VASCULAR ACCESS CARE

HACKENSACK UNIVERSITY MEDICAL CENTER

RENAL SERVICES DEPARTMENT

Presentation developed by:

Phoebe Del Boccio, CHT,BA

WHY IS VASCULAR ACCESS

CARE IMPORTANT?

LIMITED NUMBER OF

SITES FOR ACCESS

REDUCES

INFECTIONS &

HOSPITALIZATIONS

ENHANCES AND

PROLONGS QUALITY

OF LIFE FOR PATIENT

GFR < 30 ml/min

+

Creatinine > 3.0 mg/dL

+

Proteinuria > 30 milligrams of albumin

per 1 gram of creatinine =

_________________________________

STAGE 5 CKD

VASCULAR ACCESS CARE BEGINS

WITH DIAGNOSIS OF ESRD

FIRST STEPS IN CARE

EVALUATE ALL PATIENTS

FOR RRT (Renal Replacement

Therapy)

CHOOSE HD OR PD

Provide counseling and

education

Vessel mapping for All Patients

Provide Surgical Consult

Initiate Save The Vein Protocol

(STVP)

TREATMENT OPTIONS

PD VS. HD

WHICH CHOICE IS RIGHT

FOR YOUR PATIENT?

PERITONEAL DIALYSIS (PD)

CAPD

PD CATHETER IS PLACED IN THE ABDOMEN

DIALYSATE FLOWS INTO THE PERITONEAL CAVITY

DIALYSATE DRAINS FROM THE PERITONEAL CAVITY

PERFORMED BY PATIENT 4-6 X DAILY

CCPD

PD CATHETER IS PLACED IN THE ABDOMEN

DIALYSATE IS USED TO CLEAN BLOOD INSIDE ABDOMEN

MACHINE IS USED TO PERFORM EXCHANGES WHILE PATIENT SLEEPS

OVERNIGHT TREATMENT LASTS 9-12 HOURS

PERITONEAL EXCHANGE

HEMODIALYSIS

HEMODIALYSIS IS USUALLY

DONE IN A CENTER

AVERAGE TREATMENT

TAKES 3-4 HOURS THREE

TIMES PER WEEK

BLOOD FLOWS THROUGH

TUBES FROM ACCESS INTO

MACHINE

MACHINE CLEANS BLOOD

AND RETURNS FILTERED

BLOOD TO BODY VIA TUBES

PATIENT MAY READ, SLEEP,

WATCH TV, ETC.

CHOOSING AN ACCESS

VEIN MAPPING MUST BE PERFORMED ON

ALL PATIENTS

SURGICAL CONSULT MUST BE OBTAINED

PATIENT’S COMPLETE MEDICAL

CONDITION MUST BE CONSIDERED

IF PATIENT IS GOOD CANDIDATE FOR

FISTULA, INITIATE “STVP.”

SAVE THE VEIN PROTOCOL

STVP

MD SelectsAccess site

STICKER ON

MEDICAL RECORD

SIGN OVER BED

ID BRACELET PLACED ON ARM

LAB IS NOTIFIED OF STVP

“STVP” INSTRUCTIONS

PATIENT ID CARD

HEMODIALYSIS

VASCULAR ACCESS IS PLACED IN BODY

1ST CHOICE =

AVF

2ND CHOICE = AVG 3RD CHOICE – PC

VASCULAR ACCESS PROGRAM

A SUCCESSFUL V.A.P. REQUIRES A TEAM

APPROACH FOR OPTIMAL PATIENT OUTCOMES

A NEW BEGINNING -

PREPARING THE PATIENT

PLEASE TAKE

TIME TO SIT AND

TALK WITH YOUR

PATIENT IN THE

BEGINNING

REMEMBER –

THE ACCESS IS

NEW AND SO ARE

THEY!

PRIOR TO CANNULATION

IT IS MOST IMPORTANT TO:

LOOK –

DOES THE ACCESS LOOK HEALTHY? ANY OBVIOUS BUMPS, ETC.

LISTEN –

CHECK FOR THRILL/BRUIT

FEEL –

THE LENGTH OF THE FISTULA FOR COLLATERALS/BRANCHES

PROCEDURE FOR FIRST USE

1. IS THERE AN ORDER FROM MD?

2. DO THE NEPHROLOGIST AND SURGEON AGREE?

3. FIRST TIME CANNULATION OF NEW AVF BY EXPERIENCED STAFF MEMBER FOR FIRST 6 TREATMENTS USING 17g NEEDLES (DOCUMENT)

4. ATTEMPT 2 STICKS ONLY!

5. REMEMBER – ADHERING TO POLICY HELPS WITH CONTINUITY OF CARE

AFTER THE NEEDLES ARE IN:

ASK PATIENT IF

THERE IS ANY PAIN

CHECK FOR GOOD

PULLS AND FLUSHES

FEEL FOR ANY

HARDNESS OR

SWELLING

BREAKING OLD HABITS

PLEASE BREAK

THE HABIT OF

MULTIPLE STICKS!!

