Dialysis Patient And Staff Safety

After completing this module, the learner will be able to:
1. Describe the predialysis set-up of the hemodialysis machine and extracorporeal circuit.
2. Explain the start, monitoring, and end of a routine treatment.
3. Identify the vita) signs that should be monitored before, during, and after treatments.
4. Discuss the basics of infections control.
5. Explain how to draw up and give intravenous medications.
6. Describe how to draw a blood sample.
7. Discuss the importance of documenting patient care.
8. Identify the causes, signs and symptoms, and prevention of clinical and technical complications that may occur during

Introduction for Patient And Staff Safety

• Cleaning a patient's blood with dialysis is a complex process with many steps - and each step may be crucial to keeping patient safe and maintaining their comfort.
• Dialysis treatments can only be uncomplicated and routine when staff pay close attention.
• This module covers the types of patient care tasks, technical tasks, and skills you will need to learn to
deliver safe and effective treatment.
• It goes over the processes of dialysis, from set-up to clean-up.

Patient and Staff Safety

BODY MECHANICS
• When you use good body mechanics (moving your body to prevent), you can avoid muscle strain and fatigue.
• Awkward postures, repetitive motion and heavy lifting are three main risk factors in musculoskeletal injury.
• To move effectively, you need to make friction, leverage, and gravity work for you.


Lifting and Carrying
• The proper way to lift objects - like supply boxes -is to stand with your feet shoulder-width apart and bend from your hips and knees.
• Never bend at the -waist or turn your body -when you lift, push, or pull an object.
• Put your hands around the object and pick it up, holding it close to your body.
• Bend your knees and keep your back straight; you want to use your arm and leg muscles - not your back.
• If the object is too heavy for you to lift by yourself, don't try it - get help instead.


Back-saving Tips
• Think before you lift.
• Lift with your legs and hold the object close to your body.
• Start at your ideal body weight.
• Strengthen your leg and stomach muscles.
• Exercise for 30 minutes, at least 3-4 times a week. Improve your flexibility; do gentle stretches every day.
• Never twist and lift at the same time. Keep your feet, knees, and torso pointed in the same direction.
• Test the weight of the object or patient before you lift. If something is too heavy, get help from a co-worker or a mechanical aid.
• Push, don't pull. You'll have twice as much power and less chance of injury.
• Slow smooth movements are safer than fast, jerky ones.
• If you develop back pain, stop what you are doing. Patient and Staff Safety

TRANSFERRING PATIENTS
• Which technique you use will vary with how well a patient can stand up and bear his/her own weight. • Before you move a patient, check his/her general condition.
• If possible, do not move a patient who has unusual fatigue, nausea, or unstable pulse or blood pressure; an unstable patient may fall.

Patients Who Use Walkers
• You may need to help patients who use walkers to be sure they can balance and will not fall.
• Even though it may be faster for you to put a patient in a wheelchair, it is physically better for the patient to use the walker

Chair-to-Chair Transfers
 • Lock the wheelchair and apply breaks anytime you move a patient to or from a wheelchair.
• Even with the breaks on, hold the wheelchair in place or put one foot against a wheel during a transfer to keep it from slipping or tipping over

Stand and pivot technique
     • Help the patient sit on the edge of the chair.
     • Put a gait belt (heavy canvass belt) around the patient's
waist to provide stability and control during the transfer.
     • Stand in front of the patient and help him/her to stand by pulling the belt to bring the patient toward you.
     • Then, slowly pivot with the patient until you can lower the patient into another chair and then remove the belt.
     • Use good body mechanics to prevent injury.


Using a slide board (from the sitting position)
     • Hold the board steady during the transfer.
     • Lock the wheelchair and hold onto it during the transfer.
     • Have a "spotter" standing by - someone who can help the patient to the floor if he/she slip or the board moves.
     • Ask a staff to hold the dialysis chair to keep it from
moving during the transfer.


Portable lift devices
• Portable lift devices like Hoyer™ lifts or sling lifts are usually used for patients who can't bear weight, are very heavy, or can't help with their own transfers,
• Make sure the device will hold the weight of the patient you are moving before you try a transfer (the weight limit will be in the owner's manual).
• Patient transfers using portable lift devices require at least two staff members.
     • One to move the lift
     • One to pull the patient to the correct part of the chair.
• When you see a portable lift device;
     • Make sure the sling is under the patients body from shoulder to hips.
     • Check the hooks are all in the correct slots on the sling holder,
     • Raise the patient up just enough to clear the chair.
     • Be sure the patient's fingers are clear of any hooks that could pinch.
     • Release the patient down into the chair gently
     • Reposition the patient as needed.


