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1
Vascular Access
Assessment,
Monitoring, and
Surveillance
Svetlana (Lana) Kacherova,
ESRD Network 18, QI Director
WebEx s...
2
Special Acknowledgement forSpecial Acknowledgement for
Content Contributions:Content Contributions:
RMS Lifeline, Inc.RM...
Session ObjectivesSession Objectives
 Project DescriptionProject Description
 Increase understanding of vascular accessI...
4
Vascular Access Challenges in theVascular Access Challenges in the
US.US.
 Major cause of morbidityMajor cause of morbi...
V551: Vascular Access MonitoringV551: Vascular Access Monitoring
 ““ The patient’s vascular access must beThe patient’s v...
V551: Vascular Access MonitoringV551: Vascular Access Monitoring
 Patient education should address self-Patient education...
V 551: Monitoring StrategiesV 551: Monitoring Strategies
 Physical examinationPhysical examination
 Observance of change...
V 551: Surveillance StrategiesV 551: Surveillance Strategies
 Include devise-based methods such asInclude devise-based me...
Documentation Requirements:Documentation Requirements:
 Medical record should show evidence ofMedical record should show ...
Additional Vascular Access RelatedAdditional Vascular Access Related
V-Tags:V-Tags:
 V 147 & V 148 – Infection ControlV 1...
11
V626 QAPI Condition StatementV626 QAPI Condition Statement
 The dialysis facility must develop, implement,The dialysis...
12
Interdisciplinary Team:Interdisciplinary Team:
Show MeShow Me
The Progress:The Progress:
Stenosis Monitoring Project: InclusionStenosis Monitoring Project: Inclusion
Criteria for Participating Facilities:Criteri...
14
15
16
Monitoring and Surveillance:Monitoring and Surveillance:
 Access DevelopmentAccess Development
 Infection rateInfection ...
Benefits of Access MonitoringBenefits of Access Monitoring
and Surveillanceand Surveillance
 Reduce incidence of thrombos...
Surveillance TechnologySurveillance Technology
 Intra Access FlowIntra Access Flow
 TransonicsTransonics
 Static Venous...
ScheduleSchedule
 Infection Incidence – dailyInfection Incidence – daily
 Developing Access – every weekDeveloping Acces...
Action points:Action points:
 Decreased Transonics Flow – FistulogramDecreased Transonics Flow – Fistulogram
 Access Inf...
22
K-DOQI GuidelinesK-DOQI Guidelines
 Kidney Disease Outcomes Quality InitiativeKidney Disease Outcomes Quality Initiati...
23
Guideline 2: Selection and PlacementGuideline 2: Selection and Placement
of Hemodialysis Accessof Hemodialysis Access
...
24
Guideline 4: Detection of Access Dysfunction:Guideline 4: Detection of Access Dysfunction:
Monitoring, Surveillance and...
25
Guideline 4: Detection of Access Dysfunction:Guideline 4: Detection of Access Dysfunction:
Monitoring, Surveillance and...
26
Look, Listen,
Feel
Angioplasty
Fistulagram
Thrombectomy
Continuum of Vascular Access Care
Assessment
Monitoring and
Sur...
27
Physical AssessmentPhysical Assessment
 Inspection (look)Inspection (look)
 Auscultation (listen)Auscultation (listen...
28
InspectionInspection
 RednessRedness
 DrainageDrainage
 AbscessAbscess
 Skin ColorSkin Color
 EdemaEdema
 Small b...
29
Is the Access Working Properly?Is the Access Working Properly?
 Clearances (URR) greater than 65Clearances (URR) great...
30
Is New AVF Mature? Use the KDOQIIs New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s”
6 - 8 week Post Op
Check AVF ...
31
Central Stenosis and Occluded VeinsCentral Stenosis and Occluded Veins
 Arm swellingArm swelling
 Prominent veins in ...
32
What Causes the Stenosis?What Causes the Stenosis?
 Scaring at the cannulation sites from poorScaring at the cannulati...
33
Physical Findings of VenousPhysical Findings of Venous
StenosisStenosis
PARAMETERPARAMETER NORMALNORMAL STENOSISSTENOSI...
34
Clinical Indicators of StenosisClinical Indicators of Stenosis
 Clotting the system 2 or more times/monthClotting the ...
35
What is Steal Syndrome?What is Steal Syndrome?
 Access “steals” blood from the handAccess “steals” blood from the hand...
