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Vascular Access Assessment,

Monitoring, and Surveillance

Svetlana (Lana) Kacherova, RN, MPH, CPHQ

ESRD Network 18, QI Director

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Special Acknowledgement forSpecial Acknowledgement forContent 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, MBALynda K. Ball, RN, BSN, CNNLynda K. Ball, RN, BSN, CNNQI Director, ESRD Network 16QI Director, ESRD Network 16

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Today’s Challenges in Vascular Today’s Challenges in Vascular AccessAccess

Leading cause of hospitalization in the ESRD Leading cause of hospitalization in the ESRD population population Annual cost approaching $1.5 billion (USRDS, 2004)Annual cost approaching $1.5 billion (USRDS, 2004)Current Medicare expenditures for ESRD are in excess Current Medicare expenditures for ESRD are in excess of $21 billion annually (5of $21 billion annually (5--7% of total Medicare 7% of total Medicare expenditures, for only 1% of Medicare beneficiariesexpenditures, for only 1% of Medicare beneficiariesAging population with diabetes as the leading cause of Aging population with diabetes as the leading cause of ESRDESRDOur patients need an access that works better and lasts Our patients need an access that works better and lasts longer… longer… with less pain and suffering!with less pain and suffering!

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KK--DOQI GuidelinesDOQI Guidelines

Kidney Disease Outcomes Quality Initiative Kidney Disease Outcomes Quality Initiative launched in 1995launched in 1995EvidenceEvidence--Based Clinical Practice Based Clinical Practice Guidelines for patients and health care Guidelines for patients and health care providersprovidersFirst Guidelines First Guidelines –– 19971997Currently 22 topicsCurrently 22 topicsThreeThree--stage review processstage review process

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Guideline 2: Selection and Placement Guideline 2: Selection and Placement of Hemodialysis Accessof Hemodialysis Access

2.1.12.1.1-- Preferred: AV Fistulae (AVF)Preferred: AV Fistulae (AVF)2.1.22.1.2-- Accepted Accepted –– AV Graft (AVG)AV Graft (AVG)2.1.32.1.3-- Avoid if possible: LongAvoid if possible: Long--Term Term CathetersCatheters

Fistula First Breakthrough Initiative (FFBI) Fistula First Breakthrough Initiative (FFBI) goal: 66% of hemodialysis patients goal: 66% of hemodialysis patients utilizing AVF by June 30, 2009utilizing AVF by June 30, 2009

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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)

-- IntraIntra--access flowaccess flow-- Static venous pressureStatic venous pressure-- Duplex ultrasoundDuplex ultrasoundSurveillance of grafts (acceptable)Surveillance of grafts (acceptable)

-- Physical findingsPhysical findingsUnacceptable:Unacceptable:

-- UnstandardizedUnstandardized dynamic venous pressure dynamic venous pressure ((DPVsDPVs) should not be used) should not be used

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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 MeasurementsDirect Flow Measurements-- Physical findingsPhysical findings-- Duplex UltrasoundDuplex UltrasoundSurveillance of fistulae (acceptable)Surveillance of fistulae (acceptable)

-- Recirculation (using nonRecirculation (using non--urea basedurea baseddilutional method)dilutional method)

-- Static pressure, direct or derivedStatic pressure, direct or derived

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Look, Listen,

Feel

AngioplastyFistulagram

Thrombectomy

Continuum of Vascular Access Care

Assessment

Monitoring and Surveillance

Interventions

Documentation

“Everyday” Every shift,

Every patient

Vascular AccessProgram

QAStatic pressure

DVPRecirculation

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What Type of Access?What Type of Access?

How do I know if it is a fistula or graft?How do I know if it is a fistula or graft?–– Look for surgical scars at the wrist, upper arm and Look for surgical scars at the wrist, upper arm and

arm pitarm pit

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Forearm AccessForearm Access

GraftGraft–– Horseshoe shapeHorseshoe shape–– Two scarsTwo scars–– Occlude to find arteryOcclude to find artery

FistulaFistula–– Usually straightUsually straight–– One scar at the wristOne scar at the wrist–– Artery is distalArtery is distal

