2. Objectives
The 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.
06/10/15 2
3. 06/10/15 3
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.
4. 06/10/15 4
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
5. 06/10/15 5
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
6. 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.
06/10/15 6
7. 06/10/15 7
Types of Dialysis
Access
Temporary/Permanent
Hemodialysis Catheter
AV Fistula (hemodialysis)
AV Graft (hemodialysis)
Peritoneal Dialysis Catheter
22. What happens to an AV graft when
you fail to rotate needle sites
06/10/15 22
23. 06/10/15 23
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
24. 06/10/15 24
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
25. 06/10/15 25
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.
26. 06/10/15 26
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”
27. 06/10/15 27
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.
28. 06/10/15 28
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.
29. 06/10/15 29
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.
30. 06/10/15 30
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.
31. 06/10/15 31
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.
32. 06/10/15
Non-Dialysis Nurse
Reporting Potential
Access Problems
What’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).
33. 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
06/10/15 33
34. 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
06/10/15 34
35. 06/10/15 35
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
36. 06/10/15 36
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
37. 06/10/15 37
Identification of
Veteran’s Dialysis
Access (safety)
Wallet Cards
ID bracelet
Signs/Small Posters
Passing on information about
access in shift report
38. 06/10/15 38
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.
43. 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
06/10/15 43
44. 06/10/15 44
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.
46. 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
06/10/15 46
47. 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
06/10/15 47
48. 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
06/10/15 48
Editor's Notes
Good afternoon,
Knowledge of the various accesses used for hemodialysis is second nature for dialysis nursing staff, as it is part of the dialysis process. However, it’s also vital that nursing staff in the other specialty departments and medical/surgical floors also have a basic understanding of how these accesses are used, the monitoring and care they require and the safety measures that need to be taken when caring for dialysis patients.
Read slide
The vascular access problems are:
A Major cause of morbidity and hospital admissions
A cause of many lost hours on hemodialysis
The reason for most hospitalizations for hemodialysis patients
Lead to a high cost to healthcare system – Medicare, alone, spends an average of $18,000 per patient per year on a maintenance of vascular accesses. At this time, there are no numbers collected within the VA system, which show our costs for failed dialysis access. However, efforts are being made at the Central Office level to do so.
Even though a nurse may not be directly involved with the use of a dialysis access, gaining knowledge of these accesses allows them to contribute to the patient’s level of wellness by alerting dialysis staff of potential problems that may be occurring with dialysis access, while the veteran is under their care. The goal is safety and prevention of problems, before they occur.
It’s vital that nurses throughout the VA know who to call when questions, or problems arise with any dialysis access. Introduce and explain the role of each team member. When you have questions, please call the dialysis unit at 2562. Staff will direct your questions and concerns to the appropriate person.
The front line team for renal patients include the individuals on this list, however Non-Dialysis Nurses are also an integral part of the Interdisciplinary Renal Team.
The goal is to motivate patients to take an active role in their care, particularly in the selection of the type of dialysis access they will receive, which must be appropriate to their chosen method of renal replacement therapy.
This can be accomplished through one on one education, meeting with patients. For the last several years, members of our team has been holding classes for patients with CKD, in hopes that they will be better prepared to choose a therapy, which fits them and his/her personal life style. Pts. are encouraged to bring family members and/or significant others to the classes as so often these family and/or friends play a key role in helping an individual by providing emotional support. As well as sometimes they are primary care providers who offer help in many ways such as activities of daily living, preparation of meals and transportation.
Besides the vital guidance of the nephrologist, our team relies heavily on our surgical team, for without them, there will certainly be no dialysis access. Without their good communication and technical skills, dialysis access at our facility would be impossible. As for the dialysis staff, it goes without saying, play such an integral role in the education and care of these patients.
Self explanatory (read slide).
Today, we will discuss the following types of dialysis accesses:
Of all the dialysis access available to patients, catheters are the most convenient, but are also the most dangerous. In general, whether the catheter be temporary or permanent, the immediate danger of air emboli is of grave concern. As you can see in the image of this slide, central venous catheters for hemodialysis enter the internal jugular and the tip is positioned directly into the entrance of the right atrium. Risks for air emboli are highest during connection and disconnection from the hemodialysis machine, however, it is possible for the caps to become dislodged and the clamps to accidently become opened. To help prevent this from happening, a 4X4 is securely taped around the branches, of the catheter, including the clamps and caps. This is done in an effort to prevent contact with these components, when not being used. Should a non-dialysis nurse discover that the 4X4 is missing, and/or that caps are missing, replace the cap, as soon as possible. If a clamp is discovered in the open position, close it, immediately. The greatest danger to the patient is an open clamp with missing cap. If the veteran is lying down, or is in trendelenburg position, they will bleed from the catheter. If their head is elevated to any degree, an air emboli will ensue, causing immediate death. The higher the elevation of the head, the quicker the air emboli will occur. Although there are other safety concerns with catheters, Air Emboli is of the gravest concern. So, as a non-dialysis nurse, your actions, particularly in this case, would deffinately save the veteran’s life.