36
Is Steal Syndrome Serious?Is Steal Syndrome Serious?
 Necrotic tissue can not be “fixed” – it mustNecrotic tissue can ...
37
Flow Methods in Dialysis AccessFlow Methods in Dialysis Access
 Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasou...
38
Color-Flow DopplerColor-Flow Doppler
 Outpatient radiological procedure doneOutpatient radiological procedure done
qua...
39
Ultrasound Dilution TechniqueUltrasound Dilution Technique
(Transonics)(Transonics)
 Conducted quarterly or as necessa...
Transonics Flow:Transonics Flow:
 AV Graft – once a month, if stable – everyAV Graft – once a month, if stable – every
2-...
41
Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)
 Conducted and recorded at the beginning ofConducted and re...
42
Static Venous Pressure (SVP)Static Venous Pressure (SVP)
 Following a unit-specific procedure forFollowing a unit-spec...
43
Other MethodsOther Methods
 On-Line-Clearance (OLC) – conductedOn-Line-Clearance (OLC) – conducted
quarterly – Freseni...
44
KDOQI Guideline 4: When to refer forKDOQI Guideline 4: When to refer for
evaluation (diagnosis) and treatment:evaluatio...
45
Medicare Guidelines for ReferralMedicare Guidelines for Referral
 Venous outflowVenous outflow
– Elevated venous press...
46
How often for Angioplasty?How often for Angioplasty?
 Some lesions are elasticSome lesions are elastic
 Once scar sta...
47
Why Angioplasty?Why Angioplasty?
 Improves blood flow for better dialysisImproves blood flow for better dialysis
 Dec...
48
All Patient should be taught how to:All Patient should be taught how to:
 Compress a bleeding accessCompress a bleedin...
49
All patients should know to:All patients should know to:
 Avoid carrying heavy items and wearing occlusiveAvoid carryi...
50
In ClosingIn Closing
 The patient’s dialysis access is his or herThe patient’s dialysis access is his or her
lifeline;...
Project Timelines:Project Timelines:
 To implement accepted monitoring andTo implement accepted monitoring and
surveillan...
QUESTIONS?QUESTIONS?
52
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  1. 1. 1 Vascular Access Assessment, Monitoring, and Surveillance Svetlana (Lana) Kacherova, ESRD Network 18, QI Director WebEx session, December 18, 2008
  2. 2. 2 Special Acknowledgement forSpecial Acknowledgement for Content Contributions:Content Contributions: RMS Lifeline, Inc.RMS Lifeline, Inc. DaVita, Inc.DaVita, Inc. John White, RN, Manager,John White, RN, Manager, Outreach and EducationOutreach and Education Irina Goykhman, RN, MBAIrina Goykhman, RN, MBA Lynda K. Ball, RN, BSN, CNNLynda K. Ball, RN, BSN, CNN QI Director, ESRD Network 16QI Director, ESRD Network 16 Y. Foli Sekyema, MDY. Foli Sekyema, MD Danville Urologic ClinicDanville Urologic Clinic
  3. 3. Session ObjectivesSession Objectives  Project DescriptionProject Description  Increase understanding of vascular accessIncrease understanding of vascular access monitoring and surveillance and new CFCmonitoring and surveillance and new CFC requirementsrequirements  Learn something newLearn something new 3
  4. 4. 4 Vascular Access Challenges in theVascular Access Challenges in the US.US.  Major cause of morbidityMajor cause of morbidity  Many lost HD hoursMany lost HD hours  Most Hospitalizations for HD patientsMost Hospitalizations for HD patients  High $ Cost to Health Care SystemHigh $ Cost to Health Care System  Current Medicare expenditures for ESRD are in excessCurrent Medicare expenditures for ESRD are in excess of $21 billion annually (5-7% of total Medicareof $21 billion annually (5-7% of total Medicare expenditures, for only 1% of Medicare beneficiariesexpenditures, for only 1% of Medicare beneficiaries  Best type least used in the US – AV FistulaBest type least used in the US – AV Fistula
  5. 5. V551: Vascular Access MonitoringV551: Vascular Access Monitoring  ““ The patient’s vascular access must beThe patient’s vascular access must be monitored to prevent access failure,monitored to prevent access failure, including monitoring of arteriovenous graftsincluding monitoring of arteriovenous grafts and fistulae so symptoms of stenosis”and fistulae so symptoms of stenosis”  ““The facility must have an on-goingThe facility must have an on-going program for vascular access monitoring andprogram for vascular access monitoring and surveillance for early detection of failure tosurveillance for early detection of failure to allow timely referral of patients forallow timely referral of patients for intervention when indications of significantintervention when indications of significant stenosis are present.”stenosis are present.” 5