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Upper Arm AccessUpper Arm AccessGraftGraft–– Two scars: one at the venous anastomosis and one at the Two scars: one at the venous anastomosis and one at the

arterial anastomosisarterial anastomosis–– Usually straight or CUsually straight or C--shapedshaped–– Rarely a loopRarely a loop–– Arterial is distalArterial is distal

FistulaFistula–– One scar at the One scar at the anticubitalanticubital--cephalic veincephalic vein–– Long scar that runs the length of the arm Long scar that runs the length of the arm –– basilic vein basilic vein

transposedtransposed–– Other uncommonOther uncommon–– Arterial is distalArterial is distal

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CEPHALIC VEINCEPHALIC VEIN

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TRANSPOSED BASILICTRANSPOSED BASILIC

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Other Access TypesOther Access TypesThigh graftThigh graftThigh fistulaThigh fistulaChest loop graftChest loop graft

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Physical AssessmentPhysical AssessmentInspection (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 thenuse 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

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Inspection: Inspection: LookLook–– General developmentGeneral development-- AVFAVF–– Skin conditionSkin condition–– ?? Aneurysms/ Pseudoaneurysms?? Aneurysms/ Pseudoaneurysms–– Skin color of extremities (warm and dry)Skin color of extremities (warm and dry)–– Any swelling ( is there symmetry)Any swelling ( is there symmetry)–– Any sign of infectionAny sign of infection–– Capillary refill < 2Capillary refill < 2--3 seconds, look for ischemic 3 seconds, look for ischemic

spots on finger tipsspots on finger tips

InspectionInspection

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InspectionInspection

RednessRednessDrainageDrainageAbscessAbscess

Skin ColorSkin ColorEdemaEdemaSmall blue Small blue

Purple veinsPurple veins

Hands: cold, painful, Hands: cold, painful, numbnumbFingers: discoloredFingers: discolored

Infection

Central or Outflow

Veinstenosis

Steal Syndrome

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AuscultationAuscultation

Auscultation: Auscultation: ListenListen–– Quality and amplitude of bruitQuality and amplitude of bruit–– Note pitch changes Note pitch changes –– Systolic and diastolic are louder on the arterial Systolic and diastolic are louder on the arterial

sideside–– Pitch changes at areas of stenosisPitch changes at areas of stenosis–– Whistle or cough sound in the accessWhistle or cough sound in the access

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PalpationPalpation

Palpation: Palpation: FeelFeel–– Thrill or pulsation Thrill or pulsation –– Normally a thrill present at the anatomists site, Normally a thrill present at the anatomists site,

and disappears after you manually occlude the and disappears after you manually occlude the AVFAVF

–– If thrill remains = accessory veinsIf thrill remains = accessory veins–– The thrill should lessen going to the venous The thrill should lessen going to the venous

limb of the accesslimb of the access–– Thrill can be felt at the site of stenosisThrill can be felt at the site of stenosis

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Palpation (cont).Palpation (cont).

Vein DiameterVein Diameter-- Feel the entire length of the AVFFeel the entire length of the AVF-- Evaluate for needle site selectionEvaluate for needle site selection-- Check for flat spots Check for flat spots –– you can see ayou can see a

stenosis and feel its thrillstenosis and feel its thrill-- Evaluate if new AVF is ready to Evaluate if new AVF is ready to

cannulatecannulate

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Fistula ExamFistula ExamRaise the access arm above the heartRaise the access arm above the heart–– The fistula should completely collapseThe fistula should completely collapse–– Stenosis located at area of engorgementStenosis located at area of engorgement–– Evaluate arterial inflowEvaluate arterial inflow

The Allen Test The Allen Test

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Is the Access Working Properly?Is the Access Working Properly?

Clearances (URR) greater than 65Clearances (URR) greater than 65Access flow greater than 600Access flow greater than 600Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125Able to run prescriptionAble to run prescriptionOther signs and symptoms of access pathologyOther signs and symptoms of access pathology–– RecirculationRecirculation–– Difficulty Difficulty cannulatingcannulating and pain in the accessand pain in the access–– Changes in thrill and bruitChanges in thrill and bruit–– Prolonged bleeding postProlonged bleeding post--dialysisdialysis

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Is New AVF Mature? Use the KDOQI Is New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s”

6 - 8 week Post OpCheck AVF Maturation

Diameter Greater than

66 mm

Depth below skin Approximately

6 6 mm

Access Blood FlowGreater than

600 600 mL/Min

6 cm of straight segment

“ Rule of 6’s ”“ Rule of 6’s ”