Temporary
Benefits: Ease of insertion. Can be accomplished quickly for purpose of emergency hemodialysis. Can be inserted by resident, with nephrologists&apos; supervision.
Risks: Due to lack of a cuff, temporary catheter has highest risk of infection. Air Emboli.
Safety: Must be removed in 30 days. Any longer can result in blood borne infections. Confused veterans must be closely observed to prevent his/her accidental removal of the catheter. Of course, as mentioned earlier, prevention of air emboli is of greatest concern.
Care: Dressings and caps must be changed with every treatment. Care must be taken to prevent kinking of catheter material, as it is stiffer than a permanent catheter.
As you can see, the temporary catheter, on the left, is arched, inserted, most often, into the right IJ. Once inserted, it sits directly over the entrance of the right atrium. Again, note that there is no cuff to stop the migration of bacteria down the insertion tract, to the IJ and, eventually, directly into the heart. The danger being that once bacteria seeds itself in the heart, getting rid of it is very difficulty, resulting in long term administration of IV antibiotics.
On the right, you see the “permanent” IJ catheter, which is the lesser of evils, only when compared to a temporary catheter. The safety of this catheter hinges on its softer material, which is silicone, compared to the more rigid material of the temporary catheters, which come in a variety of plastic materials including polyvinyl chloride, polyethylene, polyurethane. Of course, the main feature for prevention of infection is the Dacron cuff (see arrow). The cuff functions as a barrier to motility of bacteria when granulation tissue grows into its fibers. However, complete granulation of all the fibers of the cuff cannot be guaranteed. The effectiveness of the cuff also greatly depends on how far the surgeon placed the cuff under the veteran’s tissue and how well the catheter is sewn in after implanted.
Benefits: Although this catheter is labeled as being “permanent” nothing could be farther from the truth. Due to the continued risks of infection, it can be described as “the second worst” hemodialysis catheter. That being said, due to a veteran’s poor vascular status, it may be the only option. Being made of a soft, silicone material, there is less chance of erosion of the exit site and a higher level of comfort for the veteran. As well, provided that, ideally, adequate granulation tissue in-growth of the Dacron cuff occurs should provide a barrier against the motility of bacteria into the exit site of the catheter.
Risks: As with the temporary catheter, the primary risk is air emboli. The same precautions for air emboli taken with the temporary catheter, also apply to the permanent catheter. Risk of infection is lower due to the Dacron cuff, however, due to the lowered immune response of our veterans on dialysis, the chance of infection remains high.
Safety: AIR EMBOLI is of main concern. Additionally, the risks of accidental removal by confused veterans is very high. NDNs need to remember that the dialysis catheter is the life line for veterans on hemodialysis. If the catheter is lost, it means a repeated trip to interventional radiology for placement of a new one. Furthermore, repeated access into the internal jugular increases scar tissue and increases the risk that the IJ may become thrombosed. If this happens, bilaterally, it will mean that the veteran’s options for future catheters will be greatly reduced, forcing the interventionalist to attempt femoral placement of catheters, which deffinately will increase risk of infection.
Care: Whether temporary, or permanent, after each treatment, heparin 1000 units per ml is instilled into each branch of the catheter in order to prevent clotting of the catheter between dialysis treatments. As used throughout the VA hospital, BD Q-Syte ® is a needle-less valve system applied to all hemodialysis catheters, whether temporary or permanent. The greatest benefit of this is that it reduces chances of air emboli, should the catheter become unclamped and cap be accidentally removed. The CUROS ® cap used is also used throughout the VA system, has 70% ETOH inside of it, which will help prevent the risks of infection. Last, a 4X4 should be taped around the catheter branches, covering the clamps and the caps. Dressing changes occur weekly and consist of cleaning the exit site with a ChloraPrep applicator, applying a new Biopatch, which is then covered by a clear dressing. Should the dressing be missing, for any reason, a NDN can follow this procedure.