  6. 6. V551: Vascular Access MonitoringV551: Vascular Access Monitoring  Patient education should address self-Patient education should address self- monitoring of the vascular access”monitoring of the vascular access” 6
  7. 7. V 551: Monitoring StrategiesV 551: Monitoring Strategies  Physical examinationPhysical examination  Observance of changes in adequacy or inObservance of changes in adequacy or in pressures measured during dialysis,pressures measured during dialysis, difficulties in cannulation or in achievingdifficulties in cannulation or in achieving hemostasishemostasis  Precipitating events should also be noted,Precipitating events should also be noted, such as hypotension and hypovolemiasuch as hypotension and hypovolemia 7
  8. 8. V 551: Surveillance StrategiesV 551: Surveillance Strategies  Include devise-based methods such asInclude devise-based methods such as access flow measurementaccess flow measurement  Direct or derived static venous pressureDirect or derived static venous pressure ratiosratios  Duplex ultrasound, etcDuplex ultrasound, etc 8
  9. 9. Documentation Requirements:Documentation Requirements:  Medical record should show evidence ofMedical record should show evidence of periodic monitoring and surveillance ofperiodic monitoring and surveillance of AVG or AVFAVG or AVF  Could be dialysis treatment record, progressCould be dialysis treatment record, progress notes, or a separate lognotes, or a separate log  A member of the facility staff must reviewA member of the facility staff must review the VA monitoring/surveillancethe VA monitoring/surveillance documentation to identify adverse trendsdocumentation to identify adverse trends and take action if indicatedand take action if indicated 9
  10. 10. Additional Vascular Access RelatedAdditional Vascular Access Related V-Tags:V-Tags:  V 147 & V 148 – Infection ControlV 147 & V 148 – Infection Control  V 551 – Patient assessment – evaluation ofV 551 – Patient assessment – evaluation of dialysis access type for maintenancedialysis access type for maintenance  V 633 – QAPI condition addressingV 633 – QAPI condition addressing vascular access monitoring and surveillancevascular access monitoring and surveillance 10
  11. 11. 11 V626 QAPI Condition StatementV626 QAPI Condition Statement  The dialysis facility must develop, implement,The dialysis facility must develop, implement, maintain and evaluate an effective, data driven,maintain and evaluate an effective, data driven, quality assessment and performance improvementquality assessment and performance improvement program with participation by the professionalprogram with participation by the professional members of the interdisciplinary team...members of the interdisciplinary team...  ……The dialysis facility must maintain andThe dialysis facility must maintain and demonstrate evidence of its qualitydemonstrate evidence of its quality improvement and performance improvementimprovement and performance improvement program for review by CMSprogram for review by CMS
  12. 12. 12 Interdisciplinary Team:Interdisciplinary Team: Show MeShow Me The Progress:The Progress:
  13. 13. Stenosis Monitoring Project: InclusionStenosis Monitoring Project: Inclusion Criteria for Participating Facilities:Criteria for Participating Facilities:  Based on the results of the 2008 StenosisBased on the results of the 2008 Stenosis Monitoring ScanMonitoring Scan  Facilities that either do not performFacilities that either do not perform monitoring and surveillance or performmonitoring and surveillance or perform dynamic venous pressure only (N= 15)dynamic venous pressure only (N= 15)  Facilities that did not respond to the scanFacilities that did not respond to the scan 13
  14. 14. 14
  15. 15. 15
  16. 16. 16
  17. 17. Monitoring and Surveillance:Monitoring and Surveillance:  Access DevelopmentAccess Development  Infection rateInfection rate  ThrombosisThrombosis  Other ComplicationsOther Complications 17
