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A. Hemodialysis access of less than 3 weeks’ duration should be obtained using a noncuffed, or a cuffed, double-lumen percutaneously inserted catheter.

B. These catheters are suitable for immediate use and should not be inserted before needed.

C. Noncuffed catheters can be inserted at the bedside in the femoral, internal jugular, or subclavian position.

D. The subclavian insertion site should not be used in a patient who may need permanent vascular access.)

E. Chest x-ray is mandatory after subclavian and internal jugular insertion prior to catheter use to confirm catheter tip position at the caval atrial junction or the superior vena cava and to exclude complications prior to starting hemodialysis.

F. Where available, ultrasound should be used to direct insertion of these catheters into the internal jugular position to minimize insertion-related complications.

G. Femoral catheters should be at least 19-cm long to minimize recirculation. Noncuffed femoral catheters should not be left in place longer than 5 days and should be left in place only in bed-bound patients.

H. Nonfunctional noncuffed catheters can be exchanged over a guidewire or treated with Urokinase as long as the exit site and tunnel are not infected.

I. Exit site, tunnel tract, or systemic infections should prompt the removal of noncuffed catheters

A. Catheters

Veins used:

Indication

5. Patients for venovenous or arteriovenous continuous renal replacement therapy.

Contraindication of Subclavian and Internal jugular vein catheterization

1. Patients with acute respiratory distress (cannot be supine or in Trendelenberg position. 2. Patients with subclavian vein stenosis

Nursing management (Guide)

· All of these catheters are prone to infection therefore aseptic technique when initiating and terminating dialysis is of outmost importance.

· The caps and ports should be wrapped in a dressing soaked in Betadine for 5 minutes before initiating and ending dialysis.

· The exit site should be cleaned with Peroxide and Betadine after every treatment, and a sterile dressing should be applied. The appearance of the exit site especially redness or drainage must be documented

· Careful heparinization is necessary and should be guided by manufacturer's instruction and according to the size (or dead space) of each catheter. Indwelling heparin should be aspirated before dialysis to avoid excessive heparinization. A preferable method of maintaining catheter patency is the instillation of 1000-5000 U of heparin into the catheter immediately after dialysis. The volume necessary to deliver heparin depends on the size (dead space) of the catheter. Clamp the catheter firmly and once to avoid blood suction into the tip of the catheter by dropper action

· Do not attempt to instill saline into a clotted catheter. This will force the clot into the vascular system.

· Minimal handling of the catheter is strongly advocated, and then only experienced personnel. If the catheter is needed for parentral nutrition or blood transfusion a Leuer-lok connections should be used to prevent air embolus or blood loss.

Bases for cannula selection

1. Subclavian and internal jugular vein catheter can be lift in place for several weeks while femoral catheter almost always removed within 3 days.

2. Once subclavian and internal jugular vein catheters patient can be dialyzed as an outpatient while patient with femoral catheter must be hospitalized.

3. Femoral catheter is easily insertable while subclavian and internal jugular vein catheters insertion requires a skilled operator.

4. Complication from femoral catheterization usually minor and never life threatening in contrary to subclavian and internal jugular vein catheters insertion.

5. New femoral catheter insertion for each dialysis is the best approach in bacteraemic patients

Complications

Management of technical problems

1. Poor blood flow-Lowering patient's head if using subclavian or Jugular vein

3. Kinking -Replace the catheter if the catheter has been in place for less than

A. Tunneled cuffed venous catheters are the method of choice for temporary access of longer than 3 weeks’ duration. (They also are acceptable for access of shorter duration.) In addition, some patients who have exhausted all other access options require permanent access via tunneled cuffed catheters. For patients who have a primary AV fistula maturing, but need immediate hemodialysis, tunneled cuffed catheters are the access of choice. Catheters capable of rapid flow rates are preferred. (Evidence/Opinion)

B. The preferred insertion site for tunneled cuffed venous dialysis catheters is the right internal jugular vein. Other options include: the right external jugular vein, the left internal and external jugular veins, subclavian veins, femoral veins, or translumbar access to the inferior vena cava. Subclavian access should be used only when jugular options are not available. Tunneled cuffed catheters should not be placed on the same side as a maturing AV access, if possible. (Evidence)

C. Fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The catheter tip should be adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood flow. (Atrial positioning is only recommended for catheters composed of soft compliant material, such as silicone.) (Opinion)

D. Real-time ultrasound-guided insertion is recommended to reduce insertion-related complications. (Evidence/Opinion)

E. There is currently no proven advantage of one cuffed catheter design over another. Catheters capable of a rapid blood flow rate are preferred. Catheter choice should be based on local experience, goals for use, and cost. (Evidence/Opinion)

