VASCULAR ACCESS DEVICES

CANNULATION TECHNIQUE 251 • BUTTONHOLE PUNCTURE DISADVANTAGES: o Requires same cannulator, same angle, same location o High rate of infection o Concerns of one-site-it is o Difficult with fistula covered by: ✔ Heavily scarred skin ✔ Large amount of subcutaneous tissue DIALYSIS ACCESS DEVICE

CANNULATION 252

CANNULATION A. ASSEMBLE SUPPLIES • Clean barrier • Aseptic agent • Gloves • 2 sterile dialysis needles for cannulation of AV access • 2 syringes filled with sterile saline DIALYSIS ACCESS DEVICE 253 https://onlinelibrary.wiley.com/doi/10.1111/ aor.12788

CANNULATION B. SKIN PREPARATION •• Wash skin over the AV access with soap and water Assess the AV access Watch for signs of Check for the sound Ensure blood is infection (redness, of blood moving flowing through the swelling or discharge) graft by feeling for and changes in the through your graft appearance of the by putting your ear, the vibration or skin over and near thrill. or a stethoscope the graft. over the AV graft. 254 DIALYSIS ACCESS DEVICE

CANNULATION B. SKIN PREPARATION • Assess the AV access • Clean the skin using 2% Chlorhexidine solution or Povidone-iodine using friction and a circular motion • Leave the solution to dry before needle insertion • Do not touch skin after cleaning • During the preparation of the access sites, universal precautions, including the wearing of gloves, must always be used to prevent the spread of infection 255 DIALYSIS ACCESS DEVICE

CANNULATION C. LOCAL ANESTHESIA • If the patient experiences discomfort during cannulation, the administration of an intradermal injection of lidocaine may be used immediately prior to the needle cannulation • When using lidocaine, the minimal amount (0.2 cc) should be used. Ensure that the lidocaine is injected only into the tissue on top of the access 256 DIALYSIS ACCESS DEVICE

CANNULATION D. NEEDLE SELECTION • The specific gauge of the needles used for cannulation should always be ordered by the nephrologist in order to ensure that an adequate blood flow rate is achieved for the proper delivery of the dialysis prescription • The length of the needles, on the other hand, may be altered by the dialysis staff in order to reach deep grafts • The needles used should always have a back eye to ensure that the optimal flow is achieved 257 DIALYSIS ACCESS DEVICE

CANNULATION E. CANNULATION TECHNIQUE • The needle should be held by the wings, with the bevel of the needle facing upward for the cannulation • The needle should be held at a 20- to 35-degree angle for AV fistulas, and at approximately a 45-degree angle for grafts. • Once the needle has been advanced http://dialmedsupply.com/jms/har through the skin, subcutaneous tissue, and mony.html graft or fistula wall, the blood flashback should be visible 258 DIALYSIS ACCESS DEVICE

CANNULATION 259 E. CANNULATION TECHNIQUE • Continue to advance the needle no greater than 1/8 of an inch and then rotate the needle 180 degrees • The needle bevel is rotated to help prevent a “back wall” or posterior wall infiltration, which can occur if the needle bevel tip accidentally punctures the bottom of the graft or fistula • The needle should then be leveled out (i.e., placed flat against the skin) and then advanced slowly up to the needle hub DIALYSIS ACCESS DEVICE

CANNULATION F. SECURING THE NEEDLE • The wings of the fistula needle can be secured by using a butterfly tape technique • An adhesive bandage or a 2x2 gauze pad is then placed over the needle and secured by another 6”-long piece of tape • Should any movement of the needles occur during the dialysis procedure, a 2x2 gauze pad may be placed under the needle wings to correct the needle angle https://homedialysis.org/home- dialysis-basics/solo-hhd 260 DIALYSIS ACCESS DEVICE

CANNULATION G. REMOVAL OF THE NEEDLE • The tape should be carefully removed post-dialysis to prevent movement of the needles. Each needle is then withdrawn slowly, at a 20-degree angle, until the entire needle has been removed • Once the needle has been removed, mild digital pressure should be applied to the needle exit sites of both the skin and graft or vessel wall • A gauze pad should be held over the sites with constant pressure, without peeking, for 10 to 15 minutes 261 DIALYSIS ACCESS DEVICE

CANNULATION H. DISCHARGE DRESSING AND ASSESSMENT • Always discharge the patient from the unit with an adhesive bandage or gauze pad over the cannulation sites • Before the patient leaves the unit, assess and document the quality of the bruit and thrill 262 DIALYSIS ACCESS DEVICE

NURSING CARE AND PATIENT EDUCATION 263

NURSING CARE 1. Remove any restrictive clothing or jewelry from the arm 2. 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 3. 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 4. Assess for patency at least every 8 hours 5. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency 264 DIALYSIS ACCESS DEVICE