Of all the hemodialysis access that a veteran can have, the AV fistula is the gold standard. The reason is the fact that, provided the veteran has the arteries and veins to support it, it has the least number of problems. This access is created by the surgeon poking a small hole in the veterans radial or brachial artery, then doing the same to the most available vein, and then sewing the two holes together. The arterial blood is “shunted” to the vein, causing it to hypertrophy. With exercise, the vein continues to enlarge, until it’s of a size and flow that it can be cannulated with two needles for hemodialysis. There are two nursing assessments, which tell anyone, whether, or not, the AV fistula is functioning. 1) The Bruit (sound) 2) The Thrill (feeling the vibration of the bruit). The bruit is audible and can be heard with a stethoscope. Provided that the access is working well, the sound should be like a freight train through the stethoscope. As for the thrill, it, too, should be easily palpable and strong to the touch. This should be check every shift. If caring for a patient who has just had surgical creation of the AV fistula, it should be checked, at least, every two hours. Should the NDN discover that the bruit and thrill have diminished, or that it’s not existent, the nephrologist needs to be paged and informed, as soon as possible. The sooner action is taken, the more likely that an interventionalist, or surgeon, will be able to correct the problem.
You can see from this picture how the vein of the AV fistula hypertrophies. Please note the old needle sites.
For veterans whose veins in their upper extremities have been expended, the surgeon may be forced to move down to the thigh. In this picture, your looking at an immediate post operatively created AV fistula. Once it has had time to heal, dialysis staff will cannulate this access, just as they would an AV fistula that had been created in the arm. Excessive adipose tissue could require the surgeon to transpose the vein up closer to the surface of the skin, to facilitate cannulation (dialysis needles range from 3/5th of an inch, up to 1 ½ inches in length.
It is also possible to place graft material between the saphenous vein and femoral artery, resulting in a lower extremity AV graft.
(Royalty Free Photo)
Give brief explanation of hemodialysis process.
In Center Hemodialysis
Is convenient, like Jiffy Lube
Requires a set schedule
Requires being stuck with needles
Has increased restrictions of fluid and dietary intake
Promotes dependence on professional staff
Limited therapy time due to three day a week schedule
Limits ability to travel
Travel to and from the dialysis facility may present problems
May suffer side effects like low blood pressure and cramping
Benefits: This access is the gold standard, having the lowest risk of infection of all the hemodialysis accesses.
Risks: Although it’s very low, there is a risk of infection. That being said, infiltration during cannulation for hemodialysis can be a problem until the veterans veins become fully developed. Post dialysis evaluation for bleeding from the needle sites is one of the most important assessments to be made. This is of concern for the first two hours after the veteran returns to the floor from dialysis. If left unmonitored, it is possible that a patient could bleed to death. Potential for blood loss is a concern for all hemodialysis accesses. Hypertrophy of the vein is a common problem for veterans who have had a well functioning AV fistula for many years (show them an example in the next slide). And, last, but not least, is steal syndrome, which results when too much blood is being shunted away from the hand of the access arm, resulting in peripheral ischemia.
Care: In order for the AV fistula to develop, the veteran needs to exercise his/her access arm. However, this should not be done until two weeks after creation. Once the access is developed and cannulation had begun, cleanliness of the site is very important. Prior to each cannulation, dialysis staff cleans the area to be cannulated with CloraPrep. A tourniquet may be used, depending upon the size and bruit of the access. The standard size hemodialysis needle used is 15 gauge, which is the same size used for blood donation. So, it take two needles, three days per week. Post dialysis: the needles are removed from the AV fistula and just enough pressure to prevent bleeding is applied. The site is held until the needle sites are coagulated, then a light pressure dressing is applied. It’s vital that NDNs avoid cannulation of the AV fistula arm, avoid blood pressures, IV’s and blood draws, of any kind. The access arm is for hemodialysis, only.
Safety: The most important thing, post dialysis is to assure that the needle site have, indeed, stopped bleeding. However, for various reasons, bleed can begin, again, after the veteran has been returned to the NDN. Should a NDN discover a veteran who is bleeding, simply put on a glove and apply pressure. If the bleeding does not stop, if it’s during hours of dialysis operation, call the dialysis unit at 2562. However, if it’s after hours, ask the supervisor to contact the on call dialysis nurse. The NDN holding the needle sites needs to remember to apply enough pressure to stop the bleeding, but not so much pressure that the flow of the access is diminished or stopped. Reduction in the thrill and bruit are clear indications that too much pressure is being applied. Once the bleeding has ceased, a light pressure dressing can be reapplied, using folded single ply 4X4s and one inch tape. Make sure the tape is secured and that there is a sufficient amont to hold the light pressure dressing in place.
