High venous pressure - SEDYT · for pump ﬂow (Qb), venous pressure (Pv), molecu-lar clearance and dialysis time could be improved and reductions in clinical complications can be

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34

ral circulation and the access, the blood fraction towardshe fistula decreases and the peripheral one increases

Before carrying out a DRIL, it is advisable to rule out bothnput and output arterial stenoses. Certain technical factorsust be taken into account for the DRIL technique to be

uccessful. In the immediately proximal artery segment tohe arteriovenous anastomosis, there is a low pressure areapressure background) due to the great capacitance of theenous output flow. Locating the origin of the bypass graft 3o 5 cm above the AV anastomosis is sufficient to avoid thisow-pressure background. Although it is preferable to useutologous material, the procedure has been successfullyarried out with prosthesis. The output anastomosis muste carried out in the dominant distal artery.

igh venous pressure

igh venous pressure may cause an important oedema of thextremity. This is usually caused by stenosis or obstructionf the veins proximal to the fistula, often related to therevious use of central catheters.

The treatment possibilities include: ligature of theccess, simple angioplasty or with stent in the central steno-is or the execution of an axillary jugular bypass.

ttp://dx.doi.org/10.1016/j.dialis.2012.06.010

10.8

enous catheters: problems and measures in nursing care

ilar Urzainqui-Laborda

Nephrology, Navarre Hospital Complex, Virgen del Caminoospital, Pamplona, Spain

The quality of vascular access (VA) is a determining factorn clinical results of patients receiving periodic haemodial-sis treatment (HD). The complications arising from VAysfunction constitute one of the main causes of morbiditynd mortality amongst patients and substantially increaseealth care costs.

The need for vascular access is as old as HD itself, givenhat access to the bloodstream is necessary to eliminateoxic substances.

Ideal VA should bring together at least three require-ents: i) a safe, continuous approach to the vascular

ystem; ii) provision of sufficient flow to supply an adequateD dosage, and iii) present no complications.

isk factors

ntravascular catheters are plastic devices that provideccess to the intravascular compartment at a central level,hey vary in design and structure according to if they areemporary (days) or permanent (weeks, months) as well asn the material they are made of and the reason why theyre implanted.

These devices have been of great clinical use as they
nable fast, safe access to the bloodstream to adminis-er medications, treatments fluids and parenteral nutrition.owever, they are not exempt from risks such as infectiousr mechanical complications arising from their use.
g

Ponencias/comunicaciones

. Infection from use of central vascular catheters(CVC) constitutes one of the main complications andthe main cause of primary nosocomial bloodstreaminfection. The incidence of infection attributable tocatheter use varies amongst hospitals and is about4-5 events per 1000 days of catheterisation, and anaverage mortality of 3% is linked to this sizeableprevalence.1,2

More is starting to be known about the mechanismthrough which CVC contamination is produced thanksto the development of experimental models with ani-mals. Studies using electron microscopes show that theimmense majority of catheters, even those where thequantitative culture gives negative results, are colonisedby microorganisms. The germs are usually immersed ina biofilm sticking to the interior and exterior of thecatheter formed by the interaction of the catheter wallwith host proteins.

Appearance of the film is very early, even in thefirst 24 hours after insertion, but is not necessarilya determining factor in the appearance of infection.When the density of microorganisms reaches a certainlevel, the probability of catheter related sepsis increasesconsiderably.1,2

. Vascular access dysfunction causes the highest consump-tion of resources in the population with chronic kidneydisease (CKD). Experts consider that current standardsfor pump flow (Qb), venous pressure (Pv), molecu-lar clearance and dialysis time could be improved andreductions in clinical complications can be reduced byenhancements in the process, thereby increasing thequality of life for patients and reducing the health carecosts caused by this problem.