NURSING CARE 6. Auscultate the vascular access with a stethoscope to detect a bruit or \"swishing\" sound that indicates patency 7. Check the patient's circulation by palpating his pulses distal to the vascular access; observing capillary refill in his fingers; and assessing him for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity 8. Notify the healthcare provider promptly if you suspect clotting 9. Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection 265 DIALYSIS ACCESS DEVICE

NURSING CARE 10. After dialysis, assess the vascular access for any bleeding or hemorrhage 11. When you move the patient or help with ambulation, avoid trauma to or excessive pressure on the affected arm 12. Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm that can rupture and cause hemorrhage 13. Monitor serum electrolytes, blood urea nitrogen, creatinine, and hemoglobin and hematocrit levels before and after dialysis. Monitor fluid status. Monitor coagulation studies because heparin is used to prevent clotting during dialysis 14. Document assessment findings, any interventions and patient responses, patient teaching, and the patient's level of understanding 266 DIALYSIS ACCESS DEVICE

PATIENT EDUCATION • Check the function of the vascular access several times a day by palpating it and feeling for vibration • Monitor for any bleeding after dialysis • Monitor for signs of infection (pain, redness, swelling) • Keep the site clean • Avoid wearing any clothing or jewelry that restricts the access and to prevent anyone from using the extremity to obtain BP or perform venipuncture • Do not use the arm with vascular access to carry heavy objects and not to sleep on the arm 267 DIALYSIS ACCESS DEVICE

TEMPORARY DIALYSIS ACCESS DEVICES 268

PERCUTANEOUS ACCESS • PERCUTANEOUS ACCESS o Percutaneous access is the term used to describe the insertion of a cannula or catheter into a major vein, often termed a central venous catheter (CVC) o Catheters may be inserted as a temporary measure, as in acute kidney injury, or for temporary use whilst a fistula matures. https://www.kidneycareuk.org/about-kidney- health/treatments/dialysis/haemodialysis/inser ting-your-tunnelled-haemodialysis-catheter- permcath/ o The broad categories of catheters used for hemodialysis vascular access are non-tunneled catheters and tunneled catheters 269 DIALYSIS ACCESS DEVICE

PERCUTANEOUS ACCESS • PERCUTANEOUS ACCESS o The use of the subclavian vein is not recommended in patients with end-stage kidney disease as this may adversely affect the success of the creation of an AVF due to central venous stenosis. o Femoral catheters should only be used in those who are immobile and should be changed every 1–3 days o Any patient who has the option of undergoing a kidney transplantation should not have a femoral catheter placed to avoid stenosis of the iliac vein, to which the transplanted kidney vein is anastomosed 270 DIALYSIS ACCESS DEVICE

PERCUTANEOUS ACCESS 271 • ADVANTAGES o Dialysis can be performed immediately o Readily inserted during an outpatient procedure o Easy placement and removal o Avoids extra needle sticks • DISADVANTAGES o Not ideal for use as a permanent access o High infection rates o Difficult to obtain sufficient blood flow to allow for adequate toxin removal o May cause narrowed veins o Swimming and bathing is not recommended DIALYSIS ACCESS DEVICE

TYPES OF DIALYSIS CENTRAL CATHETERS 272

NON-TUNNELED CATHETER VasCath (Quinton catheter) ARTERIAL LUMEN • A Vas Cath is a specialized non- tunneled central venous catheter VENOUS used in dialysis LUMEN • At minimum, it has two large bore BLOOD INTAKE 273 lumens, one to take blood from the LUMEN body and the other to return it after dialysis BLOOD RETURN LUMEN • There may be a third lumen, which is of much finer caliber, which is used https://www.medicalexpo.com/pro for the administration of fluids and d/bard-access-systems/product- drugs 78824-549271.html CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER • Its primary function is to be used for dialysis in patients with acute renal failure • These catheters can be placed at bedside especially in an emergent situation where large bore venous access is needed • An x-ray is usually performed after insertion to confirm the position of the catheter • To prevent the catheter from blocking, Vascath lumens need to be flushed with saline and ‘locked’ with heparin, which stops blood clots from forming. The nurse should do this with every use 274 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER CUFF PERMCATH • Permacaths are tunneled catheters used for short term dialysis or until a permanent dialysis fistula can be created • The permacath has a cuff that holds the catheter in place and acts as a barrier to infection • These catheters are blunt, soft, and https://www.indiamart.com/proddetail more flexible than non-tunneled /bard-hemosplit-long-term- catheters hemodialysis-catheters- CENTRAL VENOUS CATHETERIZATION 20546794348.html 275