This is a perfect example of AV fistula vein hypertrophy. The cause can be for many reasons, primarily the cause is long term cannulation of the access. The other cause can be stenosis of the subclavian vein, or any vein as the blood is trying to return to the right atrium.
Please note the gangrene of the fingertips, resulting from ischemia. Often, the only way to resolve this problem is to surgically ligate the AV fistula, thereby restoring flow to the hand.
This slide represents the clear difference between an AV fistula and an AV graft. To the right, you can see how the surgical anastomosis was created, connecting the radial artery with the vein. On the left, you see an example of an AV graft. It’s interesting to note that the first graft material was bovine. In fact, for many years, it was the only graft material available. The problem with this was that many patients had allergies to either the bovine material, or the solutions used to preserve the graft material. Ironically, this problem was solved when a surgeon happened to be seated on an airplane flight next to a gentleman who had invented a new plastic material being used to insulate electrical wires in large cables. After the surgeon finished lamenting to the engineer, he replied that he had a new plastic tubing that might work as a new graft material. That new material was Gortex ®, which, today, has myriad applications, non-medical and medical. The outcome of this fortuitous meeting was the creation of Gore Medical ®, which produces 70% of all the plastic AV grafts used, not only for hemodialysis, but for heart bypass grafts and other applications.
The white flexible tubing in this photo is the Gortex ® material, which is surgically attached between an artery and a vein. You can see the comparison in size between the hemodialysis needles, and the graft material.
Benefits: The new plastic grafts provide an opportunity for veterans with poor arteries and veins to be able to have an access that can be cannulated, just like the AV fistula.
Risks: Although the AV graft is superior to any catheter, it still is not as good as the AV fistula. The risks are the following: 1) laceration of the graft material with he hemodialysis needle, 2) venous stenosis immediately after graft flow, increasing back pressure in the graft, which, eventually could completely stop the flow in the graft, 3) Graft materials are more prone to infection 4) Due to the fact that the blood coming into the graft is purely arterial blood, with arterial pressure, grafts are more prone post dialysis bleeding.
Care: Unlike the AV fistula, once the AV graft has been inserted, it can be used about two weeks to a month after insertion, as there is no development to take place. The dialysis team simply has to wait for granulation tissue to complete the healing process at the arterial and venous anastomosis (connection). Like the AV fistula, the area to be cannulated needs to be disinfected with ChloraPrep ® prior to cannulation. Post dialysis needle site care is the same as the AV fistula, but with more concern for post dialysis bleeding, due to the higher arterial pressure inside the graft.
Safety: Veterans with AV fistulas or Grafts, needs to be aware of weight lifting limitations of the access arm, which, is generally limited to less than 15 pounds. Additionally, and more so with the AV graft, care must be taken to prevent impact or laceration damage to the access site. For example, a hemodialysis patient was visiting a casino in Las Vegas. While walking through the lobby, he fell. While reaching out to break his fall with his access arm, he landed on a glass table, which broke, lacerating his AV graft. Sadly, he bled to death. Although a freak accident, this could happen to any patient, at any time. It could happen here. Therefore, it’s wise to keep confused patients with AV fistulas and grafts under close observation.
Sometimes staff and veterans are resistant to rotating needle sites, primarily due to pain. Staff do not want to cause the veteran pain and anyone receiving a needle stick wants it to be as painless as possible. However, particularly with AV grafts, rotation of needle sites is vital. Once a graft has been cannulated, dialysis completed and needle removed, granulation tissue fills in the hole in the graft. However, granulation of the cannulation site takes several weeks to form a secure plug. For this reason, dialysis staff need to rotate site all around the graft, using as much of it, as possible. You can see from this picture that dialysis staff failed to rotate sites and, as a result, literally chewed up the graft, destroying its function. The real danger is the possibility that the weak spot in the graft could break loose causing a large hematoma, restricting flow to the hand. In fact, patients outside of the VA system have, indeed lost their hands in similar circumstances.
Historically, patients who have developed end stage renal disease have been referred to nephrologists for care, after there numbers have become critical. In these situations, there has been no time to educate the patient. So, they usually start out with a temporary catheter. The nephrologist and the dialysis team are attempting to educate veterans, before they have decided on the type of dialysis they want and the type of dialysis access they will need. To date, our CKD veterans have been very receptive and we are doing better at getting them prepared with an access, before they need it. In this slide, you can see how we screen and select our patients for access placement.