THERE IS ALWAYS

ANOTHER DAY FOR

DIALYSIS, AND THE

PATIENT IS THE

ONE WHO SUFFERS

IN THE LONG RUN.

COMPLICATIONS

REASONS FOR ELECTIVE INTERVENTIONS

FLOW INADEQUACY, STENOSIS, ANEURYSM AND

ISCHEMIA

PROBLEMS THAT DEVELOP WITHIN THE FIRST 6

MONTHS SHOULD BE PROPERLY ADDRESSED

STENOSIS AND ITS’ CORRESPONDING CLINICAL

PARAMETERS SHOULD RETURN TO ACCEPTABLE

LIMITS FOLLOWING INTERVENTION

EXAMPLES OF ACCESS PROBLEMS

OVER-DEVELOPMENT

OF AVF

DUE TO HEAVY LIFTING

BY PATIENT

EXAMPLES OF ACCESS PROBLEMS

•ANEURYSMS IN AVF

CAUSED BY WEAK

VASCULAR STRUCTURE

AND FAILURE TO

ROTATE SITES

•CREATED VASCULAR

INSUFFICIENCY IN

PATIENT

EXAMPLES OF ACCESS PROBLEMS

LARGE ANUERYSMS

IN AVF

CAUSED BY

REPEATED STICKS IN

SAME SPOT

EXAMPLES OF ACCESS PROBLEMS

STEAL SYNDROME

CAUSES INADEQUATE

PERFUSION OF PATIENT

EXTREMITIES

SURVEILLANCE & MONITORING

WHEN TO REFER FOR EVALUATION

AND TREATMENT

AN ACCESS FLOW RATE <600-800 IN AN

AVG USING TRANSONIC STUDIES.

AN ACCESS FLOW RATE <400-500 IN AN

AVF USING TRANSONIC STUDIES.

EXTREMITY EDEMA IN THE ACCESS LIMB

EXCESSIVE BLEEDING POST TREATMENT

CONSISTENTLY POOR BLOOD FLOWS

BENEFITS OF TRANSONIC FLOW MONITORING

IMPROVED QUALITY OF LIFE

IMPROVED TREATMENT EFFICIENCY

REDUCTION OF THROMBOTIC EVENTS/THROMBECTOMIES

REDUCTION IN NUMBER OF HOSPITALIZATIONS

DECREASED NEED FOR CATHETER PLACEMENT

REDUCTION IN MISSED DIALYSIS TREATMENTS

REDUCTIONS OF REVISIONS

INCREASED LONGEVITY OF FISTULA OR GRAFT

TRANSONIC STAFF BENEFITS

EMPOWERS STAFF IN IDENTIFYING AND

REDUCING ACCESS DYSFUNCTION AND

FAILURE

REDUCES EMERGENCIES DUE TO ACCESS

FAILURE

IMPROVES QUALITY CARE, COSTS, AND

PATIENT SATISFACTION OUTCOMES

ROLE OF THE VASCULAR ACCESS

COORDINATOR

PROVIDES SEAMLESS AND

EFFICIENT DELIVERY OF OPTIMAL

ACCESS CARE FOR PATIENTS

COORDINATES EFFORTS OF

NEPHROLOGISTS, SURGEONS

RADIOLOGISTS, AND STAFF

HELPS CREATE BETTER OUTCOMES

FOR TOTAL VASCULAR CARE

SAVES MONEY FOR FACILITY &

PATIENT!

VASCULAR ACCESS OUTCOME

IMPROVEMENTS

0

10

20

30

40

50

60

70

2005 2006 2007

AVF

AVG

PC

COMBO

Before and After Implementation of Vascular Access Program

Sources

ESRD. TARC, Trans Atlantic Renal Council. www.tarcweb.org

HUMC policies R-40, R-82. Hackensack University Medical Center.

Hackensack, NJ.

NCBI, PUBMED. Vascular Access Coordinator.

www.ncbi.nlm.nih.gov.

Vascular Access Monitoring. Transonic Systems, Inc.

www.transonic.com

Fistula First. Renal Network of Upper Midwest, Inc. St Paul Minn.

Questions and Answers

?

?

Q & A