  18. 18. Benefits of Access MonitoringBenefits of Access Monitoring and Surveillanceand Surveillance  Reduce incidence of thrombosisReduce incidence of thrombosis  Extended access use-lifeExtended access use-life  Reduce time lost from HemodialysisReduce time lost from Hemodialysis  Reduce patient morbidity/hospitalizationsReduce patient morbidity/hospitalizations  Improve quality of lifeImprove quality of life  Reduce health care costsReduce health care costs 18
  19. 19. Surveillance TechnologySurveillance Technology  Intra Access FlowIntra Access Flow  TransonicsTransonics  Static Venous HD PressureStatic Venous HD Pressure  Dynamic Venous HD PressureDynamic Venous HD Pressure  Access recirculationAccess recirculation  Unexplained Decrease Delivered HDUnexplained Decrease Delivered HD  Doppler UltrasoundDoppler Ultrasound  Physical Exam of AccessPhysical Exam of Access ((arm swelling,arm swelling, prolonged bleeding, increased + venous pressureprolonged bleeding, increased + venous pressure or – arterial pressureor – arterial pressure
  20. 20. ScheduleSchedule  Infection Incidence – dailyInfection Incidence – daily  Developing Access – every weekDeveloping Access – every week  Vascular Access Conference – every monthVascular Access Conference – every month  Transonics Flow – each 1-2 monthsTransonics Flow – each 1-2 months  Team Meeting – every 2-3 monthsTeam Meeting – every 2-3 months  External expertise - periodicExternal expertise - periodic 20
  21. 21. Action points:Action points:  Decreased Transonics Flow – FistulogramDecreased Transonics Flow – Fistulogram  Access Infections?Access Infections?  Increased Attention to Detail by all HD staff !!!!Increased Attention to Detail by all HD staff !!!!  Identify Needs for More TrainingIdentify Needs for More Training  Identify Potential Physician TrendsIdentify Potential Physician Trends  Identify Potential HD Facility TrendsIdentify Potential HD Facility Trends  Allow Objective comparison with Regional andAllow Objective comparison with Regional and National AveragesNational Averages 21
  22. 22. 22 K-DOQI GuidelinesK-DOQI Guidelines  Kidney Disease Outcomes Quality InitiativeKidney Disease Outcomes Quality Initiative launched in 1995launched in 1995  Evidence-Based Clinical PracticeEvidence-Based Clinical Practice Guidelines for patients and health careGuidelines for patients and health care providersproviders  First Guidelines – 1997First Guidelines – 1997  Currently 22 topicsCurrently 22 topics  Three-stage review processThree-stage review process
  23. 23. 23 Guideline 2: Selection and PlacementGuideline 2: Selection and Placement of Hemodialysis Accessof Hemodialysis Access  2.1.1- Preferred: AV Fistulae (AVF)2.1.1- Preferred: AV Fistulae (AVF)  2.1.2- Accepted – AV Graft (AVG)2.1.2- Accepted – AV Graft (AVG)  2.1.3- Avoid if possible: Long-Term2.1.3- Avoid if possible: Long-Term CathetersCatheters  Fistula First Breakthrough Initiative (FFBI)Fistula First Breakthrough Initiative (FFBI) goal: 66% of hemodialysis patientsgoal: 66% of hemodialysis patients utilizing AVF by June 30, 2009utilizing AVF by June 30, 2009
  24. 24. 24 Guideline 4: Detection of Access Dysfunction:Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing.Monitoring, Surveillance and Diagnostic Testing.  4.1. Physical examination (monitoring)4.1. Physical examination (monitoring)  4.2. Surveillance of grafts (preferred)4.2. Surveillance of grafts (preferred) - Intra-access flow- Intra-access flow - Static venous pressure- Static venous pressure - Duplex ultrasound- Duplex ultrasound  Surveillance of grafts (acceptable)Surveillance of grafts (acceptable) - Physical findings- Physical findings  Unacceptable:Unacceptable: - Unstandardized dynamic venous pressure- Unstandardized dynamic venous pressure (DPVs) should not be used(DPVs) should not be used
  25. 25. 25 Guideline 4: Detection of Access Dysfunction:Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing.Monitoring, Surveillance and Diagnostic Testing.  Surveillance of fistulae (preferred)Surveillance of fistulae (preferred) - Direct Flow Measurements- Direct Flow Measurements - Physical findings- Physical findings - Duplex Ultrasound- Duplex Ultrasound  Surveillance of fistulae (acceptable)Surveillance of fistulae (acceptable) - Recirculation (using non-urea based- Recirculation (using non-urea based dilutional method)dilutional method) - Static pressure, direct or derived- Static pressure, direct or derived
