating an AVG?cannulating an AVG?

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Cannulate AVGs at a 45 degree angle.Cannulate AVGs at a 45 degree angle.

Why does it matter what angel we Why does it matter what angel we cannulate an AVG and an AVF?cannulate an AVG and an AVF?

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AVG’s cannulation insertion is a steeper angle to AVG’s cannulation insertion is a steeper angle to prevent unnecessary increased puncture size prevent unnecessary increased puncture size and tearing of the graft material during needle and tearing of the graft material during needle insertion.insertion.

AVF’s on the other hand, need a lower angle to AVF’s on the other hand, need a lower angle to prevent the needle tip from puncturing through prevent the needle tip from puncturing through the other side of the fistula which could cause a the other side of the fistula which could cause a serious infiltration and potential damage to the serious infiltration and potential damage to the fistula.fistula.

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ProsPros The AVG takes about 2 weeks to heal and be The AVG takes about 2 weeks to heal and be

ready for cannulation.ready for cannulation. Graft size and blood flows don’t depend on Graft size and blood flows don’t depend on

maturation.maturation. Grafts can start out with larger gauge needles Grafts can start out with larger gauge needles

and obtain better BFRs sooner.and obtain better BFRs sooner. The AVG is a good access for those patients The AVG is a good access for those patients

who cannot maintain a fistula.who cannot maintain a fistula.

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ConsCons The biggest problems with all grafts are The biggest problems with all grafts are

infection and thrombosis.infection and thrombosis. Grafts are more likely to develop stenosis Grafts are more likely to develop stenosis

than AVFs.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 Grafts have an increased risk of infection over

the AVF.the AVF.

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Central Venous CathetersCentral Venous Catheters

Long termLong term Tunneled, cuffed catheterTunneled, cuffed catheter

Short termShort term Urgent dialysisUrgent dialysis

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CathetersCatheters

ProsPros Can be used immediatelyCan be used immediately Hidden under clothingHidden under clothing Hands and arms can be moved freelyHands and arms can be moved freely No needles No needles

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CathetersCatheters

ConsCons Increase risk of infectionIncrease risk of infection Foreign body can cause inflammation and Foreign body can cause inflammation and

clottingclotting Lower blood flows decreased adequacyLower blood flows decreased adequacy

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Care of the patient with a catheterCare of the patient with a catheter

AssessAssess SiteSite PatientPatient Catheter limbsCatheter limbs

First choiceFirst choice ChlorahexidineChlorahexidine BetadineBetadine

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Continuous Quality Continuous Quality Improvement (CQI)Improvement (CQI)

Identify Improvement is NeededIdentify Improvement is Needed Analyze the ProcessAnalyze the Process

Choose a teamChoose a team Review the dataReview the data Find the reason the problem occurredFind the reason the problem occurred Identify trendsIdentify trends

Identify the root causesIdentify the root causes What is the exact cause of the problemWhat is the exact cause of the problem Define the problemDefine the problem

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Implement PDCA CycleImplement PDCA Cycle

PLAN

DO

CHECK

ACT

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Questions?Questions???????

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