Stretcher-to-Chair Transfers
• If a patient can bear some weight, place the stretcher in a low position and use the stand and pivot technique.
• If the patient can't bear weight, use a portable lift device.


Stretcher-to-Bed (Lateral) Transfers
• Lateral transfers are used for bed-bound patients.
• You can use assist devices, like sheets or board with rollers, to help push and pull a patient from a stretcher to a bed.
• You will need several staff, but these devices avoid the need for a complete lift, which reduces the risk of injury.
• For all lateral moves, the surface to which the patient is being transferred should be a half inch
lower than the surface the patient is on.
• Using an assist device, some of the staff members will push and the others will pull the patient onto the new surface.


EMERGENCY PREPAREDNESS
• An emergency is an unexpected event, like a fire, tornado, hurricane, flood, blizzard, ice storm, or earthquake, that requires help or immediate action.
• Key points of emergency preparedness include:
     • Follow your center's plan to notify staff and emergency services personnel.
     • Know where to find all exit doors, how to locate arid use fire extinguishers, and your role if there is an emergency.

• In case of fire, remember R.A.C.E:
     • Rescue
     • Activate the alarm
     • Contain the fire (only if small)
     • Evacuate

• To use a fire extinguisher, remember P.A.S.S.:
     • Pull the pin
     • Aim the nozzle at the base of the flame*
     • Squeeze the handle
     • Spray from side to side at the base of the flames


• Disconnect patients from the machine to evacuate in this order.
     1. Patients who can walk without help
     2. Patients who can walk, but will need some staff help to do so
    3. Patients who cannot walk and will need staff help to evacuate
• Evacuate the premises using the safest and closest exit.


INFECTION CONTROL
• Pathogens (agents that cause disease, like bacteria, virus, or fungi) that invades the body can cause infection.
• Infectious disease is the second most common cause of death in dialysis patients.
• The most common pathogens normally live on the skin and on mucous membranes, (e.g., lining of the nose, mouth, and bowels). Others are found in the soil, in water, on clothing, and on all surfaces.
• Communicable disease can be spread in several ways:
     l. Direct contact: touching an infected person, such as
shaking hands or kissing.
     2. Indirect contact: touching contaminated objects such as clothing, towels, cups, water faucets, telephones, doorknobs and equipment
     3. Droplet spread: breathing in sneezed or coughed droplets from the nose, mouth, throat, or lungs of an infected person

• Infection can also occur when contaminated fluids enter the body such as through a needle stick.
• A bite of an insect can cause disease.
• Some diseases are caused by breathing in airborne fungi, bacteria, or viruses in dust or lint.
• In a dialysis center, pathogens can be spread by patients, staff, visitors, equipment, water, dialysate, and air.

Aseptic Technique
• Aseptic (free from infection) technique is used to keep an object or area sterile (free from all germs).
• Other terms that relate to aseptic technique are:
     • Clean: not free of germs, but disinfected and usable for some steps in the treatment
     • Contaminated: an object that was sterile, but then was touched by a non-sterile object (germs could now be on the object)
     • Dirty: neither clean nor sterile, cannot be used for dialysis steps that require an object to be clean or sterile


Guidelines for Aseptic Technique
• Prepackaged sterile items are sterile only if the package is closed and intact. Open sterile solutions or supplies only when you need them. Once open, they are exposed o airborne pathogens.
•  Wash your hands before you touch a package that contains a sterile item. This will help keep you from getting germs on the item. Packages that contain sterile items should not be allowed to get wet -moisture allows pathogens to pass through the wrapper and contaminate the object,
•  A contaminated object contaminates a sterile object. For example, when you spike a bag of saline, take care to insert the spike directly into the port. If the spike touches the outside of the bag or any other unsterile object, it becomes contaminated itself, and you cannot use it.
• Before you use a multidose vial, scrub the rubber stopper with disinfectant. Mark the vial with the date and time of first use.
• All fistula needles, syringes tips, and needles used to give medications or draw blood must be sterile, because they enter the bloodlines or the patient's body. When you start a treatment, do not touch the fistula needle or ends of the bloodlines to the patient or dialyzer. When you attach a heparin syringe to the heparin line, do not touch the syringe tip or the end of the heparin line.


Hemodialysis Infection Control Precautions
• Ways to prevent bloodbome infections in HD patient as recommended by the Center for Disease Control and Prevention (CDC).
• Components of dialysis precautions
     • Wash hands before and after removing gloves, or after exposure to body fluids.
     • Place infectious waste in color-coded receptacles.
     • Store properly
• Components of dialysis precautions
     • Clean all work surfaces.
     • Never mix food and medical supplies in the same refrigerator.
     • Maintain accurate records
     • Wear employee protective clothing, like gowns, masks, goggles and gloves.
     • Use sharps box.


