Patient Care & Safety

Standards in Hemodialysis
Centers:
Vascular Access Management
& Patient Monitoring
Mrs. Reena George
Professor and Nurse Manager,
Dialysis Unit, CMC, Vellore.
 Clinical Practice Guidelines/ Standards

Recommendations by KDOQI (Kidney Disease Outcomes

Quality initiative)- National Kidney Foundation

KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR

ACCESS: 2019 UPDATE
• Strong recommendation
• Conditional recommendation
 1. Patient with progressive CKD and/or
with an eGFR 15-20 mL/min/1.73 m2 or
on kidney replacement therapy -
I. Vascular individualized ESKD Life-Plan -regularly
reviewed, updated, and documented.
Access
2. Regular monitoring +
Management a minimum quarterly overall review and
update of each patient’s vascular access
functionality, complication risks, and
potential future dialysis access options.
 Consistent use of standardized
definitions - CVC-related infections to
allow comparisons across facilities.

Catheter
An infection surveillance team to
Related monitor, track (in an electronic
Infection database), help prevent, and evaluate
(CRI) outcomes of vascular access infections.
Nephrologist, Vascular Access Nurse
Specialist, HICC/ Microbiologist
 CVC Locations

Based on ESKD life plan of the patients:

• Upper extremity before lower extremity, only if choices are
equivalent

• If AV access is likely to be ready for use in near future—consider

preferential use of tunneled ,cuffed CVC in opposite extremity

• If Transplant is anticipated in near future, consider preferential

use of tunneled cuffed right IJ catheter to preserve iliac vessels
To use tunneled CVC in preference to non-tunneled CVC
due to the lower infection risk with tunneled
CVC. (Expert Opinion)

To use non-tunneled internal jugular CVC only for

temporary purposes for a limited time period (<2 weeks
or per individual facility policy) to limit infection
risk. (Expert Opinion)
 • Non-cuffed, Non-tunneled Catheters (NT-CVC)-
Timing of Temporary
CVC Maximum of 2 weeks due to increased risk of
Removal infection- To be considered only in patients
needing emergent access.

• Cuffed, Tunneled catheter- Permanent catheter

There is no maximum time limit to CVC
use, but regular evaluation is required.
 Prevention of CRI
• Hand hygiene practices
• Aseptic techniques while handling catheter- Use of sterile gloves, mask
• Minimum touch technique
• Antimicrobial ointment for exit site
• Type of dressing ( No strong evidence)
• Prophylactic antibiotic lock- NSE
• Do not expose the catheter lumen to air
• Do not wet the catheter site especially
• Antimicrobial barrier cap to help reduce CRBSI in high-risk patients or facilities- clinical discretion
 Monitoring/Surveillance of CVC Complications

Basic medical history focused on signs and symptoms of CVC-related

complications (eg, dysfunction, infection)
Check of the dialysis catheter, exit site, tunnel, and surrounding area at
each catheter dressing change or dialysis session. (Expert Opinion)

Assess for CVC dysfunction during each HD session using the following
updated definition of CVC dysfunction: failure to maintain the prescribed
extracorporeal blood flow required for adequate hemodialysis without
lengthening the prescribed HD treatment. (Expert Opinion)
Intraluminal Agents to Prevent CVC
Dysfunction
The choice to use citrate or heparin as a CVC locking solution be based on
the clinician’s discretion -inadequate evidence to demonstrate a difference
in CVC survival or complications between these locking solutions.

The use of low-concentration citrate (<5%) or Heparin as CVC locking

solution is suggested, to help prevent CRBSI and CVC
dysfunction. (Conditional Recommendation, Low Quality of Evidence)

TPA (1mg/ml )may be prophylactically used as a CVC locking solution once

per week to help reduce CVC dysfunction.
Medical Management of CVC Dysfunction

Conservative Maneuvers at bedside to manage CVC dysfunction prior to other

medical or mechanical interventions.
Pharmacologic Maneuvers
• Intraluminal administration of a thrombolytic agent in each CVC port to restore
function of dysfunctional CVCs due to thrombosis.
• Use of alteplase or urokinase plus citrate 4% per lumen for restoring
intraluminal CVC blood flow in an occluded CVC.
• Intraluminal administration of alteplase (t-PA) 2 mg in preference to alteplase 1
mg in each CVC port to restore function of dysfunctional CVCs due to
thrombosis. (Conditional Recommendation, Moderate Quality of Evidence)
Use of a catheter care protocol for exit site and hub care

• To cleanse the catheter hub when connecting and disconnecting the

catheter with a chlorhexidine based solution.

