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Vascular Access

A vascular access is the point on your body where the blood required to do a dialysis treatment is removed from you and returned to you. While the blood is out of your body (less than a cup is removed at a time), it is pumped by the dialysis machine through the dialyzer (or artificial kidney) to be cleaned and have extra fluid removed. The vascular access must be able to accommodate blood moving at a large enough rate to allow for an adequate hemodialysis treatment in a relatively short period of time.

There are three types of hemodialysis access:

  1. A-V Fistula
  2. Graft
  3. Catheter
Which type vascular access do you have?

AV FISTULA The ARTERIO-VENOUS FISTULA (fis-choo-la) is an artificial opening between an artery (a vessel that carries blood FROM your heart) and a vein (a vessel that carries blood back TO your heart). Surgically connecting an artery and a vein that lie close together in your arm creates this opening.

The strong arterial pressure will, over time, enlarge the vein and create a long-term vessel (vein) where the dialysis needles are easily placed. The AV Fistula lies under the skin and requires at least 6-8 weeks to “mature” before it can be used.

This type of access requires the most time to develop but is the longest lasting and the most trouble free. It is worth the wait! Being prepared and having a “plan for dialysis” long before your actual starting date is important for success of the fistula as your first access. Fistulas can be placed at a later date too, but will always require time to “mature”.

After a FISTULA is placed, there are exercises that can be done to help it build up or “mature.” Squeezing a soft rubber ball with the hand of your access arm 20-30 times several times a day will help. Your surgeon or dialysis team can advise other exercises and care. Be sure to ask them for written information on the care of your access.

Advantages of a FISTULA are:
Simpler surgery than a graft.
This access lasts the longest.
Infection rate is lowest of all the types of access.
Least chance of clotting problems.
This is the preferred type of access.

Disadvantages of a FISTULA are:
6-8 weeks to develop before it can be used.
You may require fistula maturation utilizing angioplasty if you have small veins.

GRAFT
A GRAFT is usually a piece of artificial tubing (polytetrafluoroethylene or gortex) or bovine (cow), that is connected at one end to an artery and at the other end to a vein, usually in your arm.

This GRAFT provides a conduit for blood to flow from the higher arterial pressure area of your access to the lower venous pressure area on its way back to your heart. The dialysis needles are placed into this piece of conduit. The graft lies under the skin and requires 2-3 weeks to heal. It is best that the swelling be gone before it is used for dialysis.

Advantages of a GRAFT are:
Can be used in 2-3 weeks.
Needles are easily placed.

Disadvantages of a GRAFT are:
Surgery is more extensive than a fistula.
Shorter “life span” - they wear-out.
Risk of infection is higher than in a fistula.
Risk of becoming clotted between treatments is higher.
There is a higher rate of complications requiring more frequent hospitalization.

CATHETER
The CATHETER is a “Y” shaped plastic tube. It is surgically placed so that the leg of the “Y” is placed down into a vein of your neck, chest, or occasionally, the groin. The upper 2armed segment of the catheter exits through the skin. Blood moves in and out of the 2 tubes (called lumen) of the catheter during the dialysis treatment. One of the lumens delivers blood to the dialyzer on the machine and the other returns the blood to you. Catheters are most commonly placed in the subclavian vein of your shoulder or the internal jugular (IJ) vein in your neck. According to DOQI*, the neck is the site that will cause the least number of problems and is the preferred site. (* DOQI is Dialysis Outcomes Quality Initiative. These are guidelines for medical practice developed by a team of experts to help improve patient outcomes.)

The CATHETER is usually a temporary (short-term) access. Most often catheters are used while the fistula or graft are healing from surgery and “maturing” (becoming useable). It is important that the arms of the catheter be clamped and capped between treatments to prevent infection and blood loss. Caution should be used in working with catheters. Only skilled persons using sterile techniques should touch catheters. This means the patient and the caregiver should have masks on and the caregiver should be wearing sterile gloves. Extreme care should be taken when working with catheters to avoid introducing bacteria into the blood. The catheter exit site should be checked, cleaned, and redressed by a skilled person at each dialysis session. The person examining the exit site should discuss the condition of the catheter with you each treatment.