Handwashing
• Washing your hands correctly is the single most important thing you can do to prevent the spread of infection.
• It protects you as well as the patient.
• The goal is to remove pathogens that might be transferred to patients, visitors, or other staff.
• Research shows that handwashing can reduce infection
rates, stop an outbreak of disease, and reduce the spread of drug-resistant bacteria,


When to Wash Your Hands
• Between contact with all patients
• Before and after you do any invasive procedures - like putting in dialysis needles - even if you wear sterile gloves
• Before you touch a wound, whether it is surgical, due to trauma, or caused by an invasive device - like a dialysis needle.
• Before you touch patients who have diseases that make them more susceptible to infection
• After you touch any body substance or mucous membrane •
• After you take off your gloves
• Between tasks and between procedures on the same patient to prevent cross contamination of different body sites
• When you enter and leave the center, to reduce the chance of spreading germs to your family, the patients, and other staff.


Handwashing
• CDC recommends:
     • That when you wash your hands with soap and water, wet your hands first with water.
     • Apply the amount of soap recommended by the manufacturer, and rub hands together briskly for at least 15 minutes, covering all surfaces of the hands and fingers.
     • Rinse your hands with water and dry thoroughly with a paper towel
     • Use a paper towel to turn off the faucet •
     • CDC also recommends that healthcare personnel who have direct contact with high risk patients - which includes dialysis patients - avoid wearing artificial nails. Keep your nails less than one quarter of an inch long.
     • If your hands are not visibly dirty, you can use an alcohol-based handrub.
     • Apply the product to the palm of one hand and rub your hands together to cover all surfaces until your hands are dry.
     • Always wash your hands with either soap or an alcohol-based handrub if your hands are not visibly dirty; after you take off gloves; each time you work with a different patient; and after you touch blood, body fluids and contaminated items.
     • Use hand lotion or cream after washing your hands to „ prevent dryness and chapping.


Protective equipment
• During a treatment, you can be exposed to blood and contaminated items.
• You must wear gloves when you care for a patient or touch the equipment.
• You must also change your gloves between patients -failing to change gloves is a common error made in heallhcare settings.

Change your gloves:
• After each patient contact
• When they are bloodstained
• After you handle infectious waste containers
• After starting a treatment
• Before you touch any surface such as machine dials, charts, and phones.


When to Use Protective Equipment

• When you do tasks that may cause blood or body fluid to splash or spray (e.g., start and end of a treatment, injecting into a bloodline, putting in needles).
• When you handle patient care equipment that is soiled with blood or body fluids, to prevent contamination of clothing or skin.

Wear a face shield and protective eyewear:
• During tasks that may cause droplets of blood or body fluids to splash or spray
• At the start and end of a treatment <> When troubleshooting the vascular access
• When you inject into the bloodlines or change the transducer protector


To avoid sticking yourself with sharps (needles):
•  Never recap needles if at all possible. If, for some reason, you must recap, use a mechanical recapping device or a one-handed method.
• Do not bend, shear, or break contaminated needles.
• Dispose of needles in puncture-resistant, color-coded boxes.
• Always point needles away from yourself.


Protective equipment
• Steps to properly remove gloves:
     1. With both hands gloved, peel one glove off from the top (wrist) to the bottom (fingers) and hold it in the gloved hand.
     2. With the exposed hand, peel the second glove off from the inside, tucking the first glove inside the second.
     3. Do not "snap" the gloves when you take them off. Throw out the soiled gloves promptlyWear a gown:

Central Venous Catheters

• Patient may have an urgent need for treatment and no access due to:
     • Acute renal failure
     • Peritonitis from Peritoneal Dialysis
     • Uremia from chronic kidney disease with no matured fistula
     • A wait for a scheduled transplant
     • An agreement with a doctor to have a trial dialysis
     • Refusal of fistula surgery
     • Access failure or infection

• All of these events occur often, so it is good that we can access the blood quickly using a percutaneous (through the skin) catheter or a subcutaneous (under the skin) port/catheter device.
• These devices are made for short-term use - days to weeks - but some patients may need them for months or even years
• Unfortunately, patients who use catheters are more likely to develop blood infections that can be fatal.
• Central venous catheters can damage the central blood .vessels as well as the heart.


Types of Catheter and Port/Catheter Devices
• A central venous catheter is a relatively large tube placed into a high-flowing central vein that leads into the heart.
• Because HD removes and returns blood at the same time, the tube has two side-by-side chambers called lumens.
     • The end of the catheter that enters the patient's blood stream is the "tip", it has holes for blood entry and exit.
     • The other end, the "tail" is outside the body with the two lumens apart.
     • Each lumen has an adapter-connector on the end.
     • The connectors attached to the bloodlines through specially-designed needles that are placed at the start of the treatment.
• The exit site, where the catheter comes out through the
skin, is covered by a sterile dressing, especially when the
catheter is not in use.

