{"id":215,"date":"2018-04-23T12:10:44","date_gmt":"2018-04-23T12:10:44","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=215"},"modified":"2023-03-09T12:23:03","modified_gmt":"2023-03-09T12:23:03","slug":"vascular-access","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/dialysis-handbook\/dialysis-information\/vascular-access\/","title":{"rendered":"Vascular access"},"content":{"rendered":"<h3><strong><span style=\"color: #993300;\">Veins<\/span><\/strong><\/h3>\n<p>Native vein fistulas are the best permanent access for haemodialysis, and damaged veins make poor fistulas.\u00a0 Therefore, when inserting IV catheters:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Avoid forearm veins &#8211; use the hand<\/li>\n<li>Do not use arm with a working fistula<\/li>\n<li>Take blood on dialysis where possible (liaise with nurses)<\/li>\n<li>Preserve veins by limiting venepuncture to one arm if possible (preferably dominant arm)<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Fistulas<\/span><\/strong><\/h3>\n<p>Fistulas are the gold standard of vascular access.\u00a0 They are end to side vascular anastamoses, usually radiocephalic, brachiocephalic or brachiobasilic.\u00a0 They are created by either the vascular or transplant surgeons.\u00a0 May also use synthetic (PTFE\/Gortex) grafts which are a conduit between artery and vein.<\/p>\n<p>Remember to update the vascular access screen on Vital Data after creation.<\/p>\n<p><strong><span style=\"color: #993300;\">When to Organise<\/span><\/strong><\/p>\n<p>Usually refer for fistula up to 1 year before required.<br \/>\nRenal Association guidelines state 67% of people should have fistula if seen by nephrologists &gt;4\/12 prior to starting dialysis (good practice).<\/p>\n<p><strong><span style=\"color: #993300;\">How to Organise<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>vascular access referral form to the vascular access coordinator (see details on <a href=\"https:\/\/edren.org\/ren\/handbook\/unithdbk\/renal-unit-contacts\/\">contacts page<\/a>) who will either see the patient on the ward (inpatients), on dialysis, or in the nurse led clinic.\u00a0 The coordinator will organize duplex scan of limb vessels, add patient to the appropriate theatre list and organise admission.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Fistula Creation<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Majority done under local anaesthetic, but some general anaesthetic cases (particularly transpositions).<\/li>\n<li>Local anaesthetic:\u00a0 Admission to day surgery unit on a non dialysis day.<\/li>\n<li>General anaesthetic:\u00a0 majority admitted to vascular ward the day before theatre.\u00a0 Ensure adequately dialysed pre-op, with other usual pre-operative assessment.<\/li>\n<li>Note: stop warfarin 48 hours prior to admission unless specific instructions from surgeons.\u00a0 No heparin, continue with aspirin.\u00a0 Seek advice from co-ordinator\/surgeon re combination of aspirin and clopidogrel.<\/li>\n<li>Antibiotic prohylaxis required:\u00a0 see antimicrobial policy.<\/li>\n<li>Post operatively: ensure BP adequate.\u00a0 Document pulses and thrill.\u00a0 Restart any stopped drugs, including anticoagulation.\u00a0 Home with prophylactic antibiotics.\u00a0 Instruct patient to contact vascular access coordinator or ward if thrill disappears.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Time to Use<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Time taken for fistula maturation is variable, average 8 weeks, but up to 6 months.<\/li>\n<li>Need to examine fistula prior to first use.<\/li>\n<li>First cannulation should be undertaken by an experienced nurse.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Complications<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>With all complications the vascular access co-ordinator and the surgeon who performed the procedure needs to be informed.\u00a0 Primary failure of fistulas occurs in 9-35% depending on the site.\u00a0 Risk factors for primary failure includes age, raised BMI, female gender, diabetes, peripheral vascular disease or cardiovascular disease.