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Dialysis Access and the Role of the Non-Dialysis Nurse

Joe Atkins, RN,MBA,CNN,CHT

And

Cheryl Harter, RN,MSN

ObjectivesThe participant will be able to:

1. Compare and contrast the benefits, deficits and safety needs of each dialysis access type

2. List the attributes of dialysis access that facilitate cannulation/connection

3. Understand the role of non-dialysis nurses in aiding dialysis staff and nephrologists in the safety, maintenance and care of dialysis accesses.

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Introduction

Goal: Help all VA Nursing Staff see the value in gaining knowledge of dialysis access, being able to see the importance of their role in dialysis access maintanence, safety and care.

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Key Resources for Dialysis Access Nephrologists S. Miller-Ward Nurse Manager C. Harter, Charge Nurse Joe Atkins, Dialysis Access

Coordinator Donna Woerner, Dialysis

Educator/Researcher Joy Spears and Spencer

Howard: Master Cannulators

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It Takes a Team to Create and Maintain Dialysis Accesses Patient/Patient’s Family Nephrologist (office staff) Vascular Surgeon (office

staff) Interventional Radiology Dialysis Staff Dialysis Access Coordinator You

The Role of the Non-Dialysis Nurse in creation and maintenance of Dialysis Access. Often, NDNs can help veterans

and families work through fears concerning Dialysis Access

NDNs can help reinforce Dialysis Access education

NDNs participate in maintenance, safety and care of Dialysis Access.

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Types of Dialysis Access Temporary/Permanent

Hemodialysis Catheter

AV Fistula (hemodialysis)

AV Graft (hemodialysis)

Peritoneal Dialysis Catheter

Hemodialysis Catheters Hemodialysis catheters may be temporary or

permanent.

Positive AspectsNegative Aspects

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Temporary (uncuffed) Hemodialysis Catheters Bennefits

Risks

Safety

Care

Temporary vs Permanent Catheter

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Permanent (cuffed) Hemodialysis Catheters Benefits

Risks

Safety

Care

Arterio-Venous Fistula

Positive Aspects Negative Aspects

AV Fistula Vein

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Sapheno-Femoral AV Fistula

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Hemodialysis

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Artio-Venous Fistula Benefits

Risks

Care

Safety

AV Fistula Vein Hypertrophy

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Steal Syndrome Results in Ischemia

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Arterio-Venous Graft

Left: AV Graft Right: AV Fistula Positive Aspects Negative Aspects

Gortex ® Graft Material From electrical insulator to medical device

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Arterio-Venous Graft

Bennefits

Risks

Care

Safety

What happens to an AV graft when you fail to rotate needle sites

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Early Referral to Nephrologist Screen patients at high risk:

Age >60, African-American, Native American, Diabetes, Hypertension

Refer to nephrologist if stable or rising Creatinine >1.5 female, >2.0 male

Proteinuria > 2 gm/day

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Glomerular Filtration Rate Nephrologist should direct when

patient gets referred for dialysis access.

GFR is widely accepted as the best overall measure of kidney function.

GFR Calculator is on Nephron.com

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When to Refer for Hemodialysis Access When GFR <30 (CKD Stage 4) and

patient chooses hemodialysis, nephrologist should refer to surgeon for AV fistula consultation.

Best for AV fistula to be created 6 months to 1 year prior to dialysis start to allow for maturation time.

Goal should be to avoid hemodialysis catheter whenever possible.

If patient is not a candidate for an AV fistula, nephrologist may want to wait until GFR lower before graft placement.

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Early Education of Pre- ESRD Patients Education should start when GFR is

<30ml/min (CKD Stage 4). Modality choices need to be presented

before appropriate access referral can be made.

Consider AV Fistula creation even if patient chooses peritoneal dialysis.

Educate patients to “Save Their Veins”

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AV Fistulas Need to Be Created Early!

Helpful if veteran understands the process Referral to surgeon Ultrasound (vein) mapping is necessary

before surgery can be scheduled Important patient have follow-up

post AV fistula creation to monitor development of AV fistula.

An AV fistula attempted and not successful should not be considered a failure! An AV fistula attempted is better than starting out with a catheter or graft.

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Provide Realistic Expectations

Access may take maintenance angiography, angioplasty, thrombectomy, revision.

Grafts clot much more often than fistulas

AV Fistulas can be fragile and can infiltrate

AV Fistulas can clot - and can be successfully de-clotted.

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Best Outcome:

Patient starts first dialysis treatment with a functioning AV fistula. Non-Dialysis Nurses are invaluable in helping ESRD patients accept and understand the need for their access.

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No Access in Place for Dialysis Start - Options

Temporary or Permanent Tunneled Catheter with AV fistula placed, if possible.