Short-term Catheters
• For patient who need short dialysis treatments.
     • Acute renal failure
     • Infection
     • Clotted fistula or graft
     • This type of catheter is short in length because it exits the skin directly over the venotomy (the site where the catheter enters the vein)


Tunneled, Cuffed Catheters
• TCC is longer than a short-term catheter because the tail is tunneled under the skin from the venotomy to the exit site, a few centimeters away.
• Most tunneled catheters have a cuff. :
     • The cuff of the catheter is fibrous material about 5 mm wide, wrapped around the catheter.
     • The cuff is placed about 1 cm up the tunnel from the exit site
     • Healing tissue inside the tunnel bonds with the cuff; this keeps the catheter from pulling out and bacteria from migrating up the tunnel and into the bloodstream.
• For this reason, TCCs are safer and are the preferred type
• Another style of TCC is the single lumen catheter
• Two single lumen catheters must be placed to do conventional HD; one to take blood to the dialyzer and the other to return it.
• These catheters are called twin catheters.


Port/Catheter Device
• Is usually a combination of a port and a single lumen catheter
• This catheter has a tip like a percutaneous single needle catheter, but the tail connects to a metal port placed under the skin (see next slide)
• Two port/catheter devices are needed to do HD.
• The shorter catheter is the "pull", or arterial, line; the longer one is the "return", or venous, line
• The blood stream is accessed by placing a needle into the metal port and opening the valve.
• 1 he dialysis needles are treated like extensions of the catheters.
• The heparin is removed and the needles are flushed with saline prior to connection with the lines.
• At the end of the treatment, the procedure is reversed.
• Removing the needles at the end of each treatment closes a valve that seals each port device internally
• Catheter and Port/Catheter Device Sites
• Catheters for HD are always places in veins tliat are able to support the high blood flows needed for dialysis
• The very large veins in the neck and chest that empty into the right atrium of the heart are the most suitable
• The largest of these, the superior vena cava, collects blood from the head and neck veins (internal and external jugular) and from the arms via the subclavian veins,
• The right internal jugular (RU) vein is the very best because:
     • In most people, it is the largest vessel
     • In most people, it is the shortest and straightest distance to the right atrium of the heart
     • It has the lowest rate of stenosis and/or clots, that would prevent return blood flow from a future fistula or graft in the arm
• Note: a catheter should not be placed on the same side as a working flatula or graft.
• The left internal jugular (L1J) is the second of choice, but t is longer and has two large curves to navigate.
     • This reduces blood flow
The subclavian veins should not be used for a catheter unless a surgeon has found that no fistula or graft can ever be placed in the ipsilateral (same side) arm or there is a life threatening emergency.
• The femoral veins in the groin can be used for catheter access when:
     • Temporary access is needed for urgent dialysis and the RU cannot be used
     • Long-term catheter access is needed and none of the upper central veins can be used.
• There are other, more exotic catheter placement such as translumbar or transhepatic for patients who no longer have any of the usual placement sites
• The following principles for venous entry are true for all HD catheters, whether percutaneous or cutaneous.
     • The tips of all catheters inserted into the chest wall should be placed well into the right atrium of the heart and the tips of all femoral veins should be well up into the inferior vena cava (1VC).
     • This tip placement assures the best flow into the catheter, for the best dialysis.

Telling an IJ Catheter Apart from a Subclavian
The subclavian vein is, as its name suggest, below the clavicle (collarbone). Because IJ TCC exit sites are often in the same place as the exit site of a short-term or TCC subclavian catheter, there can be confusion over which vein the catheter enters:

• If a TCC is seen and/or felt over the clavicle, it is IJ.
• If the catheter disappears under the clavicle, it is subclavian.


Placement of Catheters and Port/Catheter Devices
• Most catheters are placed in vascular interventional outpatient centers by a radiologist or a nephrologist.
• Vascular, transplant, and general surgeons also place them, often at the same time as they create fistula or graft.
• Most port/catheter devices are placed in hospitals.
• The main advantage of using a vascular interventional suite or operating room is that x-rays can be done during the procedure, to reduce placement problems
• Catheters must be placed with strict aseptic technique.

• All newly placed catheters are tested by saline flushing to assure function and then locked with heparin to prevent clotting.
• Local anesthetics and conscious sedation - IV medications to relieve pain and sedate the patient - are
used during catheter placements.
• Uncomplicated catheter placements take less than 30 minutes.
• Port/catheter device placement takes longer and is more complex.