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Early<\/span><\/strong><\/p>\n<table style=\"width: 100%; border: 2px solid #993300; padding: 4px;\">\n<tbody>\n<tr>\n<td style=\"width: 25.0574%; background-color: #e6f7ed; border-style: solid; border-color: #993300;\"><strong><span style=\"color: #993300;\">Complication<\/span><\/strong><\/td>\n<td style=\"width: 41.6092%; background-color: #e6f7ed; border-style: solid; border-color: #993300;\"><strong><span style=\"color: #993300;\">Associations<\/span><\/strong><\/td>\n<td style=\"width: 33.3333%; background-color: #e6f7ed; border-style: solid; border-color: #993300;\"><strong><span style=\"color: #993300;\">Action<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 25.0574%; vertical-align: top; border-style: solid; border-color: #993300;\">Stopped<\/td>\n<td style=\"width: 41.6092%; border-style: solid; border-color: #993300;\">Intravascular volume depletion<br \/>\nHypotension<br \/>\nHypercoagulability<br \/>\nMetatastic calcification<\/td>\n<td style=\"width: 33.3333%; border-style: solid; border-color: #993300; vertical-align: top;\">Potentially reversible<br \/>\nGive Fluids<br \/>\nD\/W surgeon immediately<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 25.0574%; border-style: solid; border-color: #993300;\">Bleeding<\/td>\n<td style=\"width: 41.6092%; border-style: solid; border-color: #993300;\"><\/td>\n<td style=\"width: 33.3333%; border-style: solid; border-color: #993300;\">D\/W surgeon immediately<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 25.0574%; border-style: solid; border-color: #993300; vertical-align: top;\">Infection\/abscess<\/td>\n<td style=\"width: 41.6092%; vertical-align: top; border-style: solid; border-color: #993300;\">Prosthetic grafts\/MRSA<\/td>\n<td style=\"width: 33.3333%; border-style: solid; border-color: #993300;\">Septic screen inc swab<br \/>\nAntibiotics &#8211; usually flucloxacillin or d\/w med micro<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong><span style=\"color: #993300;\">Late<\/span><\/strong><\/p>\n<table style=\"width: 100%; border: 2px solid #993300; padding: 4px; height: 624px;\">\n<tbody>\n<tr style=\"height: 24px;\">\n<td style=\"background-color: #e6f7ed; border-color: #993300; width: 33.011%; height: 24px;\"><strong><span style=\"color: #993300;\">Complication<\/span><\/strong><\/td>\n<td style=\"background-color: #e6f7ed; border-color: #993300; width: 37.1547%; height: 24px;\"><strong><span style=\"color: #993300;\">Associations<\/span><\/strong><\/td>\n<td style=\"background-color: #e6f7ed; border-color: #993300; width: 29.6961%; height: 24px;\"><strong><span style=\"color: #993300;\">Action<\/span><\/strong><\/td>\n<\/tr>\n<tr style=\"height: 48px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 48px;\">Bleeding<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 48px;\">Infection<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 48px;\">Compression. Urgent vascular referral<\/td>\n<\/tr>\n<tr style=\"height: 96px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 96px;\">Thrombosis<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 96px;\">Intravascular volume depletion<br \/>\nHypotension<br \/>\nHypercoagulability<br \/>\nMetatastic calcification<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 96px;\">Potentially reversible<br \/>\nD\/W surgeon immediately<\/td>\n<\/tr>\n<tr style=\"height: 96px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 96px;\">Infection\/abscess<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 96px;\">Prosthetic grafts\/MRSA<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 96px;\">Septic screen inc swab<br \/>\nAntibiotics &#8211; usually flucloxacillin or d\/w med micro<\/td>\n<\/tr>\n<tr style=\"height: 72px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 72px;\">Stenosis\/Poor<br \/>\nflow\/Developing<br \/>\nabnormailty\/Not maturing<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 72px;\">Inadequate dialysis<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 72px;\">Inform vascular access co-ordinator, arrange duplex, d\/w surgeons<\/td>\n<\/tr>\n<tr style=\"height: 120px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 120px;\">Distal Ischaemia\/Steal<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 120px;\">Arterial insufficiency or venous HT, large fistulas<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 120px;\">Inform vasc access co-ord\/surgeon, arrange duplex, may require closure\/revision<\/td>\n<\/tr>\n<tr style=\"height: 72px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 72px;\">Aneurysm<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 72px;\">True : Pseudo<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 72px;\">Inform vasc access coord : requires duplex and surgical revision<\/td>\n<\/tr>\n<tr style=\"height: 96px;\">\n<td style=\"border-color: #993300; vertical-align: top; width: 33.011%; height: 96px;\">High output cardiac failure<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 37.1547%; height: 96px;\">Coexistent cardiac disease, large hypertrophied high flow fistulas<\/td>\n<td style=\"border-color: #993300; vertical-align: top; width: 29.6961%; height: 96px;\">ECHO. Inform vasc access coord\/surgeon : may req banding\/revision.