Vein Vein MUSTMUST Mature Mature PRIORPRIOR to the to the FIRSTFIRST cannulationcannulation

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Central Stenosis and Occluded VeinsCentral Stenosis and Occluded Veins

Arm swellingArm swellingProminent veins in the upper chestProminent veins in the upper chestProminent veins in the armProminent veins in the armSwollen neck and faceSwollen neck and faceLook for signs of catheter on access sideLook for signs of catheter on access sideLook for pacemaker or defibrillatorLook for pacemaker or defibrillator

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What Causes the Stenosis?What Causes the Stenosis?

Scaring at the cannulation sites from poor Scaring at the cannulation sites from poor needle rotationneedle rotationScaring the vein from the high arterial flowsScaring the vein from the high arterial flowsScaring from implanted devicesScaring from implanted devicesAneurysm and pseudoaneurism formationAneurysm and pseudoaneurism formationManipulation of veinsManipulation of veins–– Transpositions, translocationTranspositions, translocation

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Physical Findings of Venous Physical Findings of Venous StenosisStenosis

HighHigh--pitch, pitch, discontinuous, discontinuous, systolic onlysystolic only

Low pitch, Low pitch, continuous, continuous, diastolic & diastolic & systolicsystolic

BruitBruit

WaterWater--hummerhummer

Soft, easily Soft, easily compressiblecompressible

PulsePulse

At the site of At the site of stenotic lesionstenotic lesion

Only at the Only at the arterial arterial anastamosisanastamosis

ThrillThrill

STENOSISSTENOSISNORMALNORMALPARAMETERPARAMETER

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Clinical Indicators of StenosisClinical Indicators of Stenosis

Clotting the system 2 or more times/monthClotting the system 2 or more times/monthDifficult needle placementDifficult needle placementPersistently swollen armPersistently swollen armIncreased machine pressuresIncreased machine pressuresDifficult achieving hemostasis at the end of Difficult achieving hemostasis at the end of treatmenttreatmentDecreased blood pump speedsDecreased blood pump speedsDecreased Kt/V or URR (due to recirculation)Decreased Kt/V or URR (due to recirculation)

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What is Steal Syndrome?What is Steal Syndrome?

Access “steals” blood from the handAccess “steals” blood from the handDecreased blood supply to the handDecreased blood supply to the handCauses hypoxia (lack of oxygen) to the Causes hypoxia (lack of oxygen) to the tissues of the hand resulting in severe paintissues of the hand resulting in severe painNeurotic damage to the hand can occurNeurotic damage to the hand can occurWithout oxygen tissue dies and necrosis Without oxygen tissue dies and necrosis occursoccurs

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Is Steal Syndrome Serious?Is Steal Syndrome Serious?

Necrotic tissue can not be “fixed” Necrotic tissue can not be “fixed” –– it must 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 you The Allen Test (within 3 seconds you should see capillary refill)should see capillary refill)

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Vascular Access ComplicationsVascular Access Complications

Infiltrations/ Hematoma Infiltrations/ Hematoma formationformation–– Needle punctures the Needle punctures the

other side of the vesselother side of the vessel–– Blood leaks out into Blood leaks out into

tissuestissuesPreventionPrevention–– Correct cannulation Correct cannulation

techniquetechnique–– Get help when you need Get help when you need

it!it!

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InfiltrationsInfiltrations

During cannulationDuring cannulation–– Remove needle and wait for bleeding to stop.Remove needle and wait for bleeding to stop.–– Where do you insert new needle?Where do you insert new needle?

During dialysisDuring dialysis–– Do not remove old needleDo not remove old needle–– Recirculate blood while inserting new needleRecirculate blood while inserting new needle–– Where do you insert new needle?Where do you insert new needle?–– Apply ice to hematomaApply ice to hematoma

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What’s Wrong with this Picture?What’s Wrong with this Picture?

Aneurysms (fistulas)Aneurysms (fistulas)Pseudoaneurysms (grafts)Pseudoaneurysms (grafts)–– Repeated cannulation Repeated cannulation

at same siteat same site–– Unsealed needle Unsealed needle

puncture sitespuncture sites–– Cause stenosis Cause stenosis

formation because of formation because of turbulenceturbulence

PreventionPrevention–– Site rotation!!Site rotation!!–– Assure hemostasis at Assure hemostasis at

end of treatmentend of treatment

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What’s Wrong with this Picture?What’s Wrong with this Picture?