Reed et al, has described all the variables that play a partn CVC complications in a microbiological and ultrastructuraltudy.2,3

) Characteristics of patient• Underlying disease• Immune system compromise

) Personnel training• Aseptic measures• Choice of catheter

) Insertion of catheter• Preparation of implant site• Choice of site• Insertion technique• Tunnelling

) Handling• Management• Rescue

) Care of insertion site• Skin antiseptic• Type of dressing• Local anti-bacterial application

f) Clinical monitoring) Connections and perfusions

• Periodic washing and lumen sealing• Impregnation of catheter with antiseptics

dx.doi.org/10.1016/j.dialis.2012.06.010

Sixth Course on Vascular Access 135

Efecto de los factores de riesgosobre el endotelio normal

Enfermedades relacionadas con la disfunción endotelial

Factores de riesgo de aterosclerosis y adherencia celular

Los factores de riesgo alteran la función de lascélulas endoteliales e inducen remodelación vascular

Hipertensión Diabetes Dislipidemia

Moléculas de adherencia

On Endotelina

Cardiopatíaisquémica

Dislipidemia

Integrinas

ICAM

Factoresquimiotácticos

Selectinas

TabaquismoDiabetesHipertensión

Glomerulosclerosis

Nefropatía

Aterosclerosis

Factor de riesgo

Insuficienciacardiaca

Permeabilidad

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Characteristics of patient

Underlying illness and immune system compromise

There are factors that depend on the patient such asthe existence of an underlying illness, immune systemcompromise, serious illness, comorbidity, etc. However,most of the other aspects can be regarded as institutional(place, insertion method, catheter material, care in hand-ling, etc), and it is precisely these factors that have animportant bearing on reducing infection.3,4

If there is septic shock, bacteraemia with hemodynamicdecompensation or tunnelitis with fever, the catheter shouldbe immediately removed. (Fig. 1)

If a patient with CVC presents fever, blood cultures ofperipheral blood from both branches of the catheter shouldbe extracted. Extractions should be simultaneous and culti-vated using quantitative techniques whenever possible.

In cases of severe infection or when the catheter isnot withdrawn, empiric antibiotic therapy should be set inmotion prior to reception of microbiological test results.Conservative treatment without withdrawing the catheteris acceptable for tunnelled catheters infected by the cus-tomary microorganisms: i) associated systemic antibiotictherapy should be administered; ii) intraluminal sealing ofthe catheter with suitable antibiotics: iii) intraluminal seal-ing with antibiotics not associated with systemic therapy isineffective. 3---5

Personnel training

Asepsis

Keep adequate hygiene of the hands by washing them withsoap and water or with alcohol-based gel, maintaining asep-tic techniques for any handling of the CVC. Use the maximumuniversal aseptic measures in the implant by maintainingall possible protective and safety barriers for the environ-
ment and handling. The skin area where insertion is to takeplace constitutes the most important source of CVC infec-tion. Prior to implanting a central catheter, the followingprocedures are important.4---6
ttpr

k factors.

. Vigorously and thoroughly wash your hands

. Wear sterile clothing

. Careful and full skin disinfection

. Avoid shaving the skin whenever possible

. Widely cover the implant area, ensuring sterility

. Carry out the implant in a clean environment free of aircurrents

. Do not inject anaesthetic into the tunnel track

. Adequate nursing personnel for the care activity ratio

nowledge

nsure that professionals responsible for managing cathetersre present to provide them with the necessary knowledgend training with regard to suitable recommendations, indi-ations and procedures for management and avoidance ofncorrect management or prevent CVC-related infectionsith the appropriate measures.

Personnel training programs significantly reduce infec-ious complications. Likewise, deviations from recommen-ations for care of accesses have been directly related ton increase in catheter-related infection.6

Antiseptic (aqueous chlorhexidine at 2%) for preparinghe skin prior to insertion reduces infection and the risk ofatheter-related infection. Chlorhexidine has been showno be more effective than povidone iodine (betadine) forleaning and disinfecting the skin and the catheter for itsactericidal capacities in reducing CVC-related infections.