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: center;\"><span style=\"font-size: 12pt;\">Duplex scans usually organised by vascular access coordinator but if unavailable then d\/w radiologist.<\/span><\/p>\n<h3><strong><span style=\"color: #993300;\">Tunnelled Central Catheters (PERMCATHS)<\/span><\/strong><\/h3>\n<p>Semi-permanent access utilised in the intermediate term. Used whilst awaiting fistula\/graft placement or maturation. Also used in those with delayed recovery from ARF or those with no further options for native vascular access.<\/p>\n<p>Remember to update the vascular access screen on Vial Data for insertion\/removal<\/p>\n<p><strong><span style=\"color: #993300;\">When to Organise<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Fistula not created<\/li>\n<li>Fistula not mature<\/li>\n<li>Fistula problem meaning it cannot be used<\/li>\n<li>Prolonged ARF req dialysis with numerous temporary lines.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">How to Organise<\/span><\/strong><\/p>\n<p>Request on TRAK and discuss with interventional radiologist. Permcaths placed under fluoroscopy.<\/p>\n<p><strong><span style=\"color: #993300;\">Pre Procedure:<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Bloods including FBC\/U+E\/Clotting\/G+S required<\/li>\n<li>Consent form (completed in radiology)<\/li>\n<li>Prophylactic antibiotics: see prophylactic antibiotic regimens<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Post Procedure:<\/span><\/strong><\/p>\n<p>Permcath can be used immediately.\u00a0 No need for CXR to check position.<\/p>\n<p>Do not use for any purpose other than haemodialysis\/CMH<\/p>\n<h3><strong><span style=\"color: #993300;\">Complications<\/span><\/strong><\/h3>\n<table style=\"width: 100%; border: 2px solid #993300; padding: 4px;\">\n<tbody>\n<tr>\n<td style=\"width: 37.2414%; border-color: #993300; vertical-align: top; background-color: #e6f7ed;\"><strong><span style=\"color: #993300;\">Problem<\/span><\/strong><\/td>\n<td style=\"width: 62.7586%; border-color: #993300; vertical-align: top; background-color: #e6f7ed;\"><strong><span style=\"color: #993300;\">Action<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 37.2414%; border-color: #993300; vertical-align: top;\">Bleeding\/haematoma post insertion<\/td>\n<td style=\"width: 62.7586%; border-color: #993300; vertical-align: top;\">Apply pressure and dressing<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 37.2414%; border-color: #993300; vertical-align: top;\">Infection<\/td>\n<td style=\"width: 62.7586%; border-color: #993300; vertical-align: top;\">Exit site swab, blood\/line cultures, Empirical antibiotics<br \/>\nMay require line removal<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 37.2414%; border-color: #993300; vertical-align: top;\">Blockage\/Poor flow<\/td>\n<td style=\"width: 62.7586%; border-color: #993300; vertical-align: top;\">Check line position<br \/>\nMay require urokinase\/line stripping (see below)<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 37.2414%; border-color: #993300; vertical-align: top;\">Inadvertent bolus of herparin lock<\/td>\n<td style=\"width: 62.7586%; border-color: #993300; vertical-align: top;\">Dialysis with no further heparin. If bleeding d\/w Haem SpR<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>If permcath providing poor blood flows (&lt;150 mls\/min) or is blocked then:<\/p>\n<ol>\n<li>Flush with 30ml boluses of normal saline.\u00a0 Remember permcaths are locked with 1000u\/ml repair which must be removed before finishing.<\/li>\n<li>Urokinase\/Alteplase\/Stripping &#8211; see below.<\/li>\n<\/ol>\n<h3 style=\"font-family: 'Source Sans Pro';\"><strong><span style=\"color: #993300;\">Infection Control<\/span><\/strong><\/h3>\n<p>Infection of any form of vascular access is a serious complication and is best avoided. To facilitate this, every patient with a tunnelled dialysis catheter must have nasal swabs performed for MRSA\u00a0<strong><span style=\"color: #993300;\"><u><span style=\"color: #993300;\">and<\/span><\/u><\/span><\/strong> MSSA (sensitive Staph. aureus); the results should be known and positive results acted upon (see protocol under Infection Control).<\/p>\n<p><strong><span style=\"color: #993300;\">Temporary lines<\/span><\/strong><\/p>\n<p>Used in acute renal failure and as a temporary measure in patients with ESRF whose other access is not available (for example, malfunctioning fistula).