• If chlorhexidine is contraindicated (e.g. sensitivity, allergy), povidone-

iodine solution (preferably with alcohol) is a reasonable substitute and
should be used.
• When there are valid reasons for CVC use and duration of use is expected to be prolonged
>3 months, without anticipated use of AV access, cuffed, tunneled CVC may be placed in the
following order of preference:

• Internal jugular vein

• External jugular vein

• Femoral vein

• Subclavian vein

• Lumbar vein

Use early cannulation grafts as a CVC-sparing strategy in appropriate patients, considering

their ESKD Life-Plan.
AV Access
KDOQI Suggestions

• AV access (AVF or AVG) is preferred to a CVC due to the lower infection risk
associated with AV access.
• The choice of AV access (AVF or AVG) be based on best clinical judgment that
considers the vessel characteristics, patient comorbidities, health circumstances, and
patient preference.
• If sufficient time and patient circumstances are favorable for a mature, usable AVF,
such a functioning AVF is preferred to an AVG due to fewer long-term vascular access
events (thrombosis, loss of primary patency, interventions)
• To use tunneled CVCs for short-term or long-term durations for incident
patients, as follows (Expert Opinion):
Short-term duration:
•AVF or AVG created but not ready for use and dialysis is required
•Acute transplant rejection or other complications requiring dialysis
•PD patient with complications that require time-limited peritoneal rest or
resolution of complication (eg, pleural leak)
• Patient has a living donor transplant confirmed with an operation date
in < 90 days) but requires dialysis.
•AVF or AVG complication such as major infiltration injury or cellulitis that
results in temporary nonuse until problem is resolved
Long-term or indefinite duration - CVC:
•Multiple prior failed AV accesses with no available options

• Valid patient preference - use of an AV access severely limit

QOL or achievement of life goals - patient properly informed of
patient-specific risks and benefits.

• Limited life expectancy

• Absence of AV access creation options due to a combination

of inflow artery and outflow vein problems

• Special medical circumstances

 In nondialysis CKD patients with progressive decline
in kidney function, referral for dialysis access
assessment and subsequent creation should occur
when eGFR is 15-20 mL/min/1.73 m2.

Vascular Earlier referral should occur in patients with

unstable and/or rapid rates of eGFR decline (eg, >10
Access mL/min/year).

Creation
In HD patients with recurrent vascular access
problems, prompt referral for assessment and
creation of a new AV access should be made.
 A predetermined In patients who have
dialysis access must unplanned or urgent
be ready to initiate dialysis started with
the planned dialysis a CVC, the ESKD Life-
(eg, an AV access is Plan is established
mature and ready with a dialysis access
for cannulation for plan within 30 days
HD). of dialysis start.
 Distal first to proximal next
approach

Location of Always preserve the integrity of

AVF/ AV vessels for future vascular access
options
Graft
Nondominant extremity in
preference to dominant, only if
choices are equivalent
 Assess or check the vascular access and surrounding area prior to
every cannulation (if AV access) or connection (if CVC) for potential
complications. (Expert Opinion)

.Vascular Rope ladder cannulation as the preferred cannulation technique for

Access Use AVFs.

Limit AV access buttonhole cannulation only to special circumstances

given the associated increased risks of infection.

Protect all central and peripheral arteries and veins from damage
whenever possible, including the avoidance of peripherally inserted
catheters and unnecessary venipunctures, for patients on dialysis or
with CKD where dialysis access is expected in the future (CKD G3-G5)
 Patient and Vessel Examination

PHYSICAL ASSESSMENT, INITIAL ASSESSMENT

AND PLANNING OF VASCULAR ACCESS SELECTIVE PREOPERATIVE ULTRASOUND USE OF UPPER EXTREMITY EXERCISE TO THE USE OF WHOLE ARM RATHER THAN
CREATION TO DETERMINE THE TYPE AND IN PATIENTS AT HIGH RISK OF AV ACCESS FACILITATE POSTOPERATIVE AVF FINGER EXERCISE, IF EXERCISE IS USED TO
LOCATION OF VASCULAR ACCESS. FAILURE RATHER THAN ROUTINE MATURATION. FACILITATE AVF MATURATION.
VASCULAR MAPPING IN ALL PATIENTS.
 (0-30 Days)—Early AV Access Complication