PERMCATH 276 • These tunneled central venous catheter can be left in place for as long as one year and provide permanent access in patients • However despite being considered permanent the longer they are in place the greater the risk that they will eventually become infected • This is why most physicians will try to use these catheters as a bridge for finding other means of even more permanent dialysis such as an arteriovenous fistula or graft CENTRAL VENOUS CATHETERIZATION

INITIATION OF DIALYSIS 277

INITIATION OF DIALYSIS A. GATHER EQUIPMENT o Non-sterile gloves o 2 x 10 mL syringes o Non-sterile gown o 4 x 10 mL syringes or 2 o Non-sterile mask (2)/eye x 20 mL syringes filled protection with normal saline for o Sterile gloves flush o Sterile dressing tray or o Patient specific dressing (gauze or equivalent transparent) o Sterile drape/gauze (or o Garbage receptacle sterile 4x4) o Antiseptic wipes (several) o 2 x 10 mL syringes to withdraw locking solution 278 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS B. PREPARATION • Place the patient supine in as flat a position as the patient can comfortably tolerate (e.g., Semi-Fowler’s position) • Perform hand hygiene • Gather supplies, including preparing 4 x 10 mL or 2 x 20 mL syringes filled with normal saline • Don non-sterile gown (staff) • Don non-sterile mask (staff and patient) and eye protection • (staff) Perform hand hygiene 279 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS C. CLEANSE PORTS, CLAMPS AND LIMBS • Don sterile gloves or, if using no-touch technique, clean gloves • Using an antiseptic wipe, cleanse each port, clamp and limb using friction scrub for 30 seconds • Un-clamp, move clamp, clean under clamp segment, and re-clamp. Use new wipes for each port • Place catheter limbs on a fresh, dry, sterile 4x4 drape/gauze Air-dry 280 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS D. WITHDRAW LOCKING SOLUTION • Ensure port/ clamps are closed • Hub-scrub the arterial port with an antiseptic wipe • Attach an empty 10 mL syringe to arterial port • Open arterial clamp and withdraw locking solution, blood • and/or clots (total 5 mL). Close clamp. Discard syringehttps://www.icumed.com/p roducts/specialty/renal- Repeat hub-scrub. Assess patency by attaching a newsystems/tego-connector empty 10 mL syringe to the arterial port and aspirate 3 – 5 mL of blood to check for clots and the flow of the lumen. If no clots are noted, continue the procedure and gently flush the catheter lumen. Clamp port 281 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS D. WITHDRAW LOCKING SOLUTION • Repeat procedure in venous catheter lumen • Remove the flushing syringe from the arterial lumen and connect the respective bloodline in an aseptic manner • Follow the same procedure for the venous lumen • Ensure all connections (catheter lumens/bloodlines) are secured and correctly positioned. Open all clamps and discard syringes • Protect the catheter with the drape during the treatment 282 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS E. CONNECT BLOOD LINES AND INITIATE DIALYSIS “DIRECT METHOD” • Repeat hub-scrub. Remove syringe from the arterial port and discard. Ensure there is no air in the arterial blood line. Connect the arterial blood line to the arterial port maintaining tip to tip sterility. Ensure connections are secure • Repeat hub-scrub. Remove syringe from venous port and discard. Ensure there is no air in the venous blood line. Connect the venous blood line to the venous port. Ensure connections are secure 283 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS 284 E. DISCONNECTION OF LINE • The disconnection of dialysis via a CVC requires similar precautions as connection, since the risks associated are also similar • After completing the hemodialysis treatment perform an assessment of the patient's' general condition (temperature, blood pressure, pulse etc.) • Perform hand hygiene • Prepare yourself with personal protective equipment (PPE) (apron, face and respiratory protection and head cover) DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS E. DISCONNECTION OF LINE • Uncover the catheter and remove the used gauze • Stop HD machine blood pump as per manufacturers operating instructions • Put on one pair of sterile of gloves • Using an aseptic technique, lift the catheter up and place a sterile drape underneath. Place dry sterile gauze under catheter lumens and wrap disinfectant soaked gauze around each catheter lumen/bloodline connection 285 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS •E. DISCONNECTION OF LINE Using sterile gauze, close the arterial catheter lumen and the arterial bloodline clamps and disconnect the arterial • bloodline from the catheter lumen Using an aseptic technique, connect the 0.9% NaCl solution syringe (never less than 10 mL syringe) to the • arterial catheter lumen, flush it and close the clamp Perform reinfusion procedure according to the • Hemodialysis System/Machine Operating Instructions Repeat the steps for the disconnection of the venous line, proceed to lock the catheter following the procedure 286 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS F. LOCKING THE LINE • Prophylaxis against catheter thrombosis, as well as against infection is important and should be started immediately after the catheter insertion and maintained during the entire life cycle of the catheter LOCKING ANTICOAGULANT BACTERICIDE RISK ASSOCIATED SOLUTION EFFECT EFFECT Bleeding/Hemorrh Heparin + - age 4% Citrate - 30-46% Citrate + +/- Cardiac arrest Urokinase ++ Bleeding/Hemorrh age +- 287 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS 288 F. LOCKING THE LINE • Before flushing and locking the catheter, make sure to gather the following information: o The internal volume of each CVC lumen o The type of locking solution (e.g. heparin, citrate,) to be used or if only saline solution is prescribed for preserving the lumens o The concentration of locking solution as prescribed o The volume of locking solution as prescribed DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS F. LOCKING THE LINE • After the blood reinfusion, and disconnection of the bloodlines, the CVC lumens clamps remain close • Immediately connect a 10 ml syringe filled with 0.9% Sodium Chloride and gently, applying a moderate pressure, flush back the residual blood on the catheter lumens • Clamp the catheter lumen prior to removing the syringe to prevent blood from flowing back to the tip of the lumen while the hub of the catheter is open 289 DIALYSIS ACCESS DEVICE