Permanent Vascular Access For Hemodialysis

Patient Evaluation Prior to Access Placement
Consideration	Relevance
Patient History
History of previous central venous catheter	Previous placement of a central venous catheter is associated with central venous stenosis.
Dominant arm	To minimize negative impact on quality of life, use of the nondominant arm is preferred.
History of pacemaker use	There is a correlation between pacemaker use and central venous stenosis.
History of severe congestive heart failure	Accesses may alter hemodynamics and cardiac output.
History of arterial or venous peripheral catheter	Previous placement of an arterial or venous peripheral catheter may have damaged target vasculature.
History of diabetes mellitus	Diabetes mellitus is associated with damage to vasculature necessary for internal accesses.
History of anticoagulant therapy or any coagulation disorder	Abnormal coagulation may cause clotting or problems with hemostasis of accesses.
Presence of comorbid conditions, such as malignancy or coronary artery disease, that limit patient’s life expectancy	Morbidity associated with placement and maintenance of certain accesses may not justify their use in some patients.
History of vascular access	Previously failed vascular accesses will limit available sites for accesses; the cause of a previous failure may influence planned access if the cause is still present.
History of heart valve disease or prosthesis	Rate of infection associated with specific access types should be considered.
History of previous arm, neck, or chest surgery/trauma	Vascular damage associated with previous surgery or trauma may limit viable access sites.
Anticipated renal transplant from living donor	Temporary access may be sufficient.
Physical Examination
Physical Examination of Arterial System
Character of peripheral pulses, supplemented by hand-held Doppler evaluation when indicated	An adequate arterial system is needed for access; the quality of the arterial system will influence the choice of access site.
Results of Allen test	Abnormal arterial flow pattern to the hand may contraindicate the creation of a radial-cephalic fistula.
Bilateral upper extremity blood pressures	Pressures determine suitability of arterial access in upper extremities.
Physical Examination of Venous System
Evaluation for edema .	Edema indicates venous outflow problems that may limit usefulness of the associated potential access site or extremity for access placement
Assessment of arm size comparability	Differential arm size may indicate inadequate veins or venous obstruction which should influence choice of access site.
Examination for collateral veins	Collateral veins are indicative of venous obstruction.
Tourniquet venous palpation with vein mapping	Palpation and mapping allow selection of ideal veins for access.
Examination for evidence of previous central or peripheral venous catheterization	Use of central venous catheters is associated with central venous stenosis; previous placement of venous catheters may have damaged target vasculature necessary for access.
Examination for evidence of arm, chest, or neck surgery/trauma	Vascular damage associated with previous surgery or trauma may limit access sites.
Cardiovascular Evaluation
Examination for evidence of heart failure	Accesses may alter cardiac output.

Arteriography is useful to avoid extremity ischemia in patients with diminished pulses in whom access in the extremity is still desired. However, the Work Group concluded that arteriography is only rarely required.

Venipucture in the non-dominant forearm should be minimized in patients with chronic renal failure

Permanent V. Access should be created when creatinin clearance drops to ~ 15 ml/minute or 3-6 months prior to initiation of hemodialysis.

The risk of subclavian vein stenosis in patient who have had previous subclavian catheter is high therefore angiographic assessment is recommended prior to access placement.

Types of permanent V. Access

The arteriovenous fistula consists of surgical anastomosis of an adjoining artery and vein. The diversion of the arterial blood causes the used veins to become enlarged and prominent and stronger because of the greater flow of the arterialized blood through them.

Selection of Permanent Vascular Access and Order of Preference for Placement of AV Fistulae (Guide 3 DOQI)

A. The order of preference for placement of AV fistulae in patients with kidney failure who will become hemodialysis dependent is:

B. If it is not possible to establish either of these types of fistula, access may be established using:

C. Cuffed tunneled central venous catheters should be discouraged as permanent vascular access.

Surgical Technique: The details of the surgical technique are beyond the scope of the Tips

a- A tourniquet may be placed around the upper arm to cause distention of the veins, leave it for about 30 minutes and may be repeated several time each day.

b- Hand exercise, such as squeezing rupper ball, while the tourniquet is in place.

B. Arteriovenous Graft (1974 / 1977)

Description: A biologic, semi biologic or prosthetic graft implanted subcutaneously and attached to an artery and vein. It is used in patients who do not have adequate vessels to create an arteriovenous fistula. It can be used after 2-3 weeks.