Besides having aGFR calculator, Nephron.com is an excellent educational source for NDN’s, patient and families on just about any aspect of kidney disease, as well as vascular access issues.
Another helpful educational website is : kidneyschool.org. It provides patient with comprehensive overview of different vascular access options as well as tips how to take care of them properly.
AV Fistula should be considered the #1 choice for vascular access because of better flow rates, lower infection rates, and it’s longevity. Therefore, every veteran needs to be evaluated as a candidate for AVF.
If the veteran is not a candidate for a fistula, the nephrologist should wait until GFR is lower before graft placement or another modality (perhaps PD) should be offered to this veteran.
Grafts, ideally, should not be placed too far in advance of the initiation of dialysis (2 months) as &quot;the clock starts ticking.” What does that mean to the veteran? It means that AV grafts are very prone to stenosis and thrombosis. Unfortunately, this process begins almost as soon as the veteran returns from recovery. It’s all a matter of a foreign material being sewn onto a natural vein. For some veterans, it may not happen for years. For others, it happens within months, or even weeks.
As mentioned earlier, veterans are being identified and education before their Creatinine is &gt;2.
“Saving their Veins”:
Patients can carry a card which says:
“Attn: Nurses or Phlebotomists: Someday I may require dialysis, so whenever possible, do not use the cephalic vein. Whenever possible draw blood from my hand veins.”
It would be helpful to discuss with veterans, if they are admitted to this hospital, that they need to be assertive and ask that an I.V. not be started in an arm that is designated for an access. As well, blood pressures should not be performed on that arm.
Kidney Treatment Options classes are vital to help veterans and their families understand the different options for dialysis. Presently, as significant number of our CKD veterans attend an educational pre-ESRD program, which explains every modality selection of renal replacement therapy, as well as the various accesses needed for each specific therapy, which stresses that fistulas are the access of choice, whenever possible, as they clot much less frequently than grafts. Transplants are also covered for that group of veterans.
Educating the veteran for EARLY REFERRAL is vital in that the first fistula attempted may not develop adequately and may need further intervention and/or possible new attempt in another area of, or possibly even the other arm. This is especially if the veteran is diabetic.
Ideally, referral should take place 6 months to one year prior to the initiation of dialysis.
Veterans may be less fearful if they have a realistic expectations regarding their access. NDN are a vital part of the team in educating veterans about this process.
Stress to pts. that if they suspect their fistula is clotted, the sooner the surgeon can get to it the better chance for a successful de-clotting (thrombectomy).
Staff dialysis staff use caution with new fistulas. We have two designated “Master Cannulators” who are the first nurses to cannulate the veteran’s new access. They begin with 17 gauge needles, are cautionary using low blood flow rates and educate the veteran to limit movement in his/her arm as much as possible.
If fistula has not matured yet, the patient may need to dialyze for a limited time with a tunneled hemo catheter.
Unfortunately, a catheter is the only option for acute dialysis. But the same hospital visit could be utilized to do a vein mapping and AVF or PD catheter placement.
Example ( use this or your own)
Mrs. Mary Z., patient with ? acute/chronic renal failure who was high risk to have hemo-catheter in due to an infectious disease. Recommended catheter removal ASAP.
This was a situation where there was no time for a fistula to mature. VAM discussed plan with nephrologist: Alternative to graft placement was a PD catheter. The VAM met with pt. twice. She was sad to hear that dialysis might be chronic because she was planning trip to visit her grandchildren. She was trained on PD and the hemo catheter removed. Several months later, she regained function and no longer required dialysis.
This was a good outcome because she was not left with any artificial material in her arm.
PD can also be used as a treatment option while waiting for fistula maturation.
Self explainatory.
Self Explanatory
Self explanatory
Every unit has a Policy and Procedure on how to use and take care of hemodialysis catheters.
Discuss care for brand-new AVF and Graft.
Patients need information in order to be active participants in their care.
Dialysis Services staff will encourage patients to carry a plastic coated wallet card with them that lists their dialysis type, the surgeon/physician who created it, or put it in, the nephrologists’ pager numbers, and Dialysis Units extension number.
This card is extremely beneficial during emergencies, as it informs EMT’s, Emergency Room staff, Nursing Home staff, etc, the do’s and don’ts the veteran’s access.
