DIALYSIS - Access, Hemo dialysis

Chronic Renal Patients are a challenge for nurses - Leading the patients to live with disease is very important.

1. The History of Dialysis Dr . Willem Kolff is considered the father of  dialysis . This young Dutch physician constructed the first dialyzer (artificial kidney) in 1943 . He treated few pts but little success in 1945 he treated a uremic coma pt after 11 hrs of dialysis and lived for another 7 yrs

2. Dialysis is a  process  of removing waste and excess water from the  blood  to provide an artificial replacement for lost  kidney   function. Dialysis works on the principles of the  diffusion  of solutes and ultrafiltration of fluid across a semi-permeable membrane . Hemodialysis removes wastes and water by circulating blood outside the body through an external filter, called a dialyzer , that contains a semipermeable membrane.

3. Mechanisms of Solute Transport Diffusion Osmosis Reverse Osmosis Ultrafiltration Convection

4. Diffusion Molecules in solution will spread as evenly as possible in a defined space Solutes will move down a concentration gradient from an area of higher concentration to an area of lower concentration

5. Osmosis The movement of water through a membrane from a higher to a lower water concentration area. Osmosis occurs between two solutions separated by a membrane non-permeable to the solutes .

6. Ultrafiltration The movement of a fluid across a semi-permeable membrane caused by a pressure gradient. The pressure gradient can be: A positive pressure ("push") A negative pressure ("suck") or osmosis .

7. Types of Dialysis Hemodialysis Peritoneal Dialysis

8. Peritoneal Dialysis (PD)

9. PD Exit site and catheter car e Preparation of patient Preparation for dialysis Catheter Exit site care/dressing Flushing of catheter ( new) PET –Peritoneal Equlibrium Test)

10. HEMODIALYSIS

11. Vascular Access Blood can be removed cleaned and returned to the body at rates between 200 –800ml/ mt First - an ACCESS must be established

12. Ideal Vascular Access An ideal vascular access would provide Ease of creation Ready to use when needed Easy maintenance with repetitive use Adequate blood flow to deliver prescribed dialysis dose Long life without complication of infection and thrombosis

13. Access for HD Blood to be filtered – Access to Blood vessel Artery or Vein 1. Subclavian , internal Jugular and Femoral CATHETERS 2. Arteriovenous (AV) GRAFT for hemodialysis 3. Arteriovenous (AV) FISTULA for hemodialysis

14. Catheters Immediate access – double lumen or multi-lumen catheter into SC, internal Jugular or femoral vein Risks : hematoma. Pneumothorax, infection, thrombosis of SC vein . Inadequate flow Can use for several weeks Another permanent access created

15. Arteriovenous (AV) Graft ( Done when pts own vessels are not suitable for fistula – Eg Diabetes ) An arteriovenous (AV) graft is created by connecting a vein to an artery using a soft Synthetic tube.( polytertrafluroethylene (PTFE) Forearm, upper arm or upper thigh) After the graft has healed, HD is done by placing two needles- one in the arterial side and one in the venous side of the graft . The graft allows for increased blood flow . Grafts tend to need attention and upkeep. Taking good care of your access may limit problems

16. AV GRAFT

17. PTFE Graft Advantages Can be needled shortly after formation Vascular access in patients who might otherwise require dialysis cathet ers Disadvantages Risk of infection Thrombosis Over time may develop “hard to needle” areas

18. Arteriovenous (AV) Fistula A fistula is created direct connecting of an artery to a vein. Once the fistula is created it is a natural part of the body. Most preferred access -once the fistula properly matures and gets bigger and stronger; it provides an access with good blood flow that can last for decades It can take weeks to months before the fistula matures and is ready to be used for hemodialysis Exercises including squeezing a rubber ball to strengthen the fistula before use. 

19. Creating AVF

20. Criteria for successful AVF formation Prior to creation Arterial diameter 2 -3.5mm Minimum of 2mm advised to decrease risk of failure Venous diameter 2.5mm with tourniquet for AVF

21. A fistula is the “Gold standard” –because---- It has a lower risk of infection than grafts or catheters It has a lower tendency to clot than grafts or catheters It allows for greater blood flow, increasing the effectiveness of hemodialysis as well as reducing treatment time It stays functional for longer than other access types; in some cases a well-formed fistula can last for decades Fistulas are usually less expensive to maintain than synthetic accesses

22. Fistula care--Cleanliness Cleanliness is one way someone on hemodialysis can keep their fistula uninfected. Keep an eye out for infections----> pain , tenderness, swelling or redness around the access area

23. Good needle sticks T he ladder and the buttonhole techniques , . The ladder technique - “stick” the fistula in a different place along the length of the fistula every time. This is called “climbing,” ( it saves from weakening a certain area by repeatedly sticking it. It also provides time for the puncture site to heal) The buttonhole technique. - needle sticks are limited to one site, which is used repeatedly . Best for one nurse /self pricking By going into the access at the same depth and angle — in the same spot — the access has fewer traumas. Scar tissue will develop at the stick site making it easier and less painful to insert the needle. This technique is usually preferred by people who stick themselves

