HEMODIALYSIS VASCULAR ACCESS

Presented By:Presented By:Hosein KarimiBSN , MSA (Anesthesia and Intensive Care)BSN , MSA (Anesthesia and Intensive Care)

HEMODIALYSIS VASCULAR ACCESS

Cardiovascular Systemy

Anatomy of vessels y

The capillariesp

Capillary Bedp y

Principle Of HEMODIALYSISp

Effects of different components on vascular tone

Systemic response to central hypovolemiaat different stageat different stage

IVC Diameter (mm) vs. CVP (mmHg)

Components of dialysis fluidComponents of dialysis fluidp y

BufferNormally bicarbonate

ElectrolytesSodium PotassiumPotassiumCalciumMagnesiumgChloride

Glucose

Change in potassium during dialysis (average for 7 sessions)(average for 7 sessions)

8 0

6 0

7.0

8.0

) 01DE

4 0

5.0

6.0

m (m

mol

/l 02ES03SK04IL05DC

2 0

3.0

4.0

Pota

ssiu

m 05DC06DS07CW08GO

0 0

1.0

2.0 09JW

0.0Pre Post 45 mins

Sample

Pre-dialysis sodium levels for 7300 sessions

2000

Normal range

1600

1800o a a ge

1200

1400

of p

atie

nts

600

800

1000

Sodium (mmol/l)Num

ber o

200

400

600

0

200

124 126 128 130 132 134 136 138 140 142 144 146 148 150

Understanding YourHEMODIALYSIS ACCESS OPTIONSHEMODIALYSIS ACCESS OPTIONS

Duration of Catheter Use

Time from 1st Dialysis to Catheter RemovalTime from 1 Dialysis to Catheter Removal

1992 1998 71 9 d1992 – 1998 71 + 9 days

1999 – 2003 141 + 26 days

New Access by Typey yp

2006 US Renal Data System2006 US Renal Data System

Fistula Graft Catheter

Insertion Techniqueq

Right external jugular

Sternocleidomastoid Muscles

Right Common Carotid Artery

Right InternalJugular

Insertion Techniqueq

Acute Catheter Tip Chronic Catheter Tip

SVC or Caval Right Atrial Junction Right Atrium

0% Recirc lation Rate5% Recirculation Rate 0% Recirculation Rate

Right Atrial Tip Placementg p

I d Fl R t

TUNNELED CATHETERS ONLY

• Improved Flow Rates

• Consistent (Reproducible) Flow Rates

• Zero Recirculation Rate

• Improved Clearance

Ante grade Tunneled CHD Catheters

Left Internal Jugular Vein Placement

Venotomy Location

Left Internal Jugular Vein Placement

Venotomy Location

Tip Location

R lResults:1. Good tip placement, but

poor cuff and exit site placement or

2 G d ff d it it2. Good cuff and exit site placement, but poor tip placement

Step 1: Place Catheter Tips First

Left Internal Jugular Vein Placement

Benefit #1: Minimizes risk of

Left Internal Jugular Vein Placement

Catheter tip malpositioningBenefit #2: Minimizes risk of catheter recirculation

Venotomy Location

of catheter recirculationBenefit #3: Minimize riskof catheter clotting

Tip Location

Advantages of Arteriovenous FistulasArteriovenous Fistulas

• Longevity - fistulas last longer than grafts

D bilitLower

• Durability - fewer complications

fewer reparative procetures

Costs

- fewer reparative procetures

Fistulas are not as good as you’ve been told ,and Grafts are not as badand Grafts are not as bad …

PTFE (PolytetraFluoroethylene) Graft ( y y )

angioplasty angioplasty

angioplasty

Fistula angioplasty

Checks each month in grafts and in A/V fistula with dysfunctionA/V fistula with dysfunction

Screening Procedure include :

1- Physical Examination1 Physical Examination

2- Measurement of Recirculation rate

3- Measurement of static and dynamic venous pressure

4- colour-coded duplex ultrasound

Recommended by DOQI (Dialysis Outcomes Quality Initiative )

Guideline

Reference :

1- Applied Physiology in Intensive CareMedicine 2006

2- FISTULA FIRST 3 On Course With Cannulation3- On Course With Cannulation4- CDC Guide Line5- Gray’s Anatomy

QuestionsQuestions