HEMODIALYSIS VASCULAR ACCESS

1. AV FISTULA
HEMODIALYSIS 2. AV GRAFTS
 It is the removal of solutes and water from body 3. AV SHUNTS
across a semipermeable membrane (dialyzer) 4. Percutaneous access

William Kolf AV FISTULA

 Father of hemodialysis
 invented the first “artificial kidney”  Anastomosis of an artery to a vein
 Sites- radial artery & cephalic vein,
PRINCIPLES underlying HD brachial artery & cephalic vein,
• Diffusion brachial artery & basilic vein
 The increased blood flow and
• Osmosis
pressure causes the vein to dilate.
• Ultra filtration & solvent drag
PRE-OP CARE IN AV FISTULA
DIFFUSION
1. Full explanation of the procedure and aftercare
• Movement of molecules from an area of higher
2. Let him talk to someone who has a well-established
concentration to an area of lower concentration
fistula
3. Should be well hydrated before the surgery
4. Part preparation

POST OP CARE IN AV FISTULA

1. Limb should be kept warm &well supported to
maintain the peripheral circulation.
2. Monitor the BP and maintained at 100 systolic
minimum to reduce the risk of fistula thrombosis.
OSMOSIS 3. Avoid antihypertensive therapy
• Movement of solvent molecules from lower 4. Examine the wound site for bleeding/swelling
concentration to higher concentration 5. Check the blood flow regularly (bruit/ thrill)
regularly

POST OP CARE OF AV FISTULA

Ultra filtration & Solvent drag
• Water moves from an area of high pressure to an
area of lower pressure
• More efficient in fluid removal than osmosis
• Molecules which are dissolved in the solvent also get
removed- solvent drag
1. Avoid using the fistula arm for carrying heavy loads
2. Avoid tight and restrictive clothing on the arm.
3. Hand exercises promote fistula maturation
4. Arm should not be used for phlebotomy cannulations
or recording the BP
5. Notify physician if any bleeding
LONG TERM CARE
- Keep your access clean at all times
- Be careful not to bump your access
- Don’t wear jewelry over your access
- Don’t sleep with your access arm under your head or
body.
- Check the pulse in your access every day.

COMPLICATIONS OF AV FISTULA

1. Thrombosis - due to hypotension

2. Aneurysm - due to repeated area puncture
3. Steal syndrome - due to reduced blood
INDICATIONS
ARTERIOVENOUS GRAFT
❖ Acute poisoning
 A graft is put b/w an
❖ Acute renal failure
artery &vein
❖ Severe edema
 Synthetic graft(PTFE)
❖ Chronic renal failure
is used most
❖ Hepatic coma • Metabolic acidosis
commonly
❖ Hyperkalemia
 Indications -
❖ Transfusion reaction
Peripheral vascular
❖ Post-partum renal insufficiency
disease - Diabetes
❖ Cardiac tamponade
 Can be used after 14 days
❖ Fluid overload not responding to diuretics & fluid
restriction AV SHUNT
CONTRAINDICATIONS  Very rarely made
→ Other chronic disease  Teflon tubings are inserted into the vessels and silicon
→ No vascular access tubings are attached.
→ Hemorrhage
→ hypertension
→ Very old people
→ Inability to cope with treatment regimen
→ Coagulopathy
→ Inability to survive procedure
 AREA PUNCTURE
• Use of one or two areas of the fistula which are
regularly used
• Aneurysm chances are more

Cannulation technique
→ Needles to be inserted at 45 deg to the skin
→ Arterial and venous needle should be placed 5 cm
apart •
PERCUTANEOUS ACCESS
→ Don’t pull or push the needle blindly
→ Internal jugular vein
→ Ask for assistance if cannulations attempt had failed
→ Subclavian vein
for 2/3 times
→ Femoral vein
HEMODIALYSIS EQUIPMENT
Indications
→ The dialyzer
- Acute dialysis
→ The membrane
- Temporary
- Inadequate vessels
- Failed access

POST INSERTION CARE

• Correct insertion is checked by X-ray DIALYZERS
• Check for pneumothorax & puncture of the adjacent
→ Coiled dialyzers
vessels
→ Parallel plated dialyzers
• Maintain the patency of the catheter - Heparin lock → Hollow fiber dialyzer
injected after each dialysis
- Heparin is removed & flushed with saline (0.9%) Membranes
before next dialysis
- Never flush the catheter if can’t be aspirated → FLUX PROPERTY: the efficiency with which a
• Examine the sites for any soreness, redness, or membrane clears water and solutes
presence of exudates → Cellulose membrane- low flux
→ Modified cellulose
CANULATION membrane: low/high flux
1. Allow the fistula to mature → Synthetic membrane:
2. A thorough physical examination is done before low/high
cannulating. Adhere to units’ protocol
3. Universal precautions are followed
4. A tourniquet may be used to get the vessels
engorged