INITIATION OF DIALYSIS F. LOCKING THE LINE • Immediately attach the syringe with the prescribed locking solution, unclamp the catheter lumen, and gently apply the appropriate volume of locking solution slowly (approximately 8-10 seconds) • Close the clamp on the catheter lumen and remove the syringe • Immediately close the hub with a sterile cap • Repeat the procedure for the other catheter lumen 290 DIALYSIS ACCESS DEVICE

5. ARTERIAL CATHETERIZATION 291

INTRODUCTION • Arterial catheterization is a https://en.wikipedia.org/wiki/Arterial_2li9ne2 procedure that is common to the intensive care and the operating room settings • It involves placement of a catheter into the lumen of an artery for invasive blood pressure (BP) monitoring and intravascular access for blood sampling ARTERIAL CATHETERIZATION

INTRODUCTION • A golden rule is that there has to PRESSURE be collateral circulation to the BAG area affected by the chosen artery, so that peripheral PRESSURE circulation is maintained by TRANSDUCER another artery even if circulation AND AUTOMATIC is disturbed in the cannulated FLUSHING artery SYSTEM ARTERIAL LINE SALINE FILLED NON- COMPRESSIBLE TUBING http://www.nu2icu.com/nu2icu-haemodynamics/nu2icu- haemodynamic-monitoring-in-icu-arterial-lines-map/ 293 ARTERIAL CATHETERIZATION

INTRODUCTION • INDICATIONS FOR ARTERIAL LINE o Continuous beat-to-beat monitoring of blood pressure in hemodynamically unstable patients o Frequent sampling of blood for laboratory analysis o Timing of intra-aortic balloon pump with the cardiac cycle • CONTRAINDICATIONS o Absent pulse o Burns over the cannulation site o Inadequate circulation to the extremity o Raynaud’s syndrome 294 ARTERIAL CATHETERIZATION

SITES FOR ARTERIAL LINE • In both adults and DEEP BRACHIAL AXILLARY ARTERY children, the most ARTERY common site of BRACHIAL ARTERY cannulation is the ULNAR ARTERY radial artery RADIAL ARTERY 295 ARTERIAL CATHETERIZATION

SITES FOR ARTERIAL LINE • The femoral artery is the FEMORAL ARTERY second most common site for arterial cannulation ADVANTAGES: ⮚ Vessel is larger than the radial artery and has stronger pulsation POSTERIOR TIBIAL ARTERY ⮚ Decreased risks of thrombosis and of accidental catheter dislodgement DORSALIS PEDIS ARTERY 296 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT 297

ARTERIAL LINE PLACEMENT A. GATHER EQUIPMENT • Blood pressure monitor: • Antiseptic solution o IV saline bag (500 ml) • Sterile drapes and towels o Pressure bag, and hanger • Sterile head caps, masks, o Integrated arterial • Gowns, gloves pressure line Face shields • Chlorhexidine patch, • Cannulation device: transparent occlusive dressing o Integrated catheter and guidewire device • Nonabsorbable suture • Local anesthetic o separate needle, • Sterile gauze guidewire and catheter • Syringes 298 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT B. POSITION THE PATIENT https://link.springer.com/cha pter/10.1007/978-3-319-91164- • Position the patient 9_29 comfortably reclined or supine • Rest the patient's forearm supinated and with the wrist extended on the bed or a bedside table; support may be useful under the wrist 299 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT C. LOOK FOR SUITABLE ARTERY • Palpate the radial artery in detail with the tip of the index finger of your nondominant hand. Systematically palpate, release, and shift slightly over the artery, to precisely discern the center axis of the artery • Some clinicians do the Allen test to determine whether there is sufficient collateral flow through the ulnar artery to perfuse the hand if the catheter occludes the radial artery 300 ARTERIAL CATHETERIZATION