Key elements at the facility level in establishing a program for Vascular Access Surveillance are:
Appropriate Policies and Procedures;
Staff training;
Documentation, tracking, and ongoing Quality Improvement (QI) monitoring
Equipment (as necessary)
There are several educational handouts for patients – refer to the website.
Beyond kidney transplantation, peritoneal dialysis is the only other modality choice that comes closest to mimicking the function of the natural kidney. This is particularly true of CAPD, which is continuous ambulatory peritoneal dialysis. Why? Because like the native kidneys, this therapy goes on, 24 hours a day, seven days a week. The advantage of this is the fact that it provides a “steady state” of baseline chemistries, waste by-products of protein metabolism and fluid. No other dialysis therapy can match its efficiency.
Insertion of the PD catheter is a simple out-patient procedure that takes about 1 hour (in surgery). The surgeon will place the catheter around the area of the veteran’s belly button. The important thing is to make sure the catheter is placed above or below the beltline, in order to prevent irritation of the exit site. Once the surgery is complete, the catheter will not be used for several weeks. During that time, the PD training nurse will teach the veteran how to care for his/her catheter and exit site. The main goal is to allow healing of the catheter exit site and avoid exit site infection. Special dressings will be used at this time, but eventually, the veteran may not require a dressing, at all.
With peritoneal dialysis, veterans are trained to become their own expert. The peritoneal training nurse puts the veteran through a carefully guided program, which gives them all the information they need to care for themselves. As well, the nurse will be available after the veteran’s training, always being a telephone call away. Concerning travel, routinely, the veteran should only have to come into the facility twice a month to have his/her blood drawn and to be seen by the PD nurse, physician, dietitian and social worker. It’s during these visits he/she can discuss problems and concerns with the dialysis team.
(Royalty Free Photos)
Home Peritoneal Dialysis
Promotes independence
Travel time and expense is greatly reduced
Requires patient to be more independent and learn self care
Provides more flexible schedule
May reduce blood pressure and other medications
Ability to travel is virtually unlimited
Provides more flexibility in fluid and dietary intake
May provide risk of peritonitis, which is no small risk
Requires a special room for veteran’s exchange
Requires storage room for supplies
Nocturnal Peritoneal Dialysis, also known as Continuous Cycling Peritoneal Dialysis is carried out at night, while the veteran is sleeping. A machine, which is kept at beside, slowly cycles warmed dialysate solution in and out of the abdomen all night. The veteran connects before he/she goes to bed and disconnects after awakening the next day. Many veterans find that this therapy gives them more freedom, particularly if they are still working. The negative aspect of this therapy is that he/she may have to disconnect to use the bathroom in the middle of the night. Additionally, if the veteran is a large person, this therapy may not be efficient enough to effectively clear the toxins and water out of his/her body. If the veteran chooses to travel, he/she will have to bring the machine, called the Home Choice, with them.
The most important point of peritoneal dialysis is to maintain the independence of the veteran. Of all the dialysis accesses we’ve discussed, this is the one that the non-dialysis will be most involved in. In fact, in this instance, you are no longer a non-dialysis nurse, but, instead, you are actually an active part of the dialysis team. By the nature of your participation, you are an auxiliary dialysis nurse. In light of this, knowing to assess and chart:
-the security of PD catheter exit site per shift, making sure that it’s secured (not being tugged at or pulled on)
-that there is no redness or drainage at the exit site (report any untoward findings).
-evaluating the veteran’s ability to carry out his/her own exchanges
-charting exchange out-flow and inflow on the PD exchange record
-charting the condition of the PD effluent at the end of the drain (is the solution that came out of the veteran clear and golden yellow, which is normal, or is it cloudy, with strings of white protein, which could mean an episode of peritonitis
-is the veteran complaining of burning in his abdominal cavity? If so, it could mean that the veteran has peritonitis
-is it taking the veteran longer than 25-30 minutes to drain before filling? This could mean that the veteran has fibrin in his/her catheter
-is it taking longer than 20 minutes to fill with new solution? This could also be a result of fibrin blocking the catheter
Another program specifically on peritoneal dialysis will be coming, soon. For today, we just wanted to give you the basics of how the PD catheter works.
It takes a multidisciplinary team of professionals together with patients to make a vascular access a success story. And Vascular Access Coordinator play a central role in coordination of the services necessary to maintain a patent vascular access – truly a Life-Line for each dialysis patient.
Nephro the Wonder Dog has a permanent cuffed hemodialysis catheter.