IJ Placement
• The IJ vein is 2-3 cm above the clavicle.
• It is found by an ultrasound device, then punctured with a large needle.
• Dark, venous blood is pulled back to prove that the vein was reached.
• A guide wire is inserted through the needle, the needle is removed, and the catheter is advanced into the vessel over the wire.
• Once the catheter is in the vein, the guidewire is removed
• The tunnel under the skin for the TCC placement may be formed first, depending on the type of catheter used.
• The tunnel is usually brought over the clavicle, with the exit site 2-3-cm below'
• Stitches are placed around the catheter at the exit sites of both temporary and tunnel-cuffed catheters.
• The stitches can be removed from a TC after 10-14 days, but should not be removed from a short-term catheters until the catheter itself is removed.
• Placement of any chest catheter can cause:
     • Bleeding ,
     • Hematoma (blood that has collected under the skin)
     • Air embolus
     • Pneumothorax
     • Hemothorax


Subclavian Placement
• As stressed before, the subclavian vein - the large vein in the shoulder that drains the majority of blood from the arm on the same side - should be the catheter site of last resort.
• It is much more likely than an IJ to become stenosed.
• If it must be used, general placement technique and procedure is the same as for an IJ catheter.


Subclavian Placement
• The doctor must take care to prevent kinking of the catheter due to the sharp angle needed to enter the vein under the clavicle.
• The risk of hemothorax and hemothorax may be higher due to the need to puncture directly over the lungs.

Femoral Placement
• The femora] vein is next to the femoral artery in the groin.
• The method for finding the vessel and placing femoral catheters is similar to IV placement.
• The most frequent complication of femoral placement is femoral artery puncture and hematoma.


Port/Catheter Device Placement
• The port is inserted through the incision into a pocket that is formed under the skin.
• After the catheter's placement and tunneling, it is connected securely to the vein.
• Prior to closing with sutures, all pocket bleeding must be stopped.
• The pocket may be flushed with an antibiotic to prevent infection.



Pros and Cons of Catheters and Port/Catheter Devices

Pros
• Patients can have vascular access for urgent treatment.
• Catheters and port/catheter devices can be hidden under most clothing.
• The patient's hands and arms can move freely during dialysis.
• Patients can shower or swim with port/catheter devices, once the incision is healed and the stitches are removed.
• Patients will say that "no needles" is the main advantage of catheters. This must be weighed against the proven higher risk of death and severe illness from long-term catheter use.

Cons
• Catheters and port/catheter devices are more likely to cause life-threatening bacteremias (blood infections).
• Catheters are foreign bodies in the bloodstream and can cause inflammation and clotting in the blood vessels, leading to stenosis and occlusion (blockages).
• Catheters generally have lower blood flows over time, for less adequate dialysis and more frequent procedures. Port/catheter devices usually have more reliably high flows over time.


Care of Catheters and Port/Catheter Devices

Preventing Infection
• The following steps will help prevent infections in catheters and port/catheter devices:
     • Always make sure you have washed yom hands and changed your gloves prior to touching the patient and his/her equipment.
     • Always make sure you and the patient each wear a mask covering both the mouth and nose whenever the catheter is opened or the exit site exposed Airborne bacteria that can infect catheters - and therefore the patient's blood - can be found in mouths and noses of both patients and staff.
• Assess the catheter exit site or port site before staring treatment. Look for any signs of redness, or drainage or pus.
• Always use aseptic technique when opening, handling, cleaning, or cannulating the port, or connecting and dressing the catheter (as per center protocol).
• Teach patients how to protect the catheter and its dressing. Most dialysis center change the dressing at each treatment, and patients shouldn't need to do this between treatments. If the dressing gets wet, it is best to remove the wet dressing, dry carefully around the catheter exit site, and cover the site with a large elastic bandage. To prevent the dressing from getting wet, most centers suggest no showers or swimming for patients with catheters.
• Patients must also be taught not to use sharp objects such as pins or scissors around their catheter. Pin holes put the patient at risk for infection and also require catheter changing before the next treatment. Accidentally cutting the catheter can cause severe blood loss or air entry. The patient should be shown to pinch off the catheter securely and seek medical help immediately.
• Report any problems with the catheter to the nursing staff as soon as possible.

Preparing to Use a Catheter
Predialysis assessment
• Ask the patient about any problems with the catheter during previous treatments or at home.
• Remove the dressing and note any changes in catheter position, such as the cuff becoming visible at the exit site.
• Observe for any redness and drainage (fluid or material coming out around the catheter) such as pus.
• Assess the ease of heparin removal and saline flushing before connecting the bloodlines. Presence of clots and/or sluggish saline flushing suggest that the catheter is blocked or compressed, or that catheter position has changed. This must be corrected before connecting the bloodlines. The nursing staff will further assess the problem and may instill a thrombolytic enzyme to dissolve the clot.