If a primary AV fistula cannot be established, a synthetic AV graft is the next preferred type of vascular access Grafts may be placed in straight, looped, or curved configurations. Designs that provide the most surface area for cannulation are preferred. Location of graft placement is determined by each patient's unique anatomical restrictions, the surgeons's skill, and the anticipated duration of dialysis)

1. Subcutaneous autogenous vein grafts. A segment of patient's own vein is attached to an artery a vein and used for dialysis after becomes prominent and healing.

2. Bovine grafts: Carotid artery from cattle is used after special processing.

3. Synthetic grafts: Many synthetic materials are available [Macron, Polytetfluoroethylene (PTFE)] inserted surgically and require 2 weeks to mature. Polytetrafluoroethylene (PTFE) tubes are preferred over other synthetic materials.

4. PTFE graft with transcutaneous device for needle free access. The system is accessed through self-sealing device with locking ring. A special set attaches to the blood tubing.

Surgical Technique: The details of the surgical technique are beyond the scope of the Tips

Access Maturation

A. A primary AV fistula is mature and suitable for use when the vein’s diameter is sufficient to allow successful cannulation, but not sooner than 1 month (and preferably 3 to 4 months after construction.)

1. Fistula hand-arm exercise (eg, squeezing a rubber ball with or without a lightly applied tourniquet) will increase blood flow and speed maturation of a new native AV fistula. (Opinion)

2. Selective obliteration of major venous side branches will speed the maturation of a slowly maturing AV fistula. (Opinion)

3. When a new native AV fistula is infiltrated (ie, presence of hematoma with associated induration and edema), it should be rested until swelling is resolved

C. PTFE dialysis AV grafts should not routinely be used until 14 days after placement. Cannulation of a new PTFE dialysis AV graft should not routinely be attempted, even 14 days or longer after placement, until swelling has gone down enough to allow palpation of the course of the graft. Ideally, 3 to 6 weeks should be allowed prior to cannulation of a new graft.

D. Patients with swelling that does not respond to arm elevation or that persists beyond 2 weeks after dialysis AV access placement should receive a venogram or other noncontrast study to evaluate central veins.

E. Cuffed and noncuffed hemodialysis catheters are suitable for immediate use and do not require maturation time. (Evidence)

Using Permanent Vascular Access

Poor vascular access is a limiting factor to patient survival on hemodilysis. Therefore great care must be taken to maintain adequate vascular access.

Kind of the needle

Sixteen, fifteen and fourteen gouge needles are used for hemodialysis. Smaller diameter (higher gouge) needles seriously limit the blood flow rate.

Higher flow rate may be possible by using bigger diameter needle, but at considerable increase in negative pressure which increased the possibility of sucking air into the system or damaging the intima of vessels. Resistance to the flow occurs in long needles, therefore the shortest practical needle is desirable.

Placing The Needle in the Access:

3-Localize the fistula or graft; depth ; angulations ; maximum thrill ; and site of insertion ; hence the angle of needle insertion is decided (~ 45 degree).

3-Insert the inlet (Arterial) needle proximal to the fistula or close to arterial anastomosis of the graft by 3 cm at least, to avoid intimal damage and the subsequent thrombosis.

4-The return ( venous )needle should inserted pointing toward the heart approximately 5 cm proximal to the arterial needle. This opposite direction meant to avoid recirculation. Such event may be undetected , the patient gets poor dialysis.

A-Black blood syndrome : When recirculation is quite severe the blood becomes very acidic (pH <7 ) the RBCs cannot carry oxygen and the blood appears very

B-If venous needle cannot be inserted ,often vein can be found in another limb or single needle technique to be used.

C-Insert the needles at least 2 cm or more from the previous sites each time to ensure complete healing of the vein.

D-Initiate heparenization after insertion of both needle,.( to avoid hematoma ).

Removing the needle

It is important to maintain adequate pressure either by hand or tight pressure dressing over the puncture site for 15-20 minutes after needles is removed.

Care required between dialysis

1-Good hygienic condition is important. Instruct the patient to wash fistula arm with water and soap predialysis.

Acute Hemodialysis Vascular Access

Tunneled Cuffed Catheter Placement

Permanent Vascular Access For Hemodialysis

A. Catheters

Veins used:

Indication

Contraindication of Subclavian and Internal jugular vein catheterization

Nursing management (Guide)

Bases for cannula selection

Complications

Management of technical problems

Permanent Vascular Access For Hemodialysis

Types of permanent V. Access

B. Arteriovenous Graft (1974 / 1977)

Access Maturation

Using Permanent Vascular Access

Kind of the needle

Placing The Needle in the Access:

Removing the needle

Care required between dialysis