Vascular Access Fact Sheet - American Nephrology Nurses ...

1 OverviewBefore beginning hemodialysis, a patient must have a vas-cular Access in place. The Vascular Access provides entryinto the patient s bloodstream. The Access will allow thepatient s blood to travel to the hemodialysis machine sotoxins, wastes, and extra fluid may be removed beforereturning the blood back to the patient. There are 3 types of Vascular accesses: arteriovenous fistu-la (AVF); arteriovenous graft (AVG); and central venouscatheter (CVC). Each Access requires a surgical on the type of Vascular Access , the Access maybe placed in the arms, legs, neck, or chest.

2 A vascularaccess should be placed well in advance of beginninghemodialysis so the Access will be ready for use. An AVFrequires 4 to 12 weeks to mature prior to the first use. AnAVF can be accessed earlier depending on rate of matura-tion, but it requires an order from the nephrologist or sur-geon before accessing. An AVG requires 2 to 3 weeks toheal, incorporate into the surrounding skin, and for theedema to resolve. Several early stick (cannulation) graftscan be used anywhere from 24 to 72 hours after place-ment.

3 A person who has sudden kidney failure that requiresimmediate hemodialysis will have a CVC placed for catheter is used until an AVF or AVG can be placed andis ready for use. The catheter should always be the lastaccess option. In some cases, a catheter may be thepatient s permanent Access for Fistula (AVF)The ideal Vascular Access for patients on hemodialysis isthe AVF. An AVF is created surgically by connecting anartery and a vein, and is usually placed in the arm. As theAVF matures (it takes 4 to 12 weeks to be ready for use),the vein will grow in diameter, and the walls will thicken fromthe blood flow of the artery.

4 The AVF can provide goodblood flow for many years of hemodialysis. Recent studiesshow that patients with AVFs have the least amount ofcomplications, such as infections or clotting. However,some patients may not be candidates for an AVF due tosmall or damaged veins or arteries, or other medical condi-tions. The physician should have this discussion with thepatient. The patient should ask for an AVF Access Fact SheetDeveloped by: ANNA Specialty Practice NetworksArteriovenous GraftThe AVG is similar to an AVF but has a manufactured, syn-thetic tubing material interposed between an artery andvein.

5 Transplanted animal or human vessels may be usedas AVGs as well. The arm is the preferred site for an AVG,but the leg can also be used. Compared to AVFs, AVGshave higher rates of clotting and stenosis. Caring for a Fistula or GraftGood AVF or AVG care will help maintain the patency of thevascular Access . Measures can be taken to prevent clottingor infection to the Access . Patency can be assessed byfeeling the thrill or vibration of blood through the Access ,or using a stethoscope to listen to the bruit or whoosh of blood through the Access should be kept clean and free of injury.

6 Theaccess should be assessed daily for signs of infection,including pain, tenderness, drainage, swelling, and rednessto the area. Infections are treated with antibiotics. Theaccess should be cleansed carefully before each dialysissession. The Access site needs to be cleansed accordingto facility protocol to prevent an Access needs to be protected from injury or restrictionto prevent clotting of the Access . Patients should beinstructed to: Avoid tight clothing, jewelry, or pressure on the accessarea.

7 Not carry heavy objects across the Access area. Avoid lying on the Access site when sleeping. Not allow venipunctures or insertion of an IV in theaccess extremity. Not allow blood pressure to be taken in the Access needle insertion technique keeps the Access workingwell. Arterial and venous needle tips should be at least 2inches apart. Needles should not be placed near surgicalscars. Examine the Access to determine the location of pre-vious needle sticks; this prevents damage to the blood sup-ply to the blood vessel wall.

8 Puncture sites should be at leastone-quarter inch from previous sites. Some facilities nowuse the buttonhole technique for Access cannulation. Thismethod uses the same site for each hemodialysis is a specialized training program for the patient andhealthcare provider before using this method. Direct pres-sure is applied to needle stick sites after each needle Access Fact SheetCentral Venous CatheterA CVC is a narrow, flexible tube used to Access the blood-stream. The CVC may be inserted into a large vein in theneck, chest, back, or groin.

9 Two ports are at each end ofthe CVC exiting from the insertion site. One port allowsblood to be removed from the body, and the other portallows blood to return into the bloodstream. CVCs areready for immediate use after insertion. There are tunneledand non-tunneled catheters. It is recommended that tun-neled, cuffed catheters are placed under fluoroscopy. Thiswill confirm the catheter tip is in the right atrium of the catheters have a radio-opaque tip that when X-rayed, will show the position of the catheter tip at the junc-tion of the superior vena cava and the right atrium of theheart.

10 There must be documentation that the CVC is in thecorrect position before initiating hemodialysis. Somepatients use permanent CVCs, but this is not the recom-mended Access for long-term dialysis. While CVCs havethe advantage of being able to be used immediately afterplacement, CVCs: Have a greater chance of becoming infected or clotted. Have a slower blood flow, thus not adequately cleaningthe blood. Are the least-preferred choice of Access for long-termdialysis. Are at greater risk for central vein thrombosis or stenosis.