AV access (AVF and AVG) to be evaluated by a

Post–AV Access surgeon/operator for postoperative complications
within 2 weeks
Creation/CVC
An appropriate member of the vascular access team
Insertion to evaluate for AVF maturation by 4-6 weeks after
Considerations AV access creation and refer for further investigation
if not maturing as expected. (Expert Opinion)
 AV Access Cannulation Complications
•Any size infiltration: apply ice for a minimum of 10 minutes and refrain from maximizing the blood pump
speed. (Expert Opinion)

• Moderate infiltration - the needle should be removed and manual pressure be applied over the infiltration
site. (Expert Opinion)

• If the infiltration is significantly large, in addition to the above, a decision on the necessity for dialysis that
day is required—if dialysis is required, a site proximal to the infiltration injury should be cannulated; if this
is not possible, reattempt at the area of injury should not proceed until manual pressure and ice is applied
for 30 minutes. (Expert Opinion)
• If a hematoma develops, close assessment of the site - measurement of swelling, assessment of the presence of
flow in the AV access both proximal and distal to the hematoma, and circulation to the associated
extremity. (Expert Opinion)
• Use ultrasound to help determine direction of flow and proper needle placement in the AV access of select
patients as needed (Expert Opinion)
 AV Access Flow Dysfunction—
Monitoring/Surveillance
AV access flow dysfunction” refers to clinically significant
abnormalities in AV access (AVF or AVG) flow or patency
due to underlying stenosis, thrombosis, or related
pathology.
Physical examination by a trained knowledgeable and
experienced health practitioner, to monitor & detect
clinical indicators of flow dysfunction of the AVF.
• KDOQI considers it reasonable to use a careful individualized

approach to the treatment of failing or thrombosed AVF and AVG

(surgical or endovascular), based on the operator’s best clinical

judgment and expertise and considering the patient’s ESKD Life-Plan.

Surveillance to Facilitate Patency
Inadequate evidence to
recommend routine AVF
surveillance by measuring access
blood flow, pressure monitoring,
or imaging for stenosis, additional
to routine clinical monitoring, to
improve access patency.
Pre-emptive angioplasty or
surgical interventions of AVFs
with stenosis, not associated
with clinical indicators, to
improve access patency.
• Clinically significant AV access lesion (eg, stenosis)- further timely
and confirmatory evaluation should proceed, including imaging of
the dialysis access circuit. (Expert Opinion)

• To use balloon angioplasty as primary treatment of AVF and AVG

stenotic lesions that are clinically and angiographically significant.

• Appropriate use of self-expanding stent-grafts in preference to

angioplasty alone to treat clinically significant graft-vein
anastomotic stenosis in AVG
 Treatment of Thrombosed AV Access

• At the clinician's best judgement and discretion,

considering patient’s dialysis access succession
plan that is consistent with the ESKD Life-Plan.

• To surgically treat a failing AV access :

(1) endovascular treatment failures
(2) clinically significant lesions not amenable to
endovascular treatment
 AV Access Infection
Monitoring and Prevention
• To educate the patient on washing the access arm using
antiseptic lotion / soap to clean the skin prior to
every cannulation. (Expert Opinion)
• To check the vascular access and surrounding area prior
to every cannulation for signs and symptoms of
infection. (Expert Opinion)
• Radiologic imaging( Duplex) to help confirm the
diagnosis of AV access infection
 Treatment
• Obtain cultures and sensitivities of the blood and any
available infected AV access vessel/material, surrounding
tissue, or drainage prior to initiating antibiotic
therapy. (Expert Opinion)

• Rapid initiation of empiric broad-spectrum antibiotics and

timely referral to surgeon for any surgical
intervention (Expert Opinion)
 To check AV access for aneurysm/pseudoaneurysms at each dialysis
session by knowledgeable care providers- dialysis technicians, nurses,
nephrologists, and vascular access coordinator. (Expert Opinion)

To proactively educate patients on emergency procedures for

aneurysm rupture and to obtain proactive surgical assessment when
AV Access clinical findings suggest an AV access aneurysm/pseudoaneurysm to
be at risk of complications. (Expert Opinion)

Aneurysms Note: An aneurysm/pseudoaneurysm that is considered at risk of

complications is one with evidence of associated symptoms or skin
breakdown.