  26. 26. 26 Look, Listen, Feel Angioplasty Fistulagram Thrombectomy Continuum of Vascular Access Care Assessment Monitoring and Surveillance Interventions Documentation “Everyday” Every shift, Every patient Vascular Access Program QI Static pressure DVP Recirculation
  27. 27. 27 Physical AssessmentPhysical Assessment  Inspection (look)Inspection (look)  Auscultation (listen)Auscultation (listen)  Palpation (feel)Palpation (feel) Use all of your senses for assessment and thenUse all of your senses for assessment and then use your memory to compare and contrast theuse your memory to compare and contrast the condition of the access to previous assessmentscondition of the access to previous assessments
  28. 28. 28 InspectionInspection  RednessRedness  DrainageDrainage  AbscessAbscess  Skin ColorSkin Color  EdemaEdema  Small blueSmall blue Purple veinsPurple veins  Hands: cold, painful,Hands: cold, painful, numbnumb  Fingers: discoloredFingers: discolored Infection Central or Outflow Vein stenosis Steal Syndrome
  29. 29. 29 Is the Access Working Properly?Is the Access Working Properly?  Clearances (URR) greater than 65Clearances (URR) greater than 65  Access flow greater than 600Access flow greater than 600  Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125  Able to run prescriptionAble to run prescription  Other signs and symptoms of access pathologyOther signs and symptoms of access pathology – RecirculationRecirculation – Difficulty cannulating and pain in the accessDifficulty cannulating and pain in the access – Changes in thrill and bruitChanges in thrill and bruit – Prolonged bleeding post-dialysisProlonged bleeding post-dialysis
  30. 30. 30 Is New AVF Mature? Use the KDOQIIs New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s” 6 - 8 week Post Op Check AVF Maturation Diameter Greater than 66 mm Depth below skin Approximately 66 mm Access Blood Flow Greater than 600600 mL/Min 6 cm of straight segment ““ Rule ofRule of 6’s ”6’s ” VeinVein MUSTMUST MatureMature PRIORPRIOR to theto the FIRSTFIRST cannulationcannulation
  31. 31. 31 Central Stenosis and Occluded VeinsCentral Stenosis and Occluded Veins  Arm swellingArm swelling  Prominent veins in the upper chestProminent veins in the upper chest  Prominent veins in the armProminent veins in the arm  Swollen neck and faceSwollen neck and face  Look for signs of catheter on access sideLook for signs of catheter on access side  Look for pacemaker or defibrillatorLook for pacemaker or defibrillator
  32. 32. 32 What Causes the Stenosis?What Causes the Stenosis?  Scaring at the cannulation sites from poorScaring at the cannulation sites from poor needle rotationneedle rotation  Scaring the vein from the high arterial flowsScaring the vein from the high arterial flows  Scaring from implanted devicesScaring from implanted devices  Aneurysm and pseudoaneurism formationAneurysm and pseudoaneurism formation  Manipulation of veinsManipulation of veins – Transpositions, translocationTranspositions, translocation
  33. 33. 33 Physical Findings of VenousPhysical Findings of Venous StenosisStenosis PARAMETERPARAMETER NORMALNORMAL STENOSISSTENOSIS ThrillThrill Only at theOnly at the arterialarterial anastamosisanastamosis At the site ofAt the site of stenotic lesionstenotic lesion PulsePulse Soft, easilySoft, easily compressiblecompressible Water-Water- hummerhummer BruitBruit Low pitch,Low pitch, continuous,continuous, diastolic &diastolic & systolicsystolic High-pitch,High-pitch, discontinuous,discontinuous, systolic onlysystolic only
  34. 34. 34 Clinical Indicators of StenosisClinical Indicators of Stenosis  Clotting the system 2 or more times/monthClotting the system 2 or more times/month  Difficult needle placementDifficult needle placement  Persistently swollen armPersistently swollen arm  Increased machine pressuresIncreased machine pressures  Difficult achieving hemostasis at the end ofDifficult achieving hemostasis at the end of treatmenttreatment  Decreased blood pump speedsDecreased blood pump speeds  Decreased Kt/V or URR (due to recirculation)Decreased Kt/V or URR (due to recirculation)
  35. 35. 35 What is Steal Syndrome?What is Steal Syndrome?  Access “steals” blood from the handAccess “steals” blood from the hand  Decreased blood supply to the handDecreased blood supply to the hand  Causes hypoxia (lack of oxygen) to theCauses hypoxia (lack of oxygen) to the tissues of the hand resulting in severe paintissues of the hand resulting in severe pain  Neurotic damage to the hand can occurNeurotic damage to the hand can occur  Without oxygen tissue dies and necrosisWithout oxygen tissue dies and necrosis occursoccurs
