av grafts and hemodialysis catheters vistana

200 Hours Course for Person In Charge

Care of AV Grafts and

Hemodialysis CathetersDr. Yudisthra M. Ganeshadeva

MBBS(Mal), MRCP(UK and London), Fellowship in Nephrology (Malaysia)


AV Grafts


What is an AV Graft?

• A Synthetic Tube used to connect an artery to a Vein

• Usually made of PTFE or Dacron

• Used primarily as access in patients with difficult veins


Surgical Placement

• Can be placed on – Forearm (Forearm loop graft)– Arm – Neck (Necklace graft)– Axilary Artery to Femoral Vein

• The longer the graft – the less likely it is to last.


Time to Maturation

• AV Grafts are usually ready to use within 2-4 weeks from placement

• May be used earlier if not much soft tissue swelling.


Determining the Direction of Flow AV Grafts

• Compress the graft in the middle with 2 fingers – milk it both ways with pressure

• Release one finger• If the graft fills up

again- the limb proximal to that finger is the arterial end.


Determining the Direction of Flow AV Grafts

• Ultrasound technique - can also use doppler to look at flow

• Most surgeons include a diagram


Post Operative Care of AV Graft

• Patient advice– If bleeding – pressure with gauze/kleenex for

10 mins– Do not get wound soaked or wet for a week

post op– Check operation site for redness, swelling,

discharge or warmth which may signify infection

– First week – need to keep arm elevated above level of heart to minimise swelling.


Chronic Care of AV Graft

• Avoid on the side of the graft– Taking Blood Pressure– Taking Blood tests

• Thrill should be palpable on working AV Grafts


Cannulation of AV Grafts

• Staff : – If hands are visibly soiled, use soap and water.– If not visibly soiled, use an alcohol-based hand rub or

soap and water. – Decontaminate hands before and after patient

contact, rubbing hands together vigorously for 15 seconds then rinsing.

– Staff members who closely follow the policies and procedures of their respective facilities will always use and change gloves when indicated.


Cannulation of AV Grafts

• It is important not to try to cannulate the same site with each treatment as this weakens the access wall – puncture graft in step ladder fashion.

• Patient: It is recommended that patients wash their site arm carefully with soap and water when arriving at dialysis..


Cannulation of AV Graft

• Skin prep – for grafts, best to wash graft arm with non drying soap and water first before skin prep with povidone/chlorhexidine.

• Skin pulled taut in opposite direction to needle• Needle inserted at 45 degree angle – once in

rotated 180 degrees so that cutting edge faces downwards

• Taped in angle of insertion


Removal of needle

• Needle pulled out – then pressure applied to puncture site.

• Do not apply pressure before needle removed.


Care of Hemodialysis Catheters


Anatomy of the Neck• The internal

jugular is the preferred site of cannulation for insertion of hemodialysis catheters.

• The Right internal jugular offers a straight path to the atrium.

• The left internal jugular has a more tortuous path

Final Position of the catheter in the right artium


Ultrasound Guidance

• Ultrasound guidance is mandatory cannulation of the internal jugular veins due to markedly variable anatomy.

• Realtime ultrasound guidance preferred.

Lin, BS, Huang, TP, Tang, GJ, et al. Ultrasound-guided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron 1998; 78:423. 190 patients undergoing percutaneous insertion of a temporary catheter into the internal jugular vein compared the complication rates among those using ultrasound-guided placement (104 patients) to those using landmark-guided insertion (86 patients). Significantly superior results were obtained with ultrasound guidance with respect to overall success rate (99 versus 86 percent, P<0.01), success rate of the first attempt (81 versus 35 percent, P<0.01), puncture trials (1.39 versus 2.58, P<0.01), and traumatic complication rate (1.9 versus 11.6 percent, P = 0.015).

http://www.uptodate.com/online/content/abstract.do?topicKey=dialysis/12059&refNum=28





Anatomy of The Subclavian Vein• The subclavian anatomy is

more fixed than that of the internal jugular vein.

• Higher risk of pneumothorax as well as bleeding and hemothorax as a result of this being a noncompressible site.

• Subclavian cannulation can result in brachiocephalic stenosis on the ipsilateral site obviating the possibility of successful fistula creation on the arm on the same side.


Catheter Care


Care of the Catheter- Patient Info

• No showers for the first 24 hours.• Showers requires catheter and dressing to

be wrapped with plastic wrap.• If the catheter comes off – compress the

insertion point with a finger until bleeding stops.


Handling the Catheter

• Hemodialysis catheter dressing changes and catheter manipulations that access the patient’s bloodstream should only be performed by trained dialysis staff.