\u00a0\u00a0 Do not use for any purpose other than haemodialysis\/CMH.\u00a0 Remember temporary lines are &#8216;locked&#8217; with 1000u\/ml Heparin and this must be removed first.<\/p>\n<p>Inserted using sterile Seldinger technique under USS guidance to minimise complications. Use either double or triple lumen (IV fluid\/drug administration). To prevent thrombus formation both lumens of catheter are instilled with heparin (1000u\/ml), the amount required is clearly labelled, this limits systemic heparinisation.<\/p>\n<p><strong><span style=\"color: #993300;\">1. Internal Jugular lines<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>R sided easier to insert than L and get higher blood flows.<\/li>\n<li>16cm line usually used.<\/li>\n<li>Allows measurement of CVP if triple lumen used<\/li>\n<li>Difficult to place in pulmonary oedema<\/li>\n<li>Complications include carotid artery puncture (minimised with USS) and pneumothorax (less risk R&gt;L)<\/li>\n<li>Check CXR mandatory<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">2. Femoral Lines\u00a0<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>19cm line usually used<\/li>\n<li>Complication rate of insertion lowest (femoral artery perforation minimised with USS, apply compression)<\/li>\n<li>Easier to place in pulmonary oedema<\/li>\n<li>Preferable for patients with respiratory disease\/distress as avoids possibility of pneumothorax.<\/li>\n<li>Infection rate higher than other temporary lines.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">3. Subclavian Lines<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Least preferred route<\/li>\n<li>Increased risk of stenoses\/thromboses with consequent loss of ipsilateral arm for future HD access<\/li>\n<li>Check CXR mandatory<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Unblocking catheters<\/span><\/strong><\/h3>\n<p>INDICATION FOR UROKINASE\/ ALTEPLASE &#8211; clearing of clotted dual lumen catheters, and those giving insufficient blood flow rate (&lt;150ml\/min) where flushing with boluses of 30ml saline has been ineffective.\u00a0 If these protocols do not clear the problem, for a tunnelled catheter consider radiological intervention for &#8216;stripping&#8217; or investigation.<\/p>\n<p><span style=\"color: #000000;\">Protocol for <strong><span style=\"color: #993300;\">ALTEPLASE<\/span> <\/strong>can be viewed <a href=\"http:\/\/edren.org\/ren\/handbook\/unithdbk\/prescribing\/renal-drugs-a-z\/alteplase\/\">here<\/a><\/span><\/p>\n<p><strong><span style=\"color: #993300;\">Catheter stripping<\/span><\/strong><\/p>\n<p>Fibrin sheaths can be removed mechanically from semi-permanent lines.\u00a0 A snare is inserted via another route (usually femoral vein).\u00a0 Discuss with interventional radiologists.<\/p>\n<p><strong><span style=\"color: #993300;\">Anticoagulation<\/span><\/strong><\/p>\n<p>Controlled trial evidence has suggested that anticoagulation for vascular access protection is more likely to cause serious bleeding than to save access.\u00a0 There may be individual circumstances where the balance of risk is different.<\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt; color: #808080;\"><strong>Acknowledgements:\u00a0\u00a0<\/strong> Angela Webster was the original author for this page. It was revised in November 2006 and the last modified date is shown in the footer.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Veins Native vein fistulas are the best permanent access for haemodialysis, and damaged veins make poor fistulas.\u00a0 Therefore, when inserting IV catheters: Avoid forearm veins &#8211; use the hand Do not use arm with a working fistula Take blood on dialysis where possible (liaise with nurses) Preserve veins by limiting\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/dialysis-handbook\/dialysis-information\/vascular-access\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":5958,"menu_order":35,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"class_list":["post-215","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/215","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=215"}],"version-history":[{"count":23,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/215\/revisions"}],"predecessor-version":[{"id":5685,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/215\/revisions\/5685"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/5958"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=215"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}