---10

Handling the connection systems of long-term CVCsncreases the risk of catheter-related infection. Impregnat-ng the connections with an antiseptic or antibiotic reduceshe probability of risks. This method effectively preventserms that migrate via the lumen to the internal or externalurface of the catheter.11

Recommendations cannot be made for the use ofhlorhexidine sponges to reduce the incidence of infection.his issue is unresolved.

Observe and frequently touch the tunnel track, theatheter exit hole and the extenders, changing the loca-
ion of the forceps. The ease with which contamination fromhe skin and hands is caused by these devices implies poorractice on the professional’s part, as well as unnecessaryeplacements or handling.12

136 Ponencias/comunicaciones

Catheter types.

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PCT is a new highly specific and sensitive bacterial infec-ion marker. It differentiates between severe bacterial andiral infections or any other non-bacterial pathology thatriggers a systemic inflammatory response. It is currentlyhe best test for early diagnosis of early or late sepsis. It isn easy, low-cost method.

The pacemaker or implantable cardioverter defibrilla-or (ICD) should not be the cause of a clinical expressionmongst patients with CVC.

ocumenting patient data2,13,14

Demographic dataPresence or not of pathologiesPrevious accesses and associated failuresMonitoring sheet and physical examination of accessBlood flow and venous pressure.AnomaliesOrifices and deterioration of the skin

election of catheter15,16

ingle and double or multi-lumen catheter (Fig. 2)Catheters are divided into:

) Single lumen catheters; used in continuous renal replace-ment therapy (CRRT) where two vascular accesses areinserted (artery-vein or vein-vein)

) Double-lumen catheters; where only one vascular accessis punctured. The proximal lumen acts as an arterial lineand the distal lumen as the venous line

) Double split catheters are two catheters that make itpossible to select the length and location of their points.

alibre

his is the main determining factor of flow. There are differ-nt measurement units that are mutually related. The mostommonly used ones are:

. French(F, FG)

. Gauge (Gg)

. In adults, the calibre of the catheter basically dependson the desired flows. Recommended calibres for adultsstart from 12-14 Fr to achieve the right flows withoutexceeding the pressure limits for the inlet and return.

Tvf

Figure 3 Catheters classified according to theircross-section.

In paediatrics, vascular access depends on the age andweight of the child.16,17

esign

atheters are classified according to their cross-sectionFig. 3):

. single catheter with different types of section

. double catheter with independent distal ends (the dualhas two lumens throughout its length and the splitcatheter divides into two at the distal third). This designminimises support of the catheter on the vessel thusallowing it to function better

. double split catheter, enabling length to be chosen

According to the lumen section, the catheter can (Fig. 4)

improve flow characteristicsimprove system pressurereduce complications, including coagulation of the systemfrom high transmembrane pressure

ength

he length should be as short as possible depending on theessel to be treated; the length has a negative effect on flowrom increase in resistance.1,15,17


double D kidney-shaped co-axial split catheter double-O

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In adults, the routes depending on the superior vena cavasystem should be:

1. The arterial and venous line in the right atrium2. The routes that depend on the inferior vena cava sys-

tem (femoral veins) should reach 25-30 cm in length. Theartery is below the vein

3. In paediatrics there are different lengths depending onthe vascular access and and age of the child (10-15 cmfor femoral route)

Material

The composition and material of the catheter has aninfluence on bacterial adhesionCatheters were initially made of polyvinyl chloride (PVC)or polyethylene, and were later rejected after showing atendency to cause vascular traumas due to the rigid mate-rial, making them easier to break along with a tendency tothrombogenicity and infections from an increase in adhesionof microorganisms.

The material used in manufacture is important as thereare certain antiseptic and antibiotic solutions that are habit-ually used when handling them which can be incompatible.Alcohol, the polyethylene glycol used in mupirocin ointmentand povidone-iodine interfere with polyurethane and crackit, leading to possible breakage of the catheter. Povidone-iodine also interferes with silicon leading to degradation andbreakage.