  36. 36. 36 Is Steal Syndrome Serious?Is Steal Syndrome Serious?  Necrotic tissue can not be “fixed” – it mustNecrotic tissue can not be “fixed” – it must be removed (amputated)be removed (amputated)  = Risk for infection= Risk for infection  = Risk for hospitalization= Risk for hospitalization  = Risk for death!= Risk for death!  The Allen Test (within 3 seconds youThe Allen Test (within 3 seconds you should see capillary refill)should see capillary refill)
  37. 37. 37 Flow Methods in Dialysis AccessFlow Methods in Dialysis Access  Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasound (DDU)  Magnetic Resonance Angiography (MRA)Magnetic Resonance Angiography (MRA)  Variable Flow Doppler UltrasoundVariable Flow Doppler Ultrasound  Ultrasound Dilution (Transonics): UDTUltrasound Dilution (Transonics): UDT  Crit-Line III or Crit-Line IICrit-Line III or Crit-Line II  Glucose Pump InfusionGlucose Pump Infusion  Urea DilutionUrea Dilution  Differential ConductivityDifferential Conductivity  In-line Dialysate (FMC) - DDIn-line Dialysate (FMC) - DD
  38. 38. 38 Color-Flow DopplerColor-Flow Doppler  Outpatient radiological procedure doneOutpatient radiological procedure done quarterlyquarterly  Also called duplex ultrasound or duplexAlso called duplex ultrasound or duplex Doppler studyDoppler study  Evaluates access flow patterns as well asEvaluates access flow patterns as well as areas of access stenosisareas of access stenosis
  39. 39. 39 Ultrasound Dilution TechniqueUltrasound Dilution Technique (Transonics)(Transonics)  Conducted quarterly or as necessaryConducted quarterly or as necessary  AKA Crit-Line III or Crit-line TKAAKA Crit-Line III or Crit-line TKA  Very popular, but not all facilities haveVery popular, but not all facilities have transonics on-sitetransonics on-site
  40. 40. Transonics Flow:Transonics Flow:  AV Graft – once a month, if stable – everyAV Graft – once a month, if stable – every 2-3 months.2-3 months.  AV Fistula – every 2-3 monthsAV Fistula – every 2-3 months  Flow:Flow: - < 600 ml/min every month with 15% -- < 600 ml/min every month with 15% - fistulogramfistulogram - > 1000 ml/min- > 1000 ml/min - 25% decrease- 25% decrease 40
  41. 41. 41 Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)  Conducted and recorded at the beginning ofConducted and recorded at the beginning of each treatment at aeach treatment at a specifiedspecified blood flow rateblood flow rate using specified/consistent needle sizeusing specified/consistent needle size  Non-standardized dynamic venous pressureNon-standardized dynamic venous pressure are consideredare considered as unacceptableas unacceptable monitoringmonitoring method by the K/DOQI workgroupmethod by the K/DOQI workgroup  Acceptable method forAcceptable method for AVFs only!AVFs only! (KDOQI 2006)(KDOQI 2006)
  42. 42. 42 Static Venous Pressure (SVP)Static Venous Pressure (SVP)  Following a unit-specific procedure forFollowing a unit-specific procedure for measurement of venous and arterialmeasurement of venous and arterial measures at zero blood flowmeasures at zero blood flow  Conducted at least every 2 weeksConducted at least every 2 weeks  Measurements plugged into mathematicalMeasurements plugged into mathematical formulaformula  Ratio > 0.5 is considered abnormalRatio > 0.5 is considered abnormal  Refer for fistulagram after 3 abnormalRefer for fistulagram after 3 abnormal readingsreadings
  43. 43. 43 Other MethodsOther Methods  On-Line-Clearance (OLC) – conductedOn-Line-Clearance (OLC) – conducted quarterly – Fresenious technology)quarterly – Fresenious technology)  Magnetic Resonance AngiographyMagnetic Resonance Angiography
  44. 44. 44 KDOQI Guideline 4: When to refer forKDOQI Guideline 4: When to refer for evaluation (diagnosis) and treatment:evaluation (diagnosis) and treatment:  Do not respond to a single isolated episodeDo not respond to a single isolated episode  Look for persistent abnormalitiesLook for persistent abnormalities  Access flow rate <600 mL.min for AVGAccess flow rate <600 mL.min for AVG and 400 to 500 mL/min in AVFand 400 to 500 mL/min in AVF  A venous segment static pressure (meanA venous segment static pressure (mean pressures) ratio > 0.5 n AVG or AVFpressures) ratio > 0.5 n AVG or AVF  An arterial segment static pressure ratio >An arterial segment static pressure ratio > 0.75 in AVG0.75 in AVG