TYPES OF CANULATIONS
1. Rope ladder
puncture
2. Area puncture
3. Button hole puncture

Rope ladder technique

→ The entire vessel is used systematically
→ Each needle is inserted at 2cm above the last site and
back again
→ It helps expand the lifespan of the fistula
→ Gives the previous stick site time to heal
→ Helps the fistula mature more evenly
Button hole technique
→ The same site is repeatedly puncture at exactly the
same angle
→ Over time the scar tissue develops guiding the needle
into the right place
→ Advantage
- Less pain
- Less hematoma
PREPARATION OF THE DIALYZER
1. Air must be completely removed from the dialyzer
and the bloodlines
2. Removal of the chemical or the sterilizing agent is
essential
3. Minimum of 1L of saline for flushing in c/o ETO
sterilization
Dialysate
→ The fluid which is pumped on the opposite side of the
semi permeable membrane to the patients blood
→ It is prepared by mixing a concentrated electrolyte
solution with a buffer(bicarbonate) & purified water.
 Composition of Dialysate 3. Monitor changes in fluid an electrolyte status, weight
changes
A. Laboratory studies
B. Assess level of responsiveness at the beginning,
throughout and the end of the dialysis
C. Pre and post dialysis weight

4. Monitor for complications

A. Infection- Bacteremia is an unwanted
complication
1. Watch for chills/fever (Antibiotics may be
given after the treatment)
2. Redness around the access (Request for
blood culture)
Observe strict aseptic technique!
Anticoagulation B. Bleeding
1. Observe site for any blood leaks
• Heparin in the beginning 2000- 5000U or 50 U/Kg 2. Monitor vital signs
and then as a continuous infusion at 1000- 1500U/hr 3. Monitor for hypertension/hypotension
till 15-60 mts before the end of dialysis
POST-DIALYSIS
• Heparin free dialysis if bleeding disorder is there.
1. Check for any blood works or medicines to be given
before terminating dialysis
2. Upon removal of fistula needle, apply pressure
dressing using sterile gauze and wait until the
puncture site has clotted.
3. Tape on a new pressure dressing and instruct pt. to
remove 4 to five hours later when possible bleeding
may occur.
4. Ask your patient to rest at least 15 minutes and
dangle their legs to prevent postural hypotension
after dialysis
5. Reinforce diet and fluid requirements of patient on
dialysis
6. Remind them about their next schedule of their
NURSING MANAGEMENT OF HEMODIALYSIS dialysis
7. Weigh patient before they leave the center
1. Before dialysis
2. During dialysis CARE OF VASCULAR ACCESS: CENTRAL
3. After dialysis CATHETERS:
→ Keeps the catheter dressing clean and dry
BEFORE DIALYSIS: → Make sure the area of insertion site is clean and
change the dressing at each dialysis session.
Initial Nursing Assessment
→ Instruct patient on how to change dressings in an
a. Weight emergency
- Present weight – dry weight = Target weight → Instruct patient not shower or swim; but tell
b. Vital Signs him/her that he/she may take a bath.
1. BP – standing and sitting → Wear a mask over nose and mouth anytime the
2. Cardiac rate and rhythm catheter is opened to prevent bacteria from
3. Pulse rate entering the catheter and the bloodstream.
4. Respiratory rate → The caps and the clamps of the central catheter
5. Temperature should be kept tightly closed when not being used
for dialysis.
DURING DIALYSIS: → Monitor exit site for soreness/redness.
Care of patient during the dialysis.
Nursing Action CARE OF VASCULAR ACCESS: AV FISTULAS/GRAFTS:
1. Promote patient comfort during the procedure → Keep the access site clean at all times.
A. Provide physical comfort measures → Avoid injections, intravenous (IV) needles or fluids,
a. Back care or taking blood samples in the access site arm.
b. Elevate head of the bed → Needle insertions for hemodialysis treatments should
c. Assist in turning be rotated.
B. Keep pt. informed of progress and results → Do not take blood pressure or put pressure on the
C. Provide any kind of activities as reading newspaper access arm
D. Provide care and attention to pt. considering → Advise patients to avoid wearing jewelry or tight
physiological, psychological care, remembering his clothing, sleeping on, or lifting heavy objects with the
needs, reactions, and concerns access arm.
→ Check the access arm for adequate circulation.
2. Maintain good outflow of blood → Check for signs of infection at the access site
A. Monitor alarms of the machine
B. Monitor Vital Signs – a drop in blood pressure
may indicate rapid fluid loss that may lead to
dehydration