Bacterial adhesion in polyvinyl chloride and polyethyl-ene > teflon > silicon > polyurethane e.g.: Staphylococcusaureus adheres more easily to polyvinyl chloride and to alesser extent to polyurethane. A prospective study in whichpolyvinyl catheters were compared to ones made of siliconshowed a lower proportion of catheter related sepsis of thelatter type when compared to the former (19-0.83 per 1000cat/day). Experimental studies on pigs have shown that theuse of catheters impregnated with antiseptics (chlorhexi-dine and sulfadiazine) before insertion significantly reduceboth bacterial adhesion of Syaphylococcus epidermidis andthe formation of biofilms.1,5,9,18

Host proteinsCertain host proteins are deposited in the irregularities ofthe catheter surface, favouring the formation of a biofilm.There is a degree of protein selectivity in this process,thus Syaphylococcus epidermidis is especially adherent tofibronectin. Flexible polyurethane tunnelled catheters are
used nowadays (silicon catheters are no longer used). Theyare very flexible and present lower risks of lesion of per-foration of the vascular wall. Studies have shown a lowerfrequency of infections from these catheters than oth-
rcta

ording to their lumen section.

rs made of PVC and polyethylene. In vitro, polyurethaneatheters impede to a greater extent the adhesion of someacterial species.1,2

nsertion of catheter

reparation and choice of location. Insertion andunnelling technique

he choice of location for inserting the catheter is deter-ined by many factors, but the most common points for

mplanting the central vascular accesses are: femoral, jugu-ar, subclavian and occasionally the axillary. The mostommonly used approach in all these cases is a direct oneia percutaneous access. The larger the number of punc-ures for the CVC implant, the more difficult the CVC implantrocedure is likely to be, which may increase mechanicalomplications.1,15,18,19

c.1.1) The femoral route should reach the inferior venacava. The arterial point should be lower than the venouspoint to minimise blood recirculation during dialysis, thedistance between the arterial and venous orifices shouldbe more than 2.5 cm. The femoral route approach is linkedto greater frequencies of colonisation due to greater con-stant humidity and rubbing, and so tunnelling the catheteris advisable. Urgent insertion should be avoided for thefemoral route, and extreme safety and precautionarymeasures should be taken.c.1.2) The subclavian route presents greater risks of severecomplications and must be channelled by experiencedmembers of staff. It is not recommended for patients withchronic renal failure because of the risk of stenosis andthrombosis that could lead to the later development ofarteriovenous fistulas.c.1.3) The internal jugular route is the first choice for tun-nelled CVC. The right jugular is better than the left jugularin this case as the latter takes a longer and more convolutedroute. The arterial and venous routes should be located inthe atrium to avoid recirculation.c.1.4) In paediatrics the accesses are similar although inneonatal treatment there is also the possibility of chan-nelling of the umbilical vein/artery.

Once the catheter is in place, check that all the air inhe lumen inside the catheter and the extender to avoidir embolism. The blood should leave and enter the vas-ular circuit correctly, both during aspiration and when
eturning. Confirm using X-ray imaging that the post-implantatheter is suitably placed; for superior vena cava implantshe arterial and venous points should be located in the righttrium.12,13

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38

unnelling

unnelling uses a subcutaneous path (adipose tissue) beforenserting the CVC in the vessel lumen. This path should note shaved or anaesthetised to avoid the possible entry oferms through the skin.19,20

The catheter has a Dacron (polyester) cuff in thextravascular section. The purpose of this catheter cuff oracron is to adhere to the muscle and cause a fibrosis to

mpede the entry of infectious agents and act as an anchor,hereby preventing any accidental escape of the catheternd retarding extraluminal migration of pathological germsowards the distal end of the catheter and the interior ofhe circulatory flow, reducing the level of risk of catheterelated sepsis.