InfectionsInfections–– Poor skin Poor skin

preparationpreparation–– Break in aseptic Break in aseptic

techniquetechnique–– Poor patient Poor patient

hygienehygienePreventionPrevention–– Proper site prepProper site prep

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Bleeding during dialysisBleeding during dialysis–– Rotated needlesRotated needles–– Manipulation of needlesManipulation of needles

RecirculationRecirculation–– StenosisStenosis–– Needles too close togetherNeedles too close together

Complications (cont).Complications (cont).

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Explanted GraftExplanted Graft

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What’s Wrong with this Picture?What’s Wrong with this Picture?

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Site PreparationSite Preparation& Cannulation& Cannulation

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Site PreparationSite Preparation

The patient should The patient should wash their access with wash their access with antibacterial soap antibacterial soap before coming to their before coming to their chairchairStaph is the leading Staph is the leading cause of infection in cause of infection in dialysis patients dialysis patients (CDC)(CDC)

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Site Preparation (cont).Site Preparation (cont).

Assess flow pattern Assess flow pattern –– Gently depress the Gently depress the

graft at the curve graft at the curve (or midpoint of a (or midpoint of a straight graft)straight graft)

–– How do you know How do you know which is the arterial which is the arterial side?side?

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Site Preparation (cont).Site Preparation (cont).

Proper needle site Proper needle site preparation reduces infection preparation reduces infection ratesratesClean sites using concentric Clean sites using concentric circlescirclesClean with Clean with betadinebetadine or other or other germicidal agentgermicidal agent–– How long do you wait How long do you wait

before inserting needles?before inserting needles?What do you do if your What do you do if your patient is allergic to patient is allergic to betadine?betadine?

Once you have preparedOnce you have prepared

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Prior to CannulationPrior to Cannulation

Inject or apply local Inject or apply local anesthesia, if anesthesia, if applicableapplicablePrepare cannulation Prepare cannulation needle, remove capneedle, remove capWith free hand With free hand stabilize the access stabilize the access without touching the without touching the cleaned sitescleaned sites

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CannulationCannulation

Insert the needle (bevel up) at a 40 to 45 ºangle Insert the needle (bevel up) at a 40 to 45 ºangle until a “flashback” of blood is visible (25 until a “flashback” of blood is visible (25 -- 30 º 30 º for AVF)for AVF)Reduce angle and advance needle to hubReduce angle and advance needle to hub

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CannulationCannulation

“Flip for a cause and “Flip for a cause and not just because”not just because”There should be no There should be no resistance or painresistance or painSecure needle with tape Secure needle with tape and cover exit site with and cover exit site with appropriate dressingappropriate dressing

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Always place the venous needle WITH the Always place the venous needle WITH the flow of bloodflow of bloodAlways keep the tips of the needles at least Always keep the tips of the needles at least 2 inches apart to prevent recirculation2 inches apart to prevent recirculationAlways keep the needles at least 1½ inches Always keep the needles at least 1½ inches away from the anastomosis siteaway from the anastomosis siteAlways rotate the puncture sites allowing Always rotate the puncture sites allowing 14 days for healing 14 days for healing Apply a clean tourniquet when Apply a clean tourniquet when cannulatingcannulatingan AVFan AVF

Cannulation RulesCannulation Rules

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Always determine the flow pattern of a loop Always determine the flow pattern of a loop graft prior to needle placementgraft prior to needle placementAlways assess for patency Always assess for patency Never “stick” a hematomaNever “stick” a hematomaNever “stick” an infected areaNever “stick” an infected areaNever “stick” an aneurysm or Never “stick” an aneurysm or pseudoaneurysmpseudoaneurysm

Cannulation Rules (cont).Cannulation Rules (cont).