• The catheter exit site should be examined at each hemodialysis treatment for signs of infection.

• Catheter exit site dressings should be changed at each hemodialysis treatment.


Handling the Catheter

• Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter exit site are recommended after catheter placement and at the end of each dialysis session.

• Manipulating a catheter and accessing the patient’s bloodstream should be performed in a manner that minimizes contamination.


Decontaminating the Catheter

• Dressing for the catheter at each visit• Povidone soak/ Chlorhexidine soak for hubs

prior to dialysis procedure.


Decontamination procedure

• Catheter hubs should be soaked for 3-5 mins in povidone iodine and allowed to dry prior to seperation

• Catheter lumens should be kept sterile.• Catheter tips should remain capped or attached

to a syringe while maintaining a clean field.• Patients should wear a mask for all catheter

procedures• Dialysis staff should wear a mask and gloves for

any procedure related to the catheter.• Gloves need to be changed for each patient.


Other infection prevention methods

• Do not recycle blood lines.

• Keep the dialysis unit clean.


Day-to-day management of CVC

Advise to patient regarding care of the CVC

Very strict aseptic technique

Sterile

Soak hub with povidone iodine for 5 minutes


TroubleshootingAV Grafts and Fistulas


When to ReferInfected AV Graft

• AV Graft Infection– May present with following over graft

• Pus• Inflammation• New Onset Pain

• Needs inpatient intravenous antibiotics ± debridement/ removal of part or all of graft.


When to referGraft Thrombosis

• Graft thrombosis is common – no thrill over graft, graft hardened & unable to use for dialysis.

• Need to refer early to salvage graft- best to return to surgeon who created graft.

• Graft salvage may be done endovascularly or through surgery


When to referGraft Hematoma

• Graft hematomas can occur due to tears of the graft during needling.

• Usually resolve spontaneously• AV graft different from vessels as tears in

material cannot seal off.


When to ReferGraft Pseudoaneurysm

• Present with localised pain and swelling.

• Pulsatile – external to graft

• Usually due to poor needling technique.

• Will require referral for repair of graft – if numerous or large.

• Avoid areas of pseudoaneurysm for cannulation.


When to referInfection of AV Grafts

• Characterised by – Redness– Pus– Skin Erosion– Exposure of the graft

• Associated with– Tenderness over graft – Fever– ± fluctuance


When to referInfection of Grafts

• Entire graft should be removed in the following conditions:– the graft is less than one month old, – graft involvement by infection is extensive and

graft infection is accompanied by sepsis or hemorrhage.


When to referDialysis Associated Steal Syndrome

• DASS occurs in 2.7-8% of PTFE grafts.

• Subjectively - coldness, numbness, tingling, and impairment of motor function (not limited by postoperative pain)

• Objectively – Cold peripheries, decreased sensation.


When to referDialysis Associated Steal Syndrome

• Left untreated – potential of gangrene• Usually needs surgical procedure to

reduce steal by cutting down arterial inflow.

• In grafts may occur immediately post surgery when compared to AV fistula where steal may develop over time.


TroubleshootingHemodialysis Catheters


Immediate Problems


Hematoma

• Hematomas can arise from tears in the jugular vein wall or from punctures into the carotid artery.

• Hematoma risk is higher in patients with coagulopathies and uraemia.


Management

• Usually conservative• Cold compress at site of hematoma may

help.


Carotid Artery Puncture

• Carotid artery punctures can result in dissection of the artery and formation of pseudoaneurysms

• May require placement of covered stent if large or can be filled in with coils


Carotid Artery Dissection

• Carotid artery dissection is as a result of traumatic accidental puncture of the carotid artery and can even result in strokes as well as bleeding.


Carotidojugular Fistulas• Carotidojugular fistulas can result

from the accidental puncture of the carotid and jugular at the same insertion.

• They are usually significant if a dilator or catheter has been passed from the carotid into the jugular or vice versa.

• Treatment can be conservative if the fistula is small – may seal up spontaneously

• Covered endovascular stent may be needed in some patients where the fistula is large.

• Stent placement will require patients to be on clopidrogrel for 3 months and aspirin for life.


Pneumothorax

• Rare but dreaded complication of catheter insertion.

• More common with subclavian catheters

• Usually present within minutes or hours of insertion


Hemothorax

• Can occur with catheter insertion.

• Usually accompanied by fall in blood pressure, pallor, tachycardia and difficulty breathing

• Can occur within hours to days of catheter insertion

http://meeting.chestjournal.org/content/vol124/issue4/images/large/cb10t1985046.jpeg

http://meeting.chestjournal.org/content/vol124/issue4/images/large/cb10t1985046.jpeg


Arrythmias• Ventricular arrythmias can

arise from catheters placed deep in the ventricles and can be fatal if not identified and terminated immeadiately.