The central venous routes should be tunnelled whenreatment requires long periods of duration and perma-ence. Tunnelling for internal jugular approaches reducesolonisation by 39% and infection from the catheter by 44%n comparison to standard procedures. Tunnelling of theemoral significantly reduces the risk of catheter relatednfection in comparison to non-tunnelled catheters.1,17,21

anagement

ascular haemodialysis catheters should only be used foraemodialysis sessions. Do not use haemodialysis cathetersor taking blood samples or other applications that are notor dialysis therapy except in emergency situations.4,5,15

Connection and disconnection should only be managedy specialist dialysis unit personnel following recommendedrotocols and procedures.1,5,13

Connection, disconnection and handling should all beanaged using stringent aseptic measures.12,14,22,23

Inform, warn and remind the patient to report any signsr symptoms he/she has or notices. Take standardised notesf any observations on handling and maintenance of theVC.4,5,24

Care of the catheter is essential and the use of alcohol-ased antiseptics, ointments or non-breathable dressings isot recommended.8,10,19,25

Thrombosis of a central vessel is an important and com-on complication in CVCs. Incidence varies between 4 and

5% of patients.1,2,26

Several factors contribute to a growth in frequency:

a) Time period of catheter use) Endothelial injury during the insertion process

c) Situation and location of catheter) Polymer characteristics) Patient’s clinical situation

ealing the catheter

his strategy uses anticoagulants such as heparin, unfrac-
ioned heparin, citrates or other anti-microbial compoundsuch as gentamicin to fill the dead space of the CVC lumenst the end of each dialysis session and after washing with0 ml of isotonic saline with positive outward pressure.4
D

Ti


d.1.1) Intralimunal heparin is retired before starting thenext dialysis and before washing the lumens with isotonicsaline.

A significant and important reduction has been shown inrates of overall infection, and a prolongation in the usefullife of the catheter, in patients under haemodialysis withtunnelled catheters. However, plasmatic levels of genta-micin determined before every dialysis session fall withina toxic range for a fraction of patients that received thiscompound, showing associated symptoms.

As regards the concentrations of heparin to be used,there are some discrepancies in the scientific literature,where concentrations vary from 20 UI/ml to 5.000 UI/ml.The use of single doses of 20 UI/ml generates perme-ability of the catheter and reduces the risks of systemicinvolvement caused by a dose of 5.000UI/ml due to chronicrepetition of treatments (risk of bleeding).21,26

d.1.2) The catheter and extender should be sealed whentherapy ends by closing the access with the clamp andluer/lock caps. Check that the connections fit and that allthe system components are compatible to minimise risksand system breakages.

The SEN and CDC do not recommend the use of systemicantimicrobial sealing.4,15

d.1.3) Catheter rescue

Fibrin in the catheter lumen

) Intraluminal) At the tip of the catheter) Formation of pericatheter fibrin sheath

he measures to be taken in cases of CVC thrombosis com-ence with aspiration (negative pressure) and washing with

eparinised saline solution next to one or more strokes withtrong positive pressure (5-10 ml syringe) to release thebrin clot from the walls and orifices. If there is still an aspi-ation flow deficit, intraluminal fibrinolytic therapy shoulde set in motion.12---14

are of insertion site

erfect, Doubtful, Good, Infectious

ssessment of tunnel orifices and tracks should be plannedn accordance with accepted internal evidence. (Fig. 5)

Skin cures are carried out in accordance with set inter-al protocols, and a recommended antiseptic is an aqueous% chlohexidine gluconate solution of the biguanides group.he mechanism of action is quickly absorbed by passive dif-usion via the membranes of the bacteria and the yeasts. Theactericidal effect of the chlorhexidine starts with it linkingo the bacteria cellular wall (negatively loaded) because ofts physiological Ph cationic molecule. Its time of action ish, due to its affinity to adhering to the skin and mucousembranes.4,5,7

ressings

he dressings that cover the outlet orifices and the cathetertself should be products that keep skin health intact and