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Needle RemovalNeedle Removal

Remove at same angle it went inRemove at same angle it went in“Flip” to original position if needle was “Flip” to original position if needle was “flipped” at initiation of treatment“flipped” at initiation of treatmentDo not apply pressure until needle is all the way Do not apply pressure until needle is all the way outout

Correct “flap” formation with good technique

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Needle RemovalNeedle RemovalPressurePressure–– Cover both skin insertion site Cover both skin insertion site

and graft insertion siteand graft insertion siteClampsClamps–– Use of clamps requires MD Use of clamps requires MD

orderorder–– Must be removed and site Must be removed and site

checked for stasis (clotting) checked for stasis (clotting) every 10 minutesevery 10 minutes

Agents used for access stasis (in Agents used for access stasis (in case of prolonged bleeding: > 30 case of prolonged bleeding: > 30 min)min)–– Gelfoam, for exampleGelfoam, for example

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Buttonhole Cannulation TechniqueButtonhole Cannulation Technique

For native AV Fistulas onlyFor native AV Fistulas onlySticking the same site using the same angle and Sticking the same site using the same angle and depth every timedepth every timeRequires the same “sticker” until the track is Requires the same “sticker” until the track is formed (8 sticks, 12 for diabetics)formed (8 sticks, 12 for diabetics)Scab removal: disinfected tweezers or normal size Scab removal: disinfected tweezers or normal size salinesaline--soaked 2x2’ssoaked 2x2’sUse a cannulation log for each needleUse a cannulation log for each needleChange to blunt needle once the track is formed so Change to blunt needle once the track is formed so scar tissue is not cut, causing bleeding or hole scar tissue is not cut, causing bleeding or hole enlargementenlargement

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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 Ultrasound Variable Flow Doppler Ultrasound Ultrasound Dilution (Transonics): UDTUltrasound Dilution (Transonics): UDTCritCrit--Line III or Line III or CritCrit--Line IILine IIGlucose Pump InfusionGlucose Pump InfusionUrea DilutionUrea DilutionDifferential Conductivity (Differential Conductivity (GambroGambro) (HDM)) (HDM)InIn--line Dialysate (FMC) line Dialysate (FMC) -- DDDD

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Stenosis monitoring Environmental Scan Stenosis monitoring Environmental Scan Results (ESRD Network 18)Results (ESRD Network 18)

Facilities responded to scan Facilities responded to scan -- 189189Facilities not performing stenosis monitoring Facilities not performing stenosis monitoring –– 2929Duplex Doppler Ultrasound (DDU) Duplex Doppler Ultrasound (DDU) –– 2222Magnetic Resonance Angiography (MRA) Magnetic Resonance Angiography (MRA) -- 99Variable Flow Doppler Ultrasound Variable Flow Doppler Ultrasound -- 77Ultrasound Dilution (Transonics): UDT Ultrasound Dilution (Transonics): UDT -- 4141CritCrit--Line III Line III --1414CritCrit--Line II Line II -- 11InIn--line Dialysate (FMC) line Dialysate (FMC) –– 5656Other: Dynamic Venous Pressure Other: Dynamic Venous Pressure –– 3030Other Other -- 99

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ColorColor--Flow DopplerFlow Doppler

Outpatient radiological procedure done Outpatient radiological procedure done quarterlyquarterlyAlso called duplex ultrasound or duplex Also called duplex ultrasound or duplex Doppler studyDoppler studyEvaluates access flow patterns as well as Evaluates access flow patterns as well as areas of access stenosisareas of access stenosis

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Ultrasound Dilution Technique Ultrasound Dilution Technique (Transonics)(Transonics)

Conducted quarterly or as necessaryConducted quarterly or as necessaryAKA AKA CritCrit--Line III or Line III or CritCrit--line TKAline TKAVery popular, but not all facilities have Very popular, but not all facilities have transonics ontransonics on--sitesite

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Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)

Conducted and recorded at the beginning of Conducted and recorded at the beginning of each treatment at a each treatment at a specifiedspecified blood flow rate blood flow rate using specified/consistent needle sizeusing specified/consistent needle sizeNonNon--standardized dynamic venous pressure standardized dynamic venous pressure

are considered as unacceptable monitoring are considered as unacceptable monitoring method by the K/DOQI workgroupmethod by the K/DOQI workgroupAcceptable method for Acceptable method for AVFs only! AVFs only! (KDOQI 2006)(KDOQI 2006)

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Static Venous Pressure (SVP)Static Venous Pressure (SVP)