• They can also arise from guidewires that irritate the ventricular myocardium

http://upload.wikimedia.org/wikipedia/commons/3/3b/Lead_II_rhythm_generated_ventricular_fibrilation_VF.JPG


Chronic ProblemsFlow Issues


Troubleshooting HD Catheters

• Poor flow Red Lumen– May be due to

sideholes resting against vessel wall – usually in a narrowed vessel

– May be due to intravascular Sheath formation – this is a fibrinous sock that covers the catheter.

Vessel

Sheath

Catheter


Troubleshooting HD Catheters

• Poor flow Blue Lumen– May be due to position

of catheter tip– May be abutting

structure e.g Tricuspid Valve or vessel wall (left sided catheters)

Vessel Wall

Catheter Tip


When To ReferPoor Flow Both or Either Lumen

• Can be due to intraluminal thrombus or external thrombus abutting openings

• No flow both lumens- new catheter– May be due to catheter

malposition– May have dissected

through vessel wall during insertion for new catheters.

– Needs Exchange

Catheter Red Lumen

Clot

Catheter Blue Lumen


Management

• Rotate Catheter gently until flow improved.• Withdraw catheter 1-2 cm• Still no improvement? Refer – may need

urokinase or intraluminal brushing if cuffed catheter

• Cathetogram if new catheter or old catheter failing urokinase/intraluminal brushing.


Management

• Usually involves exchange of catheter or reposition of catheter over guidewire for non cuffed catheters.


Other Issues


When to referExit site bleeding

• Bleeding from the sides of the catheter insertion point• May be due to crack in the

Catheter• May be due to downstream

stenosis• May be due to large

catheter insertion wound – for new catheters

• Risk of Infection


Management

• Deeper re-position of catheter for downstream stenosis– May require fluroscopy

• Purse String Suture at exit site – usually first line of management


When to referCentral Vein Stenosis

• Long term HD catheter use can result in central vein stenosis.

• Difficult to treat – can confound future fistula creation

Brachiocephalic Stenosis


When to ReferCentral Vein Stenosis

• May require plasty in the event arm having fistula is swollen and distressing to patient

• May require plasty if stridor or breathing difficulty in patient.


Infections


Infections of Catheters


• Definition:

• Localized Catheter Colonization Significant growth of a microorganism (>15 CFU) from the catheter tip, subcutaneous segment of the catheter, or catheter hub

• Exit Site Infection Erythema or induration within 2 cm of the catheter exit site, in the absence of concomitant bloodstream infection (BSI) and without concomitant purulence

• Clinical Exit Site Infection Tenderness, erythema, or site induration >2 cm from the catheter site along the subcutaneous tract of a tunneled catheter, in the absence of concomitant BSI

MMWR(CDC) August 9, 2002 / 51(RR10);27-28

Exit Site Infections(ESI)


ESI Prevention:Topical antiobiotic

• Polysporin triple antibiotic (Lok 2003)–169 patients with TCD, 6 months

Mupirocin (Johnson 2002)–50 HD patients with TCD catheters, 20 months

Infections per 1000 catheter days

Bacteremia per 1000 catheter days

Deaths

Placebo 4.10 2.48 13

Treatment 1.02 0.63 3

No exit site infection No of CRB Time to 1st infection

Control 21.7% 34.8% 55 days

Treatment 0% 7.4% 108 days


Topical antibiotics – meta analysis

• Topical antibiotics reduced the rate of:– Bacteremia

• rate ratio, 0.22 [95% CI, 0.12 to 0.40]; • 0.10 vs. 0.45 case of bacteremia per 100 catheter-days,

– Exit-site infection • rate ratio, 0.17 [CI, 0.08 to 0.38]; • 0.06 vs. 0.41 case of infection per 100 catheter-days,

– Need for catheter removal, and – Hospitalization for infection

James et al : Ann Intern Med. 2008 Apr 15;148(8):596-605.


Tunnel Infections

• Tunnel Infection Purulent fluid in the subcutaneous tunnel of a totally implanted intravascular catheter that might or might not be associated with spontaneous rupture and drainage or necrosis of the overlaying skin, in the absence of concomitant BSI


Blood Stream Infections• Infusate-Related BSI Concordant growth of the same

organism from the infusate and blood cultures (preferably percutaneously drawn) with no other identifiable source of infection

• Catheter-Related BSI Bacteremia/fungemia in a patient with an intravascular catheter with at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI except the catheter.


Infections


The End

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