  45. 45. 45 Medicare Guidelines for ReferralMedicare Guidelines for Referral  Venous outflowVenous outflow – Elevated venous pressureElevated venous pressure – Prolonged bleedingProlonged bleeding – Decreased URRDecreased URR – Decreased Kt/VDecreased Kt/V – RecirculationRecirculation – Swelling of the extremitySwelling of the extremity – Pulsatile graftPulsatile graft – Loss of thrillLoss of thrill – AneurysmsAneurysms – Difficult or painfulDifficult or painful cannulationcannulation  Arterial inflowArterial inflow – Low pressure in graft whenLow pressure in graft when outflow is occludedoutflow is occluded – Ischemic changes inIschemic changes in extremityextremity – Diminished intra-accessDiminished intra-access flow (AKA: arterial pullingflow (AKA: arterial pulling negative)negative)
  46. 46. 46 How often for Angioplasty?How often for Angioplasty?  Some lesions are elasticSome lesions are elastic  Once scar starts to grow, it continuesOnce scar starts to grow, it continues  Scar grows at a different paceScar grows at a different pace  Acceptable interval is approximately 6 monthsAcceptable interval is approximately 6 months  May be more often, depending on the caseMay be more often, depending on the case
  47. 47. 47 Why Angioplasty?Why Angioplasty?  Improves blood flow for better dialysisImproves blood flow for better dialysis  Decreased the rate of thrombosis of the accessDecreased the rate of thrombosis of the access  Prevents the need for surgeryPrevents the need for surgery  Extend the life of the access (from 2 to 7 years)Extend the life of the access (from 2 to 7 years)  There is a finite number of sites for an accessThere is a finite number of sites for an access
  48. 48. 48 All Patient should be taught how to:All Patient should be taught how to:  Compress a bleeding accessCompress a bleeding access  Wash skin over access with soap and water dailyWash skin over access with soap and water daily and before HDand before HD  Recognize s/s of infectionRecognize s/s of infection  Select proper methods for exercising fistula armSelect proper methods for exercising fistula arm with some resistance to venous flowwith some resistance to venous flow  Palpate for thrill/pulse dailyPalpate for thrill/pulse daily  Listen for bruit with ear opposite access if can’tListen for bruit with ear opposite access if can’t palpate for any reasonpalpate for any reason
  49. 49. 49 All patients should know to:All patients should know to:  Avoid carrying heavy items and wearing occlusiveAvoid carrying heavy items and wearing occlusive closing over accessclosing over access  Avoid sleeping on the access armAvoid sleeping on the access arm  Be aware of site rotation (unless buttonholeBe aware of site rotation (unless buttonhole cannulation method is used)cannulation method is used)  Be aware of proper skin preparation andBe aware of proper skin preparation and importance of staff wearing masksimportance of staff wearing masks  Report and s/s of infection and absence ofReport and s/s of infection and absence of bruit/thrill to staffbruit/thrill to staff immediatelyimmediately
  50. 50. 50 In ClosingIn Closing  The patient’s dialysis access is his or herThe patient’s dialysis access is his or her lifeline; it is the job of the entire team to try tolifeline; it is the job of the entire team to try to maintain it through routine monitoring andmaintain it through routine monitoring and surveillancesurveillance  Team education is keyTeam education is key  Patients who are able to should be taught how toPatients who are able to should be taught how to assess their own accessassess their own access  Listen to the patientListen to the patient  Follow up on the procedure reportFollow up on the procedure report
  51. 51. Project Timelines:Project Timelines:  To implement accepted monitoring andTo implement accepted monitoring and surveillance procedures by April 1, 2009.surveillance procedures by April 1, 2009.  To submit Policy & Procedure to theTo submit Policy & Procedure to the Network by April 15, 2009Network by April 15, 2009 51
  52. 52. QUESTIONS?QUESTIONS? 52

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