If veteran desires Peritoneal Dialysis a temporary hemodialysis catheter, along with a PD Catheter will suffice until PD catheter has healed and training can be initiated.

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Next Steps:

Vein mapping (as necessary) AV Graft only if veteran is not a

good candidate for AV fistula. Veterans should have a temporary

catheter for no longer than 30 days, due to risk of infection.

Although cuffed, permanent catheters are still at risk of infection.

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Non-Dialysis Nurse Reporting Potential Access ProblemsWhat’s important to report? Exit site redness or discharge from any

catheter, whether it be for PD or hemodialysis.

AV Fistula or Graft has lost Bruit and/or Thrill.

Any sign of bleeding from any access. Risk of veteran pulling out catheter. Change in bruit or Thrill (weaker than

usual).

Major Problems/Risks with Catheters Dislodgement. Infection Air Emboli (loss of caps,

unclamping of lines) Sutures that have torn through skin

and need replaced Cracked or damaged tubing

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Major Problems/Risks of AV Fistula and/or Graft Thrombosis=loss of bruit and thrill Infection=redness and/or swelling Discharge of pus from old needle

sites Venous thrombosis or stenosis

resulting in swelling of access arm Bleeding from needle sights post

dialysis Aneurysms

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Non-Dialysis Nurse Care of the Hemodialysis Catheter

Check to see that catheter is secure, sutures in, caps on, clamps closed

Veterans should not shower with hemodialysis catheter, temporary or permanent (risk of infection)

Hemodialysis catheter dressings that have come loose can be replaced

Clamp the catheter if it starts to bleed what to do if the catheter falls out who to call if they have a problem with

the catheter

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Care of the New Dialysis Access AV Fistula/Graft Maturation time takes 2-6 weeks for

AVG and 2-3 months for AVF Carefully assess VA before at the

beginning and end of each shift or when the patient enters or leaves your specialty area/floor.

Checking the Bruit and Thrill Avoiding anything that restricts flow of

blood (no ID or blood bands on access arm.

Educate patients on s/s of infection, clotting, and other complications

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Identification of Veteran’s Dialysis Access (safety)

Wallet Cards

ID bracelet

Signs/Small Posters

Passing on information about access in shift report

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Long Term Care of the Hemodialysis Access Routine monitoring and

surveillance and safety, at the facility level

Prompt referral and early intervention

Veteran’s vascular access history Veteran’s education Veteran Independence: self-

cannulation, holding own needle sites, knowledge of safety and care of access.

Peritoneal Dialysis Catheter

Peritoneal Dialysis Training

Home Peritoneal Dialysis

The Home Choice CCPD Unit

Role of the Non-Dialysis Nurse in Peritoneal Dialysis Monitoring and assessment of the PD

Catheter Supporting independent veterans as

they carry out their own PD exchanges Actually carrying out the PD exchange

for those veterans who are unable to do it, themselves

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Conclusion

Non-Dialysis Nurses play a vital and beneficial role in helping veterans, nephrologists, surgeons and dialysis staff in the coordination, care and safety of dialysis accesses.

Nephro The Wonder Dog

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Bibliography All photos and illustrations were sourced from the

public domain. AV Fistula First Initiative by CMS/Renal Networks “The Arteriovenous Fistula”, Konner,Nonnast-

Daniel, Ritz, JASN June 1, 2003 vol. 14 no. 6 1669-1680

“Long Term Survival of arteriovenous fistulas in home dialysis” Lynn, Buttimore, Wells, Roake and Morton, Kidney International (2004) 65, 1890-1896

“Vascular Access for Haemodialysis”, The Renal Association, Fluck and Kumwenda, 1/5/2011

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Bibliography Continued “Preventing Infections in Hemodialysis Fistula and

Graft Vascular Accesses” Nephrology Nursing Journal/Sept-Oct 2012, Kim Deaver

“Prevention of hemodialysis central line-associated bloodstream infections in acutely ill individuals” Nephrology Nursing Journal/ Sept/Oct, 2012, Nancy Colobong Smith

“The culture of vascular access cannulation among nurses in a chronic hemodialysis unit” CANNT Journal, 2012 Jul-Sep;20(3):35-42, Wilson, Harwood, Oudshoom, Thompson

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Bibliography Continued “Impact of multidisciplinary, early renal education

on vascular access placement” Nephrology News Issues, 2005, Fed:19(3):35-6, 41-3. Linberg, Husserl, Ross, Jackson, Scarlata, Nussbaum, Cohen, Elzein

“Peritoneal dialysis and hemodialysis: similarities and differences” Nephrology Nursing Journal/Sep-Oct, 2004 Mary M. Zorzanello

“A Patient Centered Decision Making Dialysis Access Algorithm” The Journal of Vascular Access 2007; 8: 59-68, Davidson, Gllieni, Saxena, Dolmatch

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