Always be on the LOOKOUT for signs and symptoms of infection:
REDNESS
SWELLING
PAIN, NUMBNESS
DRAINAGE (pus) or BLEEDING
INCREASED TEMPERATURE (at the exit)
FEVER with chills
CLOTTED CATHETER

If any of the above are present, the charge nurse or your Nephrologist needs to be notified immediately.
Dressings on the exit site should also be changed anytime they become wet or soiled. Do not hesitate to call your dialysis unit or Nephrologist if you have any concerns between dialysis treatments. This is your lifeline, you must protect it!

Advantages of a CATHETER are:
Surgery is not extensive.
Can be used immediately after insertion.
No needles are required.
Easy for dialysis personnel to connect you to the dialysis machine.

Disadvantages of a CATHETER are:
Can become clotted easily.
High risk of infection which can spread to the entire body.
Must be cleaned and evaluated in a specific manner by a trained individual several times a week.
Risk of high amount of blood loss if not kept capped and clamped when not in use.
Risk of stenosis (narrowing of the vein) of vessel where catheter is placed.
Under-dialysis can result if adequate blood flow cannot be maintained or if the catheter arms are not connected to the proper blood-lines (arterial to arterial, venous to venous).

Which ACCESS is best for you?
It is important for you and your doctor to make the decision TOGETHER about which access would serve you best. You only have a few sites on your body that can be used for vascular access. The access will need to be cared for and watched carefully by YOU so that it will last as long as possible and be relatively TROUBLE-FREE. If you think an alternate type of access would be better for you, bring this up with your doctor. It is important that you “shop around” to find a surgeon who is well trained to work with you and your access. There are surgeons who specialize in vascular access.

What can I do?
DISCUSS concerns and questions with your doctor.
CHECK your access every day! If you have a catheter you do not want to remove the dressing unless you have been trained to do this properly.

TALK to the dialysis team about your access.
INSIST the dialysis team treat your access as if it were their access.
REMEMBER – an adequate hemodialysis treatment is dependent on a well-functioning access!

Assess your access every day!!!!!
Check your Graft or Fistula EVERY DAY!
LOOK at the access. Are there any signs of infection?
REDNESS?
SWELLING?
BLEEDING?
DRAINAGE?

FEEL the access with your fingertips. Is anything different from yesterday?
PULSE present?
Any HARDNESS or SWELLING?
Any PAIN?
HOT to touch?
NUMBNESS in arm or fingers?
Call your dialysis unit RIGHT AWAY if you notice anything out of the normal.

ACCESS CARE
1. Your access is your life line. You must protect it all the time. You are responsible to wash your access site before your treatment, unless your access is a catheter. Make sure your nurse or technician cleans the skin over your access site with alcohol and betadine before inserting the needles. Your nurse should clean your catheter ports with betadine before opening the ports.

2. Your VASCULAR ACCESS MUST BE EXPOSED to staff at all times during your treatment. Your needle could dislodge causing bleeding that would not set off any alarms on the dialysis machine. You could lose a significant amount of blood before it would be noticed if your arm is covered. Blood could drip onto the floor or be absorbed into your clothing and sheets. The staff must have visual access to your access.

3. Make sure the blood is flowing by feeling for the buzz or thrill each morning and night and a few times during the day.

4. Don’t wear tight clothes around your access.
5. Never let anyone take your blood pressure, draw blood or stick a needle in your access arm.
6. If you think your access is clotted (not functioning), call the dialysis center or doctor at once. You may be able to have the clot removed and save your access.
7. If your access starts to bleed hold direct pressure on it. Teach your family how to do this, too. If you cannot stop the bleeding call for help.

 
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