Consideration for accessing catheters and cleansing exit sites
• Prepare procedure site using dialysis precautions.
• Conduct procedures using aseptic technique (correct handwashing, masks for patient and staff, "no-touch" technique, and disposable clean gloves).
• Chlorhexidine 2% with 70% alcohol is the preferred solution for cleansing of central venous catheter sites. (check catheter manufacturer's warnings about the effect of disinfectants on catheter material).
• For patients who are sensitive to chlorhexidine aqueous, povidone solution may be used (use according to manufacturer's directions).
• Skin cleansing should include the following steps:
     1. Apply solution/swab in a circular motion working from catheter exit site outwards.
     2. Cover an area 10 cm in diameter.
     3 Perform this step twice. Do not rinse off or blot excess
solution from skin.
     4. Allow solution to dry completely before applying dressings
• To cleanse the connection between any CVC catheter hub and cap use two swabs;
     1. Hold up the catheter at the connection site with one swab
     2. Use second swab to clean from catheter connection up catheter for 10cm.
     3. Cleanse hub connection site and cap vigorously with the first swab. Discard swab.
     4. Do not drop a connection site once it is cleaned

• To cleanse the section of the catheter that lie next to the skin, gently swab the top and underside of the catheter starting at the exit site and working outwards.
• Always be sure the clamps are closed before opening the catheter to air when pulling off the catheter caps, removing a syringe, or undoing the Luer-Lok® connectors in the lines.


Monitoring Catheters During the Treatments
If pressure alarms signal that the flow cannot be maintained at the prescribed rate, you must:
1. Look at the patient and the lines to make sure there is no major bleeding or air entry. Call immediately for help if there is.
2. Next, assess for mechanical obstruction. Are the lines kinked
anywhere along the circuit? Check again that the catheter is in place.
3. Reposition the patient - lower the head of the chair, have the patient turn his head, cough, etc., to help move the tip of the catheter for better How.
4. Flush with saline to help further assess the condition of the catheter.
5. "Switch" or reverse the lines so that blood is pulled through the "venous" port and returned through the "arterial" port. This should be done to complete a treatment only with the permission of the charge nurse. Line reversing creates recirculation of the blood, which leads to less adequate dialysis - and does not correct the problem. It is also another chance for infection, and all the precautions taken to start dialysis must be repeated.
6. Ask the nurse to assess the problem. He/She may give a thrombolytic enzyme to clear the catheter of a clot.

• If these measures do not restore the prescribed blood flow, the patient should be referred to the interventional doctors or surgeons to correct the problem. This may require a new catheter placement.
• Monitor blood flow through the dialyzer, noting the amount of arterial and venous pressure exerted on the catheter to achieve the prescribed blood How. Always keep the pre-pump arterial monitor connected and open. It tells you the condition of the arterial catheter lumen, as does the venous pressure monitor for the .returning lumen.

Improving Vascular Access Outcomes

Continuous Quality Improvement (CQI)
• CQI can be a powerful tool to help reduce the rate of vascular access problems and provide the best outcomes.
• Collecting data and forming a CQI team are the first steps toward making a plan,
• For example, it might be helpful to begin a log or computer database to track vascular access problems. The log could include:
     • Access type
     • Date of placement
     • Surgeon
     • Continuous Quality Improvement (CQI)
• Type of complication
     • Action taken
     • Data from monitoring tests
     • Clinical assessments
     • Dialysis adequacy measurements
     • Rates of hospitalization, etc.
• By charting this information on bar graphs pattern, patterns can be seen.
• Based on a pattern, your team can devise a plan to solve a problem or improve the practice or process.


Improving Vascular Access Outcomes


Clinical Practice Guidelines
• The KDOQI Clinical Practice Guidelines for Vascular Access give ways to check and preserve a patient's access.
• You can help protect patients' accesses when you use good technique to put in needles, help patients put the right pressure on needle sites after a treatment, and report problems to a nurse or doctor right away.


Conclusion
• Vascular access is one of the most important and
challenging parts of dialysis.
• As a dialysis staff, you have a vital role in caring for your patients' vascular accesses.
• It is your job to learn how to correctly cannulate AVFs and grafts and to assess access sites for problems.
• At all times, remember that each patient's vascular access is a lifeline and must be treated with a great degree of care.