Figure 5 Care in

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Figure 6 Patches to reduce catheter colonization risk.

prevent erosions and infection. There is no evidence-basednursing about which dressing to use.12,21

Types of protection:

1. Gauze + tape2. Transparent polyurethane dressings have become pop-

ular recently as they allow the incision site to be seen. Itwas demonstrated that this type of transparent dressingcould be linked to CVC related bacteriemia. This mech-anism has been attributed to bacterial colonisation inthe insertion site that may be increased by the humid-ity created below the transparent dressing from lack ofpermeability or less frequent changes.

Changes have been made to the design of transparentdressings to increase permeability.

3. Chlorhexidine-impregnated patches (BiopatchTM)reduce the risk of colonisation of the catheter and haveshown no adverse effects during use (Fig. 6)

Changing dressingsHoffman (1992) stated that transparent dressings are adetermining factor for a higher risk of infection than gauzeones. However, Gilles (2003), in a systematic revision, statesthat there is uncertainty over which is more appropriate andrecommends further rigorous research on this issue. Morerecent studies confirm that there is no difference in termsof the risk of infection when using a gauze or transparentpolyurethane dressing.

It is considered that non-tunnelled catheter dressingsshould be changed every two days (48) if they are gauze,and every week if they are tunnelled and when the dressingis clean and intact.1,4,5,18

Advice on choosing a dressinga) Protection against microbial infection

aei

insertion site.

) Keep skin dry) Make sure catheter is securely fixed) Minimise growth of skin flora under dressing) Good tolerance and non-irritant

f) Comfortable and accepted by the patient) Easy to apply and remove

It should be highlighted that not all transparentolyurethane dressings are indicated to cover central venousatheters as not all of them breathe adequately or theirater vapour transmission rate is low, with consequent

ncrease in moisture below the dressing and skin maceration,eading to an increase in microbial activity. The increase inumidity below the dressing means that it also comes loose,hich leads to a risk of contamination and increase in theumber of dressing changes.4,14,25

ecommended

) Check manufacturer’s indications) Only use transparent polyurethane dressings recom-

mended for CVCs.) pocket dressings increase patient comfort

Different types of pocket dressing are currently avail-ble:

) Plastic; non-breathable, rigid dressing that creates anincrease in patient sweating. They are uncomfortable asthey create heat and noise at night when the patientmoves.

) Padded dressings, more comfortable than the ones men-tioned above, but the design means that a first dressingneeds to be applied to cover the inlet orifice; theyare also impermeable to water, which makes personalhygiene more difficult

) The databases do not show research studies on thesedressings. Although they are more comfortable forpatients, some unsuitable features need to be modified.

onnections and perfusion

ny accidental or voluntary breakage or disconnection ofhe catheter or the caps must be avoided to prevent gasmbolisms. The clamps at the extensions do not always guar-ntee closure of the extenders and so luer/lock caps shoulde used (Fig. 7). The zone where the clamps are used shoulde changed to prevent wear and breakage of the lumen.5,18

Handling CVC connections with fluid systems leads ton increase in the risk of catheter-related sepsis (CRS),specially in long-term CVCs. The use of a new modelmpregnated with antiseptic (alcohol iodine) has reduced

140

Figure 7 Connection caps.

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Figure 8 Sutureless devices.

he probability of CRS by a factor of 4 (IC95% 0,1-0.7).his method, which effectively prevents germs that migratehrough the lumen towards the internal wall of the catheter,s not obviously effective against migration via the externalurface.26

