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HEMODIALYSIS VASCULAR ACCESS
Presented By:Presented By:Hosein KarimiBSN , MSA (Anesthesia and Intensive Care)BSN , MSA (Anesthesia and Intensive Care)
HEMODIALYSIS VASCULAR ACCESS
Cardiovascular Systemy
Anatomy of vessels y
The capillariesp
Capillary Bedp y
Principle Of HEMODIALYSISp
Effects of different components on vascular tone
Systemic response to central hypovolemiaat different stageat different stage
IVC Diameter (mm) vs. CVP (mmHg)
Components of dialysis fluidComponents of dialysis fluidp y
BufferNormally bicarbonate
ElectrolytesSodium PotassiumPotassiumCalciumMagnesiumgChloride
Glucose
Change in potassium during dialysis (average for 7 sessions)(average for 7 sessions)
8 0
6 0
7.0
8.0
) 01DE
4 0
5.0
6.0
m (m
mol
/l 02ES03SK04IL05DC
2 0
3.0
4.0
Pota
ssiu
m 05DC06DS07CW08GO
0 0
1.0
2.0 09JW
0.0Pre Post 45 mins
Sample
Pre-dialysis sodium levels for 7300 sessions
2000
Normal range
1600
1800o a a ge
1200
1400
of p
atie
nts
600
800
1000
Sodium (mmol/l)Num
ber o
200
400
600
0
200
124 126 128 130 132 134 136 138 140 142 144 146 148 150
Understanding YourHEMODIALYSIS ACCESS OPTIONSHEMODIALYSIS ACCESS OPTIONS
Duration of Catheter Use
Time from 1st Dialysis to Catheter RemovalTime from 1 Dialysis to Catheter Removal
1992 1998 71 9 d1992 – 1998 71 + 9 days
1999 – 2003 141 + 26 days
New Access by Typey yp
2006 US Renal Data System2006 US Renal Data System
Fistula Graft Catheter
Insertion Techniqueq
Right external jugular
Sternocleidomastoid Muscles
Right Common Carotid Artery
Right InternalJugular
Insertion Techniqueq
Acute Catheter Tip Chronic Catheter Tip
SVC or Caval Right Atrial Junction Right Atrium
0% Recirc lation Rate5% Recirculation Rate 0% Recirculation Rate
Right Atrial Tip Placementg p
I d Fl R t
TUNNELED CATHETERS ONLY
• Improved Flow Rates
• Consistent (Reproducible) Flow Rates
• Zero Recirculation Rate
• Improved Clearance
Ante grade Tunneled CHD Catheters
Left Internal Jugular Vein Placement
Venotomy Location
Left Internal Jugular Vein Placement
Venotomy Location
Tip Location
R lResults:1. Good tip placement, but
poor cuff and exit site placement or
2 G d ff d it it2. Good cuff and exit site placement, but poor tip placement
Step 1: Place Catheter Tips First
Left Internal Jugular Vein Placement
Benefit #1: Minimizes risk of
Left Internal Jugular Vein Placement
Catheter tip malpositioningBenefit #2: Minimizes risk of catheter recirculation
Venotomy Location
of catheter recirculationBenefit #3: Minimize riskof catheter clotting
Tip Location
Advantages of Arteriovenous FistulasArteriovenous Fistulas
• Longevity - fistulas last longer than grafts
D bilitLower
• Durability - fewer complications
fewer reparative procetures
Costs
- fewer reparative procetures
Fistulas are not as good as you’ve been told ,and Grafts are not as badand Grafts are not as bad …
PTFE (PolytetraFluoroethylene) Graft ( y y )
angioplasty angioplasty
angioplasty
Fistula angioplasty
Checks each month in grafts and in A/V fistula with dysfunctionA/V fistula with dysfunction
Screening Procedure include :
1- Physical Examination1 Physical Examination
2- Measurement of Recirculation rate
3- Measurement of static and dynamic venous pressure
4- colour-coded duplex ultrasound
Recommended by DOQI (Dialysis Outcomes Quality Initiative )
Guideline
Reference :
1- Applied Physiology in Intensive CareMedicine 2006
2- FISTULA FIRST 3 On Course With Cannulation3- On Course With Cannulation4- CDC Guide Line5- Gray’s Anatomy
QuestionsQuestions
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