24. Monitoring …. Post creation, each dialysis throughout the life of the acces s Physical examination ( look, listen, feel) to detect physical signs of dysfunction or loss of patency Dialysis clearance ,recirculation and pressures Presence of clinical evidence of dysfunction (Difficult cannulation , prolonged bleeding after dialysis, swelling of the extremity, aneurysm formation)

25. AVF Initial evaluation Should be done at 4 weeks after creation to evaluate maturity and development Rule of 6’s for maturity 6mm diameter 6mm or less in depth 6cm straight segment for cannulation 600ml/min blood flow

26. Routine AV access monitoring Begins with a good history!!! Prior central venous catheters, pacemakers , CABG, mastectomy, neck surger y Swelling of arm, neck or breast / chest Prolonged bleeding, extravasation Frequent clotting Difficulty with needle placement, aspirating clots Presence of dilated collaterals, aneurysms Clotting risk factors

27. Aneurysm Risk factors Over needling of one or more areas Fistula age – the longer it has been cannulated the greater the likelihood of an aneurysm developing High intra-AVF pressures , i.e. in high flow AVF or where stenosis exists

28. Collateral veins

29. Physical Examination This is crucial for monitoring Look Listen Feel Should be done before every use! Accurate records of the assessment and the ongoing plan of access management

30. PULSE - indicator of downstream (ante grade) resistance Soft / compressible = Low resistance, no stenosis Hard /firm vessel during palpation = High resistance, stenosis present (Intensity of the hyper-pulsatile pulse is proportional to the severity of the stenosis) ARTERIAL INFLOW (Degree of increased pulse intensity is proportional to arterial inflow pressure. Detects anastomotic stenosis, stenosis of the feeding artery, problem with arterial inflow)

31. ANASTOMOSIS EXAMINATION THRILL (indicator of flow) Strong = Good flow Weak = Poor Flow Thrill felt during Systole & Diastole (Biphasic) = Good Flow Thrill during Systole ONLY = downstream ( antegrade ) stenosis = PULSE

32. Ischemia : Clinical Indicators Pain and coldness in AVF hand Necrosis of fingertips “Steal syndrome” mostly occurs soon after AVF formation but about 25% of all cases occur months or years post surgery Stage 4 Steal Syndrome

33. A. Steal syndrome with painful necrotic ulceration of the middle finger .(B) Stage 4 steal syndrome .(Diabetic ) Simple test – presence of a weak or absent RADIAL pulse which normalises on compression of the fistula

34. Body of fistula Examination Palpate entire length of AVF. Compare to other arm/leg Check for signs and symptoms of infection – redness, warmth, swelling, ooze, pain, fevers, night sweats (paying close attention to buttonholes) New/ increased thrill proximal to anastomosis may indicate stenosis Elevate arm. Entire AVF should collapse. Any segment that remains dilated indicates a stenosis proximal to the dilated segment Aneurysmal segments. Are they increasing in size? Take photo. Is the skin integrity over the aneurysm compromised? Evidence of area needling. Are there other possible cannulation sites? Assess with ultrasound if available

35. Examination for venous outflow stenosis Arm elevation test The AVF should be distended in dependent position Upon raising the arm above the head, the fistula should collapse Failure to collapse will indicate stenosis in outflow

36. Caring for a patient's vascular access for hemodialysis Follow your facility's policies and procedures to protect and preserve the vascular access and avoid complications. Remove any restrictive clothing or jewelry from the arm. To prevent injuries , place an armband on the patient or a sign over the bed that says no BP measurements, venipunctures , or injections on the affected side. When blood flow through the vascular access is reduced, it can clot. Perform hand hygiene before you assess or touch the vascular access. If it's a new vascular access with a wound, don gloves. Position the patient's arm so the vascular access is easily visualized. Assess for patency at least every 8 hours .

37. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular ac cess with a stethoscope to detect a bruit or "swishing" sound that indicates patency. If whistling bruit ? clot – stenosis Check the patient's circulation by palpating his pulses distal to the vascular access; observing capillary re fill in his fingers; and assessing him for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity. Assess access for signs and symptoms of inf ection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection

38. After dialysis, assess the vas cular access for any bleeding or hemorrhage. When you move the patient or help with ambulation, avoid trauma to or excessive pressure on the affected arm. Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm that can rupture and cause hemorrhage. Monitor S.Elect , BUN , creatinine , and Hb and HCT levels before and after dialysis . Monitor fluid status . Monitor coagulation studies because heparin is used to prevent clotting during dialysis

39. Miscellaneous Hematoma Seroma Neuropathy High output cardiac failure Infection Cosmetic issues

40. Infection

41. Cosmetic Issues

42. Preventing Access Complications Prevention of infection (hand washing, needling techniques) Minimize needling trauma Avoidance of hypotension Awareness of risk factors for thrombosis Investigate needling problems Report change in character of thrill/bruit Report physical changes in AVF

43. Thank You Very Much