Patient and Family Guide to Vascular Access IMPORTANT INFORMATION YOU NEED TO KNOW! Vascular Access Choosing the One that is Right for You! There are 3 kinds of vascular access for hemodialysis: AV fistula, graft and catheter. ARTERIOVENOUS FISTULA (AV FISTULA) Fistulas are the Preferred Hemodialysis Vascular Access! The arteriovenous or AV fistula is a type of vascular access involving a direct connection between an artery and a vein. This connection is made underneath the skin with a surgical procedure that can often be performed on an outpatient basis. The connection between the vein and artery allows for adequate blood flow during dialysis. This increased blood flow leads to larger and stronger veins and makes repeated needle sticks easier. Fistulas require time to mature (get stronger) before cannulation (8-12 weeks). Ideally, a fistula should be placed long before a person needs dialysis treatments. A fistula lasts longer than other access types, has fewer complications and provides better blood flow. GRAFT A graft is a surgical joining of an artery and a vein by a synthetic tube. A tunnel is created under the skin, the tube is inserted into the tunnel and then the tube is attached to an artery and a vein. Grafts can usually be used for dialysis treatments in about 3-4 weeks after they are placed or when the swelling goes down. CATHETER A catheter is a plastic tube inserted into a vein and extended into the heart. The catheter has two ports; one to draw blood from the body and the other to return blood to the body. Catheters are most commonly used as a temporary access. This is often done when a patient needs dialysis immediately and is waiting for a fistula or graft to mature. They are also used when a permanent access fails and a patient is too unstable to delay treatment. One of the main reasons hemodialysis patients are hospitalized is because problems with their vascular access.
Patient and Family Guide to Vascular Access Page 2 Buttonhole Cannulation Technique The buttonhole technique is a cannulation technique used in hemodialysis. The needles are inserted into the exact same spot, at the exact same angle and the exact same depth each time. The Buttonhole cannulation site needs to be established by the same person cannulating the site every time. Therefore, this is the perfect option for patients that self-cannulate. When using the buttonhole technique, a track is created by the formation of scar tissue (just like the hole created in an earlobe for a pierced earring). This track goes from the surface of the skin to the outside wall of the fistula. Once the track is healed there are no nerves or tissue in the path of the needle and therefore no pain! Benefits of the Buttonhole Cannulation Technique Less pain Fewer infections Fewer missed needle sticks Fewer infiltrations Cannulation takes less time Prolonged AV Fistula life Decreased hospitalizations associated with vascular access infections and complications Everyone s fistula is different. Talk to your healthcare team to see if Buttonhole cannulation is right for you. Many patients who use the Buttonhole technique for self-cannulation report that taking more responsibility for their health and well being is empowering. Your Role in AV Fistula Cannulation It is important to take an active part in your vascular access care. Even if you don t insert your own needles (cannulate), it is important for you to understand what is going on. Below are some tips for making your AV fistula last for a very long time. Assess Your Access: At least two times a day, check your access to make sure it is working (patent). Place two fingers over the site where your surgery was (anastomosis), and feel for one of two sensations, called a thrill a purring like a cat, or a vibration like a vibrator. A thrill should never feel like a bass drum thumping because this is a sign that there is a problem with your fistula, and you need to tell your nurse. Continued on Page 3
Patient and Family Guide to Vascular Access Page 3 Your Role in AV Fistula Cannulation (Continued from Page 2) Signs and Symptoms of Infection: There are several clues that will tell you that your AV fistula could be infected. Always look for redness of the skin over your fistula or drainage coming from your fistula. Use the back of your hand and feel if the skin is warmer over your fistula than your other arm. Taking your temperature before dialysis will also help the staff determine if you have an infection. Exercise Your Access: Starting one week after access surgery, you should start to exercise your arm to develop your new fistula. Exercise is good for small, problem fistulas too. If your AV fistula is in your lower arm, squeeze a small rubber ball several times a day for five minutes at a time. If your AV fistula is in your upper arm, hold on to a soup can or bottle of water and do curls - bending your arm up slowly at the elbow, then stretching it out. Even though it is the pressure of the blood flowing through your fistula that makes it big enough for cannulation, exercise can help. Washing Your Access: The nurses and technicians may ask you to wash your arm before coming to your chair. This helps to reduce the amount of staph, a bacteria that is on everyone s skin. Staph is okay on you skin, but can make you very sick if it gets into your bloodstream. Dialysis patients have a lot on their skin, and even in their noses, so it is important to wash some away just before cannulation. Learn to Self-Cannulate: Many people are afraid of needles, myself