Las competencias demandadas por las empresas

For hemodialysis to be started, a patient must have a vascular access (surgically created or inserted) for hemodialysis use. Currently, the types of vascular access being utilized are:

Arteriovenous Fistula (AVF) Arteriovenous Graft (AVG)

Central Venous Catheter (Temporary and Tunneled) (National Kidney Foundation, 2015)

Section 4.1

Arteriovenous Fistula: (Canadian Association of Nephrology Nurses and Technologists, 2015)

A vascular surgeon will surgically connect an artery to a vein. When the artery and vein are joined (or anastomosed) together the vessel with time will grow in strength, blood flow, and diameter to allow for cannulation for hemodialysis purposes.

Figure 4.1: Surgical creation of an AVF

Figure 4.2: Anastomosis of artery with vein

The two most common sites for artery and vein anastomosis are the: 1] Radial artery to the cephalic vein (placement: mid-forearm)

2] Brachial artery to the cephalic OR basilica vein (placement: upper arm)

In a patient that has a fistula created there will be a faint incisional scar noted to be the anastomosis (where the artery and the vein were joined together).

Note: The AVF, can be placed in the forearm, upper arm, or in the thigh if vascular

access option sites are limited.

When a patient is in Stage 4 ESRD (eGRF 15-30mL/min) vein preservation should begin. This means protecting the arm from: venipuncture, intravenous catheters (IV), blood pressure monitoring, tight occlusive clothing/jewelry, subclavian vein catheter, and peripherally inserted central catheters (PICC) lines.

The vascular surgeon may see the patient for physical examination of arm veins and venous mapping prior to the creating of the AVF.

Pre-Operative Education:

Prior to AVF creation, the patient should receive information and education surrounding the creation of the AVF and recommendations that they need to follow to increase AVF maturation success. Patients should receive information about:

Patient Education Needed What is a AVF? What does the surgery

involve?

• A AVF if the lifeline needed for hemodialysis treatment. Placing needles in the AVF allows for access to the body’s blood which can be filtered in the hemodialysis machine for cleaning (the removal of waste products) and for the removal of fluid. Why is it needed? • It is needed to provide access to the

body’s blood. How to increase changes of surgical

success?

• Pre-operative isometric hand exercises to increase handgrip should be

employed (such as squeezing a ball) to increase blood flow to increase vein maturation.

How long with the AVF last? • This will vary. Some AVF will never progress to be used. Others can last 15 + years.

How to know if the access is working? • The AVF should be assessed for a thrill (buzzing feeling) and a bruit (whooshing sound).

When will it be used? • The AVF should be created 6 months prior to its intended use to maximize success rate but can be used 6 weeks after creation.

How will it be used?

• The use of the AVF will vary if you have a CVC or not. There is a

protocol to use for new AVF without existing CVC and another protocol for a new AVF with an existing CVC. Initially cannulation will start with 17 gauge 1 inch needles and gradually move up in gauge size if no

complications are encountered. What are the risks? /Complications • The risks of AVFs include but are not

limited to:

-AVF failure (does not mature). -Bleeding (from fistula).

-Pain. -Infection. -Steal syndrome.

What blood work is needed? • Prior to having AVF created, pre- operative bloodwork will need to be completed. This includes: CBC (Complete Blood Count), PTI (Prothrombin time/International Normalized Ratio), T&S (Type and Screen), & RENFUP (Renal Function Panel) and electrolytes to be drawn post hemodialysis (for patients currently on hemodialysis.

Post-Operative Education:

Post-operatively the patient should be made aware that is it normal for the AVF site to be swollen and tender and due to this, mobility and use of AVF arm may be limited. Nursing interventions/ education included in the post-operative care of a AVF creation include:

• Elevating AVF arm to decrease swelling.

• Ensure dressing is not occlusive. Occlusive dressings will compress the blood flow going throughout the AVF which may potentially clot off the access. • Monitor blood pressure and maintain over 100mm/Hg systolic. Inadequate blood

flow (low blood pressure), decreases AVF perfusion which may increase potential clotting.

• Observe for bleeding. Although a scant amount of old dried blood may be present post-surgery there should be no active bleeding from the AVF site.

• Nurses can auscultate for bruit (whooshing sound). Every AVF should have a bruit. If there is no bruit contact the Vascular Access Nurses/Nephrologist to report findings.

• Palpate for the thrill (buzzing sensation). Every AVF should have a thrill. If there is no thrill contact the Vascular Access Nurse/ Nephrologist.

• The patient education about vein perspective should be reinforced: to never have venipuncture, intravenous catheters (IV), blood pressure monitoring, tight occlusive clothing/jewelry, subclavian vein catheter or peripherally inserted central catheters (PICC) lines in their AVF arm.

• Patient should be advised to avoid sleeping on AVF fistula arm as compression may clot off access.

• The patient should be taught to listen and feel for the bruit and thrill also. They can listen by bringing AVF arm to opposite ear (for example if there is a right arm AVF, listen with left ear). They can feel for the thrill with their hand opposite to the AVF arm. This should be done routinely each day. If any issues are noted they should be instructed to contact their dialysis unit. If the unit in not opened they should go to Emergency to be seen.

• Approximately 2 weeks post operatively healing should be complete and patients again would be encouraged to perform isometric hand exercises to increase handgrip and blood flow should be employed.

• Dressing changes should be performed on newly created AVF using normal saline and covered with a gauze dressing (ensuring the dressing is not tight).

Advantages Versus Disadvantages of AVF over CVC

Increased vascular access longevity.

AVF does not develop (cannot be used). Can be contributed to:

• Inadequate access flow. • Small vessel size. • Venous Stenosis. Increased blood flow (better

dialysis cleaning).

Infection. Can be contributed to: • Improper postoperative care. • Patient hygiene practise.

• Nursing practices (handwashing, cleansing of AVF, cannulation technique).

Lower infection rates from vascular access dysfunction.

AVF thrombosis (clotting). Can be contributed by:

• Hypotension.

• Tight clothing/jewelry. • Sleeping on AVF site.

• Restrictive bandages/dressings. • Stenosis in AVF outflow.

• Increased coagulation state (monitor patients taking anticoagulants).

Lower risk of mortality contributed from vascular access

dysfunction

Pain due to cannulation. Unsuccessful cannulation or infiltrations cause lead to:

• Hematoma.

• Aneurysm formation. • Infection.

• More than 2 needles needing to be inserted.

• Steal Syndrome: Steal syndrome occurs when the blood flow is shunted away from the distal extremity (fingers/hand) into the fistula. Due to inadequate blood flow to the extremity along with poor tissue perfusion patients

experience: pain, coldness to extremity, and often tissue death due to poor perfusion. If steal syndrome is noticed contact your vascular access

nurse/nephrologist immediately. Most cases the AVF can no longer be used

due to risk of ischemic limb therefore the patient would need a different vascular access surgically

created/inserted and the old AVF would be ligated.

Figure 4.3 Steal Syndrome noted in AVF from cannulation.