Multiple studies (mostly cohort) show an increase in therequency of CRS when traditional connection systems arerofusely used. The ease of contamination of these devicesuggests design problems and poor practice by professionalsespecially the latter), insufficient replacement of contam-nation during handling when washing the lumen, sincedequate practice and handling of the CVC prevents the riskf CRS. However, newly improved designs of connectors haveeen developed.3,24,26

e.3) SuturelessTM devices may be more advantageoushan sutures in preventing CRS, these avoid external sutureshat tend to scratch and erode the skin at the catheterutlet. (Fig. 8)

linical follow up

linical follow-up should be based on the search for signsnd symptoms that lead to the suspicion of an infection oralfunction. Body temperature and signs of inflammation of

he outlet or tunnel orifice should be investigated at eachialysis session. The presence of oedema in upper extremi-
ies or the face indicate the possibility of thrombosis in theentral veins, any sudden change should be considered as aossible severe complication.
1


The aim of the functional follow-up is to detect alter-tions that impede effective dialysis, such as lack of flow,igh pressures, recirculation or symptoms of malaise or pain

ssessment

a) Skin intact) No signs or symptoms of inflammation or pain

c) Lines and extender intact) Lumen closure intact) Permeability of catheter lumens

Recirculation is effectively minimal in double and splitatheters placed in the internal right jugular, if and whenhe arterial and venous points are distanced in the atrium,nd so any recirculation above 5-10% indicates alteration inhe catheter.13,24

ibliography

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2. Raad II, Hanna HA. Intravascular catheter-related infec-tions: new horizons and recent advances. Arch Intern Med.2002;162:871---8.

3. Reed CR, Sessler CN, GlauserbFL, Phelan BA. Central venouscatheter infections: Concepts and controversies. Intensive CareMed. 1995:21177---83.

4. Guía de prevención de infecciones Relacionadas con CatéteresIntravasculares. Versión espanola adaptada 2003, de Guidelinesfor the prevention of Intravasclar Catéter-Related Infections2002. CDC. USA.

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http://vascularaccesssociety.com/guidelines/7. Derivados de biguanidas y amidinas: lorhexidina.8. Humar A, Ostromecki A, Direnfeld J, Marshall JC, Lazar

N, Houston PC, et al. Prospective randomized trial of 10%povidone-iodine versus 0.5% tincture of chlorhexidine as cuta-neous antisepsis for prevention of central venous catheterinfection. Clin Infect Dis. 2000;31:1001---7.

9. Chaiyakunapruk N, Veenstra DL, Lipsky BA. Chlorhexidine com-pared with povidone-iodine solution for vascular catheter-sitecare: a meta-analysis. Ann Int Med. 2002;136:792---801.

0. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trialof povidone-iodine, alcohol, and chlorhexidine for prevention ofinfection associated with central venous and arterial catheters.Lancet. 1991;338:339---43.

1. Mimoz O, Pieroni L, Lawrence C, Edouard A, Costa Y, Samil K,et al. Prospective, randomised trial of two antiseptic solutionsfor prevention of central venous or arterial cathéter coloniza-tion and infection in intensive care unit patients. Crit Care Med.1996;24:1818---23.

2. Guía de Cuidados de Enfermería para vías venosas. Comisión devías venosas. Hospital Virgen del Camino. Pamplona 2010.

3. Sociedad de Enfermería Intravenosa. http://www.ins 1.0rg.4. Tratado de administración parenteral. Carmen Carrero

Caballero. Ed. Difusión Avances de Enfermería 2006; cap.8:255---70.

5. Guías de acceso vascular en hemodiálisis. Sociedad Espanola de

6. Delgado M, Reglan A. Accesos vasculares en técnicas dedepuración renal. Técnicas Continuas de reemplazo renal.Nefrología. 2005;25:63---72.

http://vascularaccesssociety.com/guidelines/

http://www.ins/


17. Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong 2nd JD.Perforation of the great vessels during central venous line place-ment. Arch Intern Med. 1995;155:1225---8.

18. Armada E, Trillo M, Perez C. Programa de monitorizaciónde accesos vasculares nativos para hemodiálisis. Nefrología.2005;25:57---65.