Continuious Quality Improvements / CQI Process

1. Identify Improvement Needs• Collect data
• Analyze data
• Identify problem statement » Prioritize activities

2. Analyze the Process
• Select a team
• Review the data
• Study the process/problem
• Identify partners/trends

 3. Identify Root Causes• Identify probable root causes
• Define/refine the problem

Graft Complication

Graft Complication
Infection
• Is more common in grafts than in fistula
• A break in the use of the aseptic technique is the main cause of infection.
• Signs and symptoms of an infected graft:
     • Redness
     • Swelling
     • Pain
     • Fever
     • Chills

Image Source: riversideonline.com

Stenosis
• Stenosis at the venous end of the graft is the most
common problem. i It can also develop along the length of the graft.
• Graft-vein stenosis develops when smooth muscle cells at the venous anastomosis grow more than they should.
• The cell form extra layers that fill up the graft lumen, reducing blood flow. This problem is called neointimal hyperplasia.
• Turbulence at either anastomosis and/or within the graft may play a role in this problem.
• KDOQI Clinical Practice Guidelines for Vascular Access recommend that grafts be checked for stenosis at least monthly.
• Grafts can be tested by measuring venous pressure or access flow.


Thrombosis
• Is the most common reason for AVGs to fail.
• A decreased or absent thrill/pulse is a sing of thrombosis.
• To check for thrombosis, look at the graft and palpate for thrill/pulse throughout the length of the graft.
• Teach patients how to palpate for the thrill/pulse in their access and report any changes to dialysis staff right away,


Steal Syndrome
• Can occur with grafts as well as fistula
• Some symptoms to watch for include pain, tingling, coldness, and a change in motor skills in the hand, blue nail beds, and/or decreased sensation in the access hand.
• The access surgeon should be told, so alert the nurse or nephrologist if you suspect steal syndrome.
• Try to keep the patient's hand warm during dialysis, perhaps with a mitten or tube sock.
• Changing the position of the patient's arm may help Increase blood circulation in the hand.


Dialysis Related Complications of Graft
The same dialysis-related complications that happen with fistulas also occur with grafts.


Complications Related to Poor Needle Insertion
• Pseudoaneurysm (a bubble-like blister in the graft caused by weakness in the graft wall) and graft collapse can occur if needle sites are not rotated well.
• For pseudoaneurysm to develop, the graft needs a defect and increased pressure from a venous stenosis.
• Each time a graft is cannulated, the needle cuts a hole in the graft.
• If the cannulation sites are not rotated, the holes will come together to form larger holes. Informally termed "one-site-itis", this overuse of the graft can have grave .consequences.
• The graft may start to come apart, which lead to graft collapse. At the same time, the frequent placement of needless in the same area damages the tissue above the graft, slowing healing and weakening all the protective skin layers.
• In time, the pressure of the blood flow - following the path of least resistance - will be stronger than the tissue covering it, and the pseudoaneurysm may rupture.
• If this occur, the patient can die ina matter of minutes if he/she is alone.
No graft should be allowed to reach this point.
• The graft may start to come apart, which lead to graft collapse.
• At the same time, the frequent placement of needless in the same area damages the tissue above the graft, slowing healing and weakening all the protective skin layers.
• In time, the pressure of the blood flow - following the path of least resistance - will be stronger than the tissue covering it, and the pseudoaneurysm may rupture.
If this occur, the patient can die in a matter of minutes if he/she is alone.

Vascular Access: Graft

Image Source: barwonvascular.com.au

• An arteriovenous graft (AVG) is an artificial blood
vessel used to connect an artery and a vein.
• Grafts can be long enough to connect vessels in very
different parts of the body, if needed.
• Many materials can be used for AVGs. These materials can be divided into biologic and synthetic categories.

Graft Material

Biologic
• Some human biologic AVGs were made from a vein from a patient's leg.
• Veins from the umbilical cords of newborn infants were also used.
• But they have high risk of infection and aneurysms.
• Bovine (cow) and ovine (sheep) carotid arteries used for grafts were treated to remove proteins that would cause the human body to reject them.
• These grafts also had high rates of infection and aneurysms.
• Veins from the umbilical cords of newborn infants were also used.
• But they have high risk of infection and aneurysms.
• Bovine (cow) and ovine (sheep) carotid arteries used for grafts were treated to remove proteins that would cause the human body to reject them.
• These grafts also had high rates of infection and aneurysms.

Synthetic
• Synthetic materials are now used for nearly all grafts.
• The most widely used synthetic graft material today is expanded polytetrafluoroethylene, or PTPE.
• Collagen is another material that is used to make grafts.
• Grafts may be straight, curved, or looped. .
• Some designs provide a larger surface area for needle insertion.


