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Medical Surgical: Access for Hemodialysis

This post will cover Access for Hemodialysis.

Before we start, be sure to download the free PDF study guide with this post to enhance your learning. The link is listed here!

Subclavian and Femoral Catheters

A subclavian or femoral catheter may be inserted for short-term or temporary use for Acute Kidney Injuries..

The catheter could also be used until a fistula or graft matures, which takes typically 4 to 6 weeks. A catheter may also be required when the patients fistula or graft access has failed because of infection or clotting.

Interventions include assessing the insertion site for hematoma, bleeding, catheter dislodgement, and infection. Remember that these catheters should only be used for dialysis treatments and accessed by dialysis personnel only. For infection control purposes, it is important to maintain an occlusive dressing over the catheter insertion site.

A Subclavian Vein Catheter

A subclavian catheter is usually filled with heparin and capped to maintain patency between dialysis treatments. Heparin is later aspirated from the line before dialysis. For infection control reasons, the catheter should not be uncapped except for dialysis treatments.

A Femoral Vein Catheter

Interventions for a femoral vein catheter include:

  • assessing the extremity for circulation, temperature, and pulses.

  • prevent pulling or disconnecting the catheter during treatment

  • avoid kinks or occlusions, let the patient know that they should not sit up more than 45 degrees or lean forward during treatment.

Now if a catheter is located on the groin area, what do you think would be the number one concern?

The number one concern is infection.

Because the groin is not a clean site, meticulous perineal care is required.

An External Arteriovenous Shunt

An external arteriovenous shunt are two cannulas surgically inserted into an artery and vein in the forearm or leg to form an external blood path. When dialysis is complete, the cannulas are clamped and reattached, forming a “U” shape.

Let's go over the pros and cons of an external arteriovenous shunt. Starting with the pros.

The external arteriovenous shunt can be used immediately once placed and no venipuncture is necessary for dialysis.

Now with the cons, there is a risk of disconnection or dislodgement of the external shunt. Also there is a risk of hemorrhage, infection, or clotting.

Let's talk about the important nursing actions of an external arteriovenous shunt.

Interventions include:

  • making sure to avoid getting the shunt wet.

  • wrapping a dressing completely around the shunt

  • keeping it dry and intact

  • keeping cannula clamps at the patient's bedside in case of accidental disconnection.

  • educating the client that the shunt extremity should not be used for monitoring BP, drawing blood, placing IV lines, or administering injections because this will cause damage.

  • monitoring skin integrity around the insertion site to make sure there are no signs of infection.

Now if there are any signs of clotting, hemorrhage, or infection occurring, notify the provider immediately.

Signs of Clotting

There are many signs of clotting when checking the tubes of the shunt. Signs would be white flecks due to the fibrin. Also when there is a separation of serum and cells, this is also a sign of clotting. When auscultating the shunt, there would be an absence of a bruit as well as coolness of the extremity.

An Internal arteriovenous fistula

An Internal arteriovenous fistula is a permanent access of choice for a patient with Chronic Kidney Disease requiring lifelong dialysis.

How is the fistula created? Well, the fistula is created surgically by anastomosis of a large artery and large vein in the arm.

How it works is that the flow of arterial blood into the venous system causes the vein to become mature and large.

Maturity takes about 4 to 6 weeks, depending on the patient's ability to do hand-flexing exercises such as ball squeezing, which helps the fistula to mature.

In order to use the fistula, it must be mature before it can be used because the engorged vein is punctured with a large-bore needle for the dialysis procedure.

So what happens if the access is not yet mature? Then a subclavian or femoral catheter, or an external arteriovenous shunt can be used for dialysis while the fistula is developing.

Lets go over the pros and cons of an Internal arteriovenous fistula starting with the pros.

The risk of clotting and bleeding is low because the fistula is internal.

The fistula can be used multiple times.

The fistula has a decreased incidence of infection because it is internal and is not exposed.

Once healing has occurred, no external dressing is required.

The fistula allows freedom of movement which is great for the patient.

Now some of the cons are that the fistula cannot be used immediately after insertion, so planning ahead for an alternative access for dialysis, such as a catheter, is important.

Needle insertions through the skin and tissues to the fistula are required for dialysis. This causes anxiety for patients that have a fear of needles.

Infiltration of the needles during dialysis can occur and cause hematomas.

An aneurysm can form in the fistula.

Heart failure can occur from the increased blood flow in the venous system.

The most important con to be aware of is Arterial steal syndrome can develop in a patient with an internal arteriovenous fistula. With this complication, a large amount of blood is diverted to the vein causing arterial perfusion in the hand to be compromised.

An Internal Arteriovenous Graft

So why would an internal arteriovenous graft be used? Well it may be used for chronic dialysis patients that do not have adequate blood vessels for a fistula. A graft would be their next option.

The procedure involves the anastomosis of an artery to a vein, using an artificial graft.

The graft can be used 2 weeks after insertion.

Complications of the graft include clotting, aneurysms, and infection.

The pros and cons are the same as an internal arteriovenous fistula

Interventions For An Arteriovenous Fistula and Arteriovenous Graft

Actions include the following;

  • educating the client that the extremity should not be used for monitoring BP, drawing blood, placing IV lines, or administering injections, and that the client should inform all healthcare personnel of its presence.

  • educating the client with an arteriovenous fistula to perform hand-flexing exercises such as ball squeezing to promote graft maturity.

  • Monitoring the temperature and capillary refill of the extremity so that you can see whether there is good perfusion.

  • Palpating pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia.

  • Monitoring for clots.

  • Monitoring for arterial steal syndrome and infection.

  • listening to lung and heart sounds for signs of heart failure because of the sudden increase of blood volume during treatment

Mini quiz: What are the four most important abnormal assessments that must be told to the provider? Test your knowledge before reading the next sentence!

So the four most important abnormal assessments that must be told to the provider are signs of clotting, infection, arterial steal syndrome and absent bruit sound.

Complications of Hemodialysis

Now that we covered many different accesses of hemodialysis, let's go over some common complications. If signs of complications occur, the dialysis is slowed or stopped, depending on the complication, and the provider is notified immediately.

Always stay with the patient and monitor their condition when complications occur. While staying with the patient, continuously monitor their vital signs and have a charge nurse obtain initial prescriptions from the provider.

What To Do If A Patient Has an Air Embolism

1. Stop the hemodialysis.

2. Turn the client on the left side, with the head down This is also known as the Trendelenburg position.

3. Notify the health care provider and Rapid Response Team depending on the setting.

4. Administer oxygen.

5. Gather vital signs and pulse oximetry.

6. Document the event, actions taken, and the client's response.

Signs of an Air Embolism

The signs of air embolism include dyspnea, tachypnea, chest pain, hypotension, reduced oxygen saturation, cyanosis, anxiety, and changes in sensorium.

So here's what we learned in this video. In this video, we went over different types of hemodialysis accesses which includes subclavian -femoral catheters, external arteriovenous shunt, interval arteriovenous fistula and grafts. We covered signs of clotting, complications of each assess type, interventions of each and what to do when a patient has an air embolism.

So that concludes this post, join us in the next video as we cover Peritoneal Dialysis and Complications. As always, thanks for reading!

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