Following a unitFollowing a unit--specific procedure for specific procedure for measurement of venous and arterial measurement of venous and arterial measures at zero blood flowmeasures at zero blood flowConducted at least every 2 weeksConducted at least every 2 weeksMeasurements plugged into mathematical Measurements plugged into mathematical formulaformulaRatio > 0.5 is considered abnormalRatio > 0.5 is considered abnormalRefer for fistulagram after 3 abnormal Refer for fistulagram after 3 abnormal readings readings

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Other MethodsOther Methods

OnOn--LineLine--Clearance (OLC) Clearance (OLC) –– conducted conducted quarterly quarterly –– Fresenious technology)Fresenious technology)Magnetic Resonance AngiographyMagnetic Resonance Angiography

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Access Assessment Flow SheetAccess Assessment Flow SheetFistula or GraftFistula or Graft

Step 1:

Step 2:

Step 3:

Step 4:

Attempt cannulation

Perform dialysis

Yes

Yes

Yes

No

No

Refer for evaluationNo

Good Thrill and Bruit?

Good gentle pulse

throughout?

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Access Assessment Flow SheetAccess Assessment Flow SheetCatheterCatheter

Step 1:

Step 2:

Step 3:

Step 4:

Exit site clean without drainage

or redness?

Cuff exposed or extruding?

Aspirating air from catheter?

Neck, facial or extremity swelling?

Yes

Yes

Yes

No

No

Refer for evaluation

No

Perform dialysisStep 5:

No

See catheter infection

Yes

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Fistula or GraftFistula or Graft

IDEALIDEAL400 400 –– 500 ml/min500 ml/min

BORDERLINEBORDERLINE350350--400 ml/min400 ml/min

Refer for evaluation if URR < 70,Refer for evaluation if URR < 70,abnormal or decreasing Transonicabnormal or decreasing Transonic

SUBOPTIMALSUBOPTIMAL< 350 ml/min< 350 ml/min

Refer for evaluation if needles and sites have Refer for evaluation if needles and sites have been adjusted and continue to be a problem. been adjusted and continue to be a problem.

Abnormal venous pressures and falling Abnormal venous pressures and falling Transonic values Transonic values MAYMAY be an indication of be an indication of

early fistula/graft failureearly fistula/graft failure

Prolonged bleeding post dialysis or oozing Prolonged bleeding post dialysis or oozing from puncture sites while needles are infrom puncture sites while needles are inHematoma formationHematoma formationHyperpulsalityHyperpulsality or wateror water--hammer pulsehammer pulseHigh pitched bruit, especially systolicHigh pitched bruit, especially systolic--only bruitonly bruitDifficult or unusually painful cannulationDifficult or unusually painful cannulationHypoperfusionHypoperfusion of hand (cold, weak or of hand (cold, weak or painful hand)painful hand)Painful dialysisPainful dialysisPulling clotsPulling clotsArm swellingArm swellingNew or worsening aneurysm (avoid New or worsening aneurysm (avoid sticking this area and run patient)sticking this area and run patient)Elevated venous pressure on more than Elevated venous pressure on more than one occurrenceone occurrenceAbnormal or decreasing TransonicAbnormal or decreasing TransonicImmature access 4Immature access 4--6 weeks6 weeks

Blood Flow Assessment Indications for Evaluation

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CatheterCatheter

IDEALIDEAL> 350 ml/min> 350 ml/min

BORDERLINEBORDERLINE300300--350 ml/min350 ml/min

Refer for catheter change if URR < 70Refer for catheter change if URR < 70

SUBOPTIMALSUBOPTIMAL250250--300 ml/min300 ml/min

Refer for catheter change if URR < 70Refer for catheter change if URR < 70

POORPOOR< 250 ml/min< 250 ml/min

Activase per your center protocol, if no help Activase per your center protocol, if no help refer for catheter change. If Activase is refer for catheter change. If Activase is

needed more than once per month, patient needed more than once per month, patient NEEDSNEEDS a catheter changea catheter change

EXIT SITE / TUNNEL INFECTIONEXIT SITE / TUNNEL INFECTIONExit site red with drainage?Exit site red with drainage?YesYes –– culture site, blood culture x 2 and notify culture site, blood culture x 2 and notify MDMD