19. Hosp. Epidemiol Infct Control, 2nd Edition, 1999.20. JBI Manejo de los dispositivos intravasculares periféricos Best

Practice 12;2008.21. McKnight S. Nurse’s guide to understanding and treating throm-

botic occlusion of central venous access devices. Medsurg Nurs.2004;13:377---82.

22. Barra C, Garcia R, Mora V. Higiene de manos y uso de guantesen una unidad de hemodiálisis. Libro de comunicaciones pre-sentadas al XXXII Congreso Nacional SEDEN. 2008.

23. Ferre C, Almirante B. Higiene de las manos; una prioridad parala seguridad de los pacientes hospitalizados. Eferm Infecc Micro-biol Cli. 2007;25:365---8.

24. Sherertz MD, Wesley E, Education of Physiocians-in-Trainin.25. Ed:Becton-Dickinson y 3M(Espana)3◦ Ed. Málaga 2004.26. Stewart D. La técnica de perfusión para restablecer la per-

meabilidad de los catéteres venosos centrales. Cuidado de losenfermos críticos. 2001:17---20.

http://dx.doi.org/10.1016/j.dialis.2012.06.011

110.9

Ultrasounds as a management tool in nursing for vascularaccesses for haemodialysis

Javier Hernandez Lopez

Nurse of the Nephrology Service, Galdakao-Usansolo Hospi-tal, Galdakao. Bizkaia, SpainE-mail address: [email protected].

Vascular Access is a fundamental element for the correctmanagement of patients with Chronic Renal Insufficiency(CRI), who are included in the Haemodialysis (HD) pro-gramme.

The autologous internal arteriovenous fistula (autolo-gous IAVF) is the permanent vascular access of choice forpatients who require haemodialysis. (degree of evidence a).(Figs. 1 and 2)

Figure 1 Longitudinal cut femoral prosthesic fistula.

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igure 2 Left brachial thrombosed fistula distal venous area.

For these patients with CRI in HD programmes, the Vascu-ar Access of choice is Internal Arteriovenous Fistula (IAVF),lthough it is not the only one. The alternative vascularccess to IAVF is Arteriovenous Prosthesis (AVP), due to iteing the most commonly used. The normal material used isXPANDED POLYTETRAFLUOROETHYLENE (PTFE). The thirdccess modality is Central Venous Catheter (CVC), both inemporary catheter and in permanent tunnelled catheter.

One of the aims of haemodialysis units is for the majorityf patients to be able to start the haemodialysis via a goodascular access, which, by choice, is the autologous internalrteriovenous fistula (IAVF A). The IAVF A has an average lifef 5 to 10 years’ survival. The AVP has an average life of 2o 3 years’ survival.

Whilst haemodialysis, as a technique, has evolved spec-acularly during the second half of the 20th century, noascular access has surpassed the success and initial effec-iveness of the internal arteriovenous fistula (IAVF). It haseen demonstrated that the radiocephalic IAVF, describedy Brescia-Cimino, is still, today, the best vascular accessor haemodialysis. It has a low complication rate and itresents an excellent long-term permeability and use rate.t also satisfies the objective of ideal vascular access, as its a peripheral access, which is easy to approach (extensivend surface venous trajectory), with sufficient flow for theaemodialysis and it offers the possibility of carrying outore proximal fistulae.Any internal vascular access must be assessed and its evo-

ution tracked, since creation, by the haemodialysis nursingtaff of the Dialysis Unit, nephrologists and the actualatient.

During the monitoring of the access function, a system-tic physical examination is compulsory before and afterach haemodialysis session:

1) Direct observation, 2) Palpation, and 3) Auscultation.

bservation

valuate the venous trajectory, noticing the existencef haematomas, stenosis, aneurysms, pseudo-aneurysms,

dx.doi.org/10.1016/j.dialis.2012.06.011

mailto:[email protected]

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High venous pressure - SEDYT · for pump ﬂow (Qb), venous pressure (Pv), molecu-lar clearance and dialysis time could be improved and reductions in clinical complications can be