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AV Vascular Access - Hemodialysis

The Hemodialysis Arteriovenous Vascular Access: AVF, AVG

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AV Vascular Access - Hemodialysis

  1. 1. The AV Vascular Access REYNEL DAN GALICINAO SA 1565
  2. 2. Taking Care of the AVF
  3. 3. Keep Your AV Access Healthy 1. Feel the thrill every day 2. Do not carry heavy objects with the fistula arm 3. Do not wear watch or other accessories, on this arm 4. Do not use too tight clothes 5. Do not allow drawing blood and IV drip in the arm of the fistula
  4. 4. Keep Your AV Access Healthy 6. Do not allow evaluation of the arterial tension in the arm of the fistula 7. Exercise the arm in order to develop fistula 8. Maintain good personal hygiene (bathing) 9. Wash the arm of the fistula before starting EVERY treatment 10.Do not shave the arm of the fistula 11. Do not scratch the skin, or remove crusts from any wound in the arm of the fistula
  5. 5. Recommended Exercises
  6. 6. Arm Fistula  Press and release with fast moves, a soft ball  10 minutes, 6 times per day  Press repeatedly a clothes-hanging clip  5 minutes, 6 times per day  Touch the tip of the thumb with every finger of your hand, opening your hand after every touch  5 minutes, 6 times a day.
  7. 7. Upper Arm Fistula  Use a weight, ≤1.5kg and with slow movements go up and down, with your arm  10 minutes, 6 times per day.
  8. 8. AV Access Needle Placement
  9. 9. Assessment Before EVERY Cannulation  Observation:  Alterations in the access: Compare to the other arm or leg  (skin color, circulation, integrity)  Signs and symptoms of steal syndrome  Size of the cannulation vein, areas of cannulation, signs of infection, presence of aneurisms
  10. 10. Assessment Before EVERY Cannulation  Palpation:  Alterations on temperature of the arm or leg  Presence of thrill and pulse  Auscultation:  Presence of bruit throughout the access
  11. 11. Identify Cannulation Sites: AVF  The arterialized vein, the segment must be as straight as possible  Segment should have at minimal the size of the needle  Arterial cannulation ≥ 3.5cm from the arterial anastomosis  Distance between needles ≥ 2.5cm (6cm between the tip of the needles)
  12. 12. Identify Cannulation Sites: AVF  Arterial cannulation maybe in any direction, but when possible antegrade direction is recommended.  Venous cannulation always towards the blood flow of the access  Avoid aneurisms and doubtful trajectories.
  13. 13. Identify Cannulation Sites: Straight AVG  Divide the graft’ in half’;  Start cannulating at middle and move out  Subsequent needle sites 0.5 to 1 cm apart  When 2.5 cm from anastomosis return to start
  14. 14. Identify Cannulation Sites: Looped AVG  Divide at mid point  Don’t cannulate in the loop area, only the straight segments  Dedicate one segment to arterial sites and the other to venous sites  Move needle sites 0.5-1 cm apart  When 2.5 cm close to the anastomosis return to the start of the segment
  15. 15. AV Access Cannulation
  16. 16. Cannulation Site Technique  Preferable use rope ladder or buttonhole technique  Avoid area technique
  17. 17. Choose the Right Needle Size Needle Gauge BFR (mL/min) 17 <250 16 <300 15 <450 14 ≥450 AP >-250 mmHg VP <200 mmHg
  18. 18. Prepare for Cannulation  Ensure appropriate hand hygiene and PPE  Wash arm:  Transient flora is a source of infection  Ensure that skin is properly dried  Ensure appropriate supplies are at hand
  19. 19. Skin Preparation  Clean with antibacterial agent:  −70% alcohol  −2% chlorhexidine in 70% alcohol  Do not go over the already cleaned area with the same cleaning wipe  Allow adequate contact time: 15 seconds  −Allow area to dry
  20. 20. Cannulate the Access  Stabilize the patient’s hand  Hold and slightly secure the skin  Chose the appropriate angle of cannulation:  20-35° in fistulas  45° in grafts  Cannulate, preferably, with the bevel up
  21. 21. Cannulate the Access  Verify if there is blood flow to the needle, as soon as the vessel is penetrated  Always aspirate blood first  Progress the needle in the same angle of cannulation  Verify if blood flow is adequate  If necessary, as a last resource, rotate the needle  Release the tourniquet if used
  22. 22. Safe Taping – Prevent VND  Place 1st tape strip over the needle insertion site and wings  Chevron  Place 2nd tape strip  Place 3rd tape strip around needle tubing and secure it
  23. 23. AV Access Needle Removal
  24. 24. Needle Removal  Wear PPE  Do not apply pressure as needle is withdrawn  Press immediately upon needle removal  Remove needle using the same angle performed during cannulation
  25. 25. Compression  Two fingers to compress  Pressure applied at 90 degree angle to the skin  Try to avoid clamps as the pressure is static  Involve patient  Vary pressure to maintain equal pulse/thrill and control bleeding
  26. 26. Post Needle Removal Care  Apply dressing post treatment  Adequate to cover site and protect  Avoid excessive pressure that may restrict blood flow
  27. 27. Cannulation Protocol for New AV Access
  28. 28. Maturation of New AVF: Rule of 6  6 weeks old  >600 mL/min flow  >6 mm in diameter  <6mm below skin surface
  29. 29. Maturation of New AVG  2-4 weeks from creation
  30. 30. First Cannulation STAGE I SINGLE CANNULATION  1st Arterial cannulation (preferable upwards, downwards if necessary):  Cannulated only by the most experience or accurate nurse in cannulation.  Use of 17G needles recommended. 2nd – 3rd Arterial cannulation:  Cannulated only by the most experience/accurate nurse in cannulation; use17G needle
  31. 31. Double Cannulation STAGE II DOUBLE CANNULATION  1st Double cannulation (preferable upwards; venous always upwards:  Cannulated only by the most experience or accurate nurse in cannulation; G17  2nd – 3rd Double cannulation  CVC can be possibly removed after 2 weeks of double cannulation without complications
  32. 32. Double Cannulation With CVC Removed  STAGE III DOUBLE CANNULATION WITH CVC REMOVED  Double cannulation  Cannulated recommended by the most experience or accurate nurse in cannulation.  Use of 16G needles recommended until the 8th week or upon assessment of experience nurse.
  33. 33. Double Cannulation With CVC Removed STAGE IV DOUBLE CANNULATION WITH CVC REMOVED  Double cannulation  Cannulation endorsed by the most experience or accurate nurse in cannulation to the Charge Nurses/ Senior Nurses/Junior Nurses.  Increase to 15G or 14G upon assessment of experience nurse.
  34. 34. VND Risk Assessment
  35. 35. Thank you and Advance