To obtain emergent surgical assessment and treatment for AV access

aneurysm/pseudoaneurysm complications such as erosion or
hemorrhage.
 Prevention
• Appropriate cannulation techniques
- Angle of cannulation
- Rope ladder technique
- Securing cannula
- Distance from anastomosis, between needles
• Structured training and supervision of nurses and dialysis
therapists to maintain cannulation competency.
• Support and educate eligible patients on self-cannulation of their
AV access
Management

The presence of an aneurysm/pseudoaneurysm alone in the absence of symptoms

(ie, asymptomatic) is not an indication for definitive treatment. (Expert Opinion)
Avoid cannulating the access segment(s) that involve the
aneurysm/pseudoaneurysm if there are alternative sites.
When no suitable alternative cannulation sites- the sides (base) of the
aneurysm/pseudoaneurysm should be cannulated.
Appropriate imaging of the arterial inflow and venous outflow to assess volume flow
or stenotic problems (Expert Opinion)
Surgical management is the preferred treatment for patients with symptomatic,
large, or rapidly expanding AV access aneurysm
A definitive surgical treatment is usually required
for anastomotic aneurysms/pseudoaneurysms.

Covered intraluminal stents (stent grafts) as an alternative to

open surgical repair of AV access aneurysms/ pseudoaneurysms -
contraindication to surgery or lack of surgical option
 AV Access Steal

Post AV access creation- Monitor closely for signs and symptoms

associated with AV access steal

Mild to moderate signs and symptoms - close monitoring for

progression of ischemia and worsening of signs and symptoms

Moderate to severe signs and symptoms -urgent surgical

intervention to correct the hemodynamic changes and prevent any
longer-term disability.
Assessment of patients Before, During and After Haemodialysis
Before Dialysis

• Assess the pre dialysis weight and calculate Ultra Filtration (UF) rate.
The UF is calculated as weight gain + oral fluid intake during dialysis + IV
fluids (Saline, Iron, antibiotics etc) + Blood/ blood products transfusion
during dialysis
• Blood pressure is checked and recorded which would serve as baseline.
• If blood pressure is below the regular baseline or if the patient is
symptomatic, Normal Saline bolus is to be given as prescribed before
starting dialysis.
• Oxygen saturation and Temperature is checked and documented
• Assess the vascular access site and document the findings.
Arteriovenous fistula / graft:
• Impaired healing of the incision site over AVF/ graft. Swelling, redness, bleeding,
tenderness
• Aneurysm formation Skin irritation Maturation of fistula
• Presence and quality of thrill and bruit
• Cyanosis, numbness, tingling sensation or pain of the finger tips Any abnormal
warmth around AV anastamosis site.

Central Venous Catheter (CVC):

• Pain Bleeding
• Patency of lumens (by aspirating with 10 cc syringes) Discharge or redness at the exit
site
• Neck or facial swelling
 • The patient is monitored every 30-40 minutes once
initiated on dialysis.
• The following parameters are assessed and
documented.- Blood pressure, Blood flow rate, Dialysate
Flow Rate, Venous pressure, Trans Membranous Pressure
(TMP), Ultrafiltration, Heparin flow, Normal saline bolus if
During any.
Dialysis • Access site is assessed for any dislodgement of catheter or
needles, any bulging or pain
• Assess for signs and symptoms of complications such as
hypotension, hypertension, cramps, hypoxemia,
hypoglycemia, febrile reaction, convulsions, dyspnoea,
arrhythmia, headache, etc.
• Follow up the results of blood tests and intervene
accordingly
After Dialysis

Check the blood pressure after re transfusion and before disconnecting patient
from the machine.
If the blood pressure is below baseline or if he is symptomatic, infuse bolus Normal
Saline according to the discretion of nurse/ therapist.
If patient is on CVC, exit site dressing is performed as per protocol.

A standing BP is checked after disconnecting patient from the machine. Post

dialysis weight is checked and net UF achieved is documented.
Weight, Net UF
Teamwork • Standards, Protocols,
Procedures laid down
• Competency Training for
staff
• Periodic Audits
• Good documentation
system
• Identifying performance
indicators and have
performance measures
• Coordinated Teamwork