Exit site with drainage Exit site with drainage ANDAND catheter tunnel catheter tunnel red and painful?red and painful?YesYes –– culture site, blood culture x 2, notify culture site, blood culture x 2, notify MD and schedule catheter removalMD and schedule catheter removal

POSITIVE BLOOD CULTURESPOSITIVE BLOOD CULTURESAsymptomatic bacteremia with Coag Neg Asymptomatic bacteremia with Coag Neg Staff and Staff and NONO exit site/tunnel infection?exit site/tunnel infection?YesYes –– refer for catheter exchange after refer for catheter exchange after antibioticsantibiotics

Staph Areus or Gram negative bacteremia?Staph Areus or Gram negative bacteremia?YesYes –– refer for catheter removal and refer for catheter removal and replacement on separate days after antibioticsreplacement on separate days after antibiotics

Blood Flow Assessment Catheter Infections

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KDOQI Guideline 4: When to refer for KDOQI 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 episodeLook for persistent abnormalitiesLook for persistent abnormalitiesAccess flow rate <600 Access flow rate <600 mLmL.min for AVG .min for AVG and 400 to 500 and 400 to 500 mLmL/min in AVF/min in AVFA venous segment static pressure (mean A venous segment static pressure (mean pressures) ratio > 0.5 n AVG or AVFpressures) ratio > 0.5 n AVG or AVFAn arterial segment static pressure ratio > An arterial segment static pressure ratio > 0.75 in AVG 0.75 in AVG

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Medicare Guidelines for ReferralMedicare Guidelines for ReferralVenous 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–– PulsatilePulsatile graftgraft–– Loss of thrillLoss of thrill–– AneurysmsAneurysms–– Difficult or painful Difficult or painful

cannulationcannulation

Arterial inflowArterial inflow–– Low pressure in graft when Low pressure in graft when

outflow is occludedoutflow is occluded–– Ischemic changes in Ischemic changes in

extremityextremity–– Diminished intraDiminished intra--access access

flow (AKA: arterial pulling flow (AKA: arterial pulling negative)negative)

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How often for Angioplasty?How often for Angioplasty?

Some lesions are elasticSome lesions are elasticOnce scar starts to grow, it continuesOnce scar starts to grow, it continuesScar grows at a different paceScar grows at a different paceAcceptable interval is approximately 6 monthsAcceptable interval is approximately 6 monthsMay be more often, depending on the caseMay be more often, depending on the case

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Why Angioplasty?Why Angioplasty?Improves blood flow for better dialysisImproves blood flow for better dialysisDecreased the rate of thrombosis of the accessDecreased the rate of thrombosis of the accessPrevents the need for surgeryPrevents the need for surgeryExtend 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

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All Patient should be taught how to:All Patient should be taught how to:

Compress a bleeding accessCompress a bleeding accessWash skin over access with soap and water daily Wash skin over access with soap and water daily and before HDand before HDRecognize s/s of infectionRecognize s/s of infectionSelect proper methods for exercising fistula arm Select proper methods for exercising fistula arm with some resistance to venous flowwith some resistance to venous flowPalpate for thrill/pulse dailyPalpate for thrill/pulse dailyListen for bruit with ear opposite access if can’t Listen for bruit with ear opposite access if can’t palpate for any reasonpalpate for any reason

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All patients should know to:All patients should know to:

Avoid carrying heavy items and wearing occlusive Avoid carrying heavy items and wearing occlusive closing over accessclosing over accessAvoid sleeping on the access armAvoid sleeping on the access armBe aware of site rotation (unless buttonhole Be aware of site rotation (unless buttonhole cannulation method is used)cannulation method is used)Be aware of proper skin preparation and Be aware of proper skin preparation and importance of staff wearing masksimportance of staff wearing masksReport and s/s of infection and absence of Report and s/s of infection and absence of bruit/thrill to staff bruit/thrill to staff immediatelyimmediately

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In ClosingIn ClosingThe patient’s dialysis access is his or her The patient’s dialysis access is his or her lifeline; it is the job of the entire team to try to lifeline; it is the job of the entire team to try to maintain it through routine monitoring and maintain it through routine monitoring and surveillancesurveillanceTeam education is keyTeam education is keyPatients who are able to should be taught how to Patients who are able to should be taught how to assess their own accessassess their own accessListen to the patientListen to the patientFollow up on the procedure reportFollow up on the procedure report