Graft Procedure
• Construction of a graft is a surgical procedure that bridges an artery and a vein.
• During the surgery, incisions are made over the vessel entry sites.
• The vein is checked to ensure that there is enough blood flow.
• A tunnel is then made under the skin, and the graft is attached to one vessel, passed through the tunnel, and attached to the other vessel (anastomosis)
• Straight grafts are usually placed in the forearm (radial artery to basilic vein).
• Loop grafts are placed in either the forearm (brachial artery to basilic vein), in the upper arm, or the thigh,
• The most common graft in the upper arm is curved from the brachial artery to either the basilic or axillary vein.
• A new graft should be placed at least 3-6 weeks before use, unless a graft material is used that can be cannulated right away.


Graft Pros and Cons
Pros
• Graft take less time to mature before the first cannulation
• Graft size and blood flows don't depend on the maturation
• Grafts may also have larger cannulation areas than fistula.
• Grafts are often used in patients who are not good candidates for native fistula due to advanced age or other health problems, like diabetes, that dammage blood vessels.
• The biggest problems with all grafts are infection and thrombosis.
• Grafts develop stenosis at the venous anastomosis most commonly, and clot at a much higher rate than native fistula.
• No graft material now exists that is as good as a native vessel.


Starting Dialysis with a Graft
Wash your Hands
• Washing your hands is always the first step before you touch any dialysis access.
• Clean hands and gloves help keep bacteria on the skin's surface from being pushed into the patient's bloodstream by the needle.


Graft Assessment
• General outline for assessing graft:
• Look for:
     • Swelling and redness
     • Pain and tenderness
     • Drainage from puncture sites, or from the skin around the graft
     • Bruises
     • Healing at previous cannulation sites
     • Localized warmth and fever


Graft Assessment
• General outline for assessing graft:
• Listen for:
     • Bruit- should be low-pitched and continuous
• Feel for:
     • Pulse - feel for a soft compressible pulse
     • Thrill-continuous (feel without compression only)
     • Skin temperature - should be normal, not hot
     • Hardness or pain


Confirm the Direction of Blood Flow
• To find the direction of the blood flow, feel the entire length of the graft
• Compress the middle of the graft with two middle ringers and feel for the pulse and/or thrill on both sides of the area to be compressed.
• You will feel the strongest pulse on the arterial side.
• The pulse or thrill will be faint or not palpable at the venous end.


Assess Blood Flow
• Every graft should have a strong flow of blood from the artery through the access and into the vein.
• The pulse of a graft feels like a pounding or buzzing with each heartbeat, as arterial blood is pumped by the heart to the rest of the body.
• This pulse, or thrill, should be strong, and you should be able to palpate it over the entire length of the access.
• The thrill should decrease over the venous portion of the graft.
• The sound should be strong and steady
• Like the thrill, the bruit should decrease over the venous portion of the graft.

Preparing to use a Graft
• The steps for preparing access skin, reducing pain from injection, applying tourniquets, and inserting needles use for grafts are exactly the same as in the fistula


Inserting Needles
Selecting a Cannulation Site
• Select a site that is at least a half inch away from any previous needle side.
• Do not cannulate near anastomoses
• The site should be at least one inch from an anastomosis, obstructions, or restrictions.
• Keep arterial and venous needles at least 2 inches apart.

Site Rotation of a Straight Graft
• To decide the needle site rotation in a straight graft, first divide the graft into equal halves at its middle. Use the middle as a reference.
• Cannulate the arterial half of the graft by moving toward the arterial anastomosis. Cannulate the venous half by moving towards the venous anastomosis.
• Each time you use a graft, space the needle sites equally along the length of the graft. Each needle insertion should be 0.25-0.5 inches from the last site. Place needles along three sides of a graft, not just along lie top.


Site Rotation of a Loop Graft
• To decide the needle site rotation in a loop graft, first divide the graft into equal halves at its middle. Use the middle as a reference.
• Cannulate the arterial half of the graft by moving toward the arterial anastomosis. Cannulate the venous half by moving towards the venous anastomosis.
• Rotate sites by equally spacing the sites along the graft. The space should be between 0.25-0.5 inches away from last site.
•Place needles along all three sides of the graft, not just along the top.


Needle Direction
• The venous needle is inserted in antegrade (in the direction of the blood flow) placement.
• This is needed to prevent excessive venous return pressure and damage to the blood cells.
• The arterial needle can be placed antegrade or retrograde (against the direction of blood flow)
• Retrograde placement of the arterial needle is preferred.


Graft Care Postdialysis

Postdialysis graft care is the same as postdialysis fistula Care.

Dialysis Rn Skills Checklist

Dialysis Rn Skills Checklist