included, because they can cause pain. If you have had needles inserted into your skin before, you know that depending on who inserts your needles, it may hurt more or less. This has to do with their technique, or how they were trained to insert needles. The best thing about putting in your own needles is you take the guesswork out of which cannulator will show up. Patients are better able to feel where the fistula is. Whether it is your concentration or your technique, you will find self-cannulation is a lot less painful and stressful, especially if you choose to use the Buttonhole Technique. Three Strikes and You re Out! Remember this tip, no one should attempt more than three needles sticks in your access. Two is normal, a third if there is a problem but no more. Ask them to have another cannulator come and insert your needle. Please don t be afraid to speak up, it s your lifeline, and you are the caretaker. By Lynda Ball BS, BSN, RN, CNN Quality Improvement Director, ESRD Network 16
Patient and Family Guide to Vascular Access Page 4 The Importance of Washing Your Hands You have probably been asked to wash your access just before going to your dialysis chair. And, I know that some of you have questioned the nurse or technician about the need for washing your access you took a shower before you came to dialysis or they imply that you have poor hygiene. Actually, there are several important reasons why you should wash you arm right before sitting down. First, your immune system does not protect you from infection like it did when you did not have kidney disease and your doctor may have told you that you are now immunosuppressed. What this means is that you are at increased risk of developing an infection. Vascular access infection is the most common infection in hemodialysis patients and is the second most common cause of death (15%), according to the Centers for Disease Control and Prevention (CDC). 1 The biggest risk factor is the type of vascular access you have catheters have the highest infection rate, followed by grafts, and AV fistulas have the lowest infection rate. So, prevention of infection is the key and it is important that you can recognize the symptoms of infection: unexplained pain, chills, fever, drainage, and redness or swelling. Second, all of us have bacteria on our skin that help to protect us from other kinds of germs. The name of this bacteria is called Staphylococcus aureus, but the nurses and technicians may use the shortened name - staph. Some people also have staph in their noses and can spread bacteria simply by breathing. Did you know that dialysis patients have more staph on their skin and in their noses than the general population? Several studies have confirmed this, and it is the major reason that nurses and technicians ask you to wash your arm before dialysis to reduce the number of bacteria on your skin. 2 Simply stated, my staph protects me and your staph protects you, but your sterile bloodstream does not like staph either from you or anyone else and a severe infection could result. That is why patient care staff wear gloves during cannulation. Third, antibiotic resistance has been rising sharply over the last decade. Antibiotic resistance occurs from people taking antibiotics frequently, not taking the entire prescription, or taking them when they were not needed. The bacteria learn to change their DNA or mutate so the antibiotic cannot kill the bacteria, and this forces the doctor to find another antibiotic to try and cure the infection. Continued on Page 5
Patient and Family Guide to Vascular Access Page 5 The Importance of Washing Your Hands (Continued) Because dialysis patients are at high risk for antimicrobial resistant infections, the CDC has developed a fact sheet called Tips for Dialysis Patients to Prevent Antibiotic Resistance. This fact sheet is available on the CDC website, or if you do not have access to the Internet, ask your dialysis facility to print you a copy. One of the tips says to follow the unit policy on cleaning instructions for your access carefully before every cannulation. 3 In closing, because we care about you, we ask you to wash your access before coming to your chair in order to protect you from infection by reducing the number of bacteria on your access, which, in turn, keeps you off antibiotics to prevent resistance. References: 1. Centers for Disease Control and Prevention: Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. MMWR 2001; 50(5): 13. 2. Kaplowitz, L.G. Comstock, J.A., Landwehr, D. M., Dalton, H.P. and Mayhall, C.G. Prospective study of microbial colonizationof the nose and skin and infection of the vascular access site in hemodialysis patients. Journal of Clinical Microbiology. 26 (7):1257-1262. 3. Centers for Disease Control and Prevention. CDC campaign to prevent antimicrobial resistance in healthcare settings, tips for dialysis patients to prevent antibiotic resistance. Retrieved on 7/18/05 from the webpage www.cdc.gov/drugresistance/healthcare/dialysis/ Tips_for_Dialysis_Patients.pdf. By Lynda Ball BS, BSN, RN, CNN Quality Improvement Director, ESRD Network 16 For more Vascular Access information, visit www.esrdnetwork6.org or www.fistulafirst.org Do you have questions about your access? Contact us at 800-524-7139
Patient and Family Guide to Vascular Access Page 6 A Patient s View I know many of you may be new to dialysis. The first thing I want to tell you is that you can live a long, productive, and happy life as you fit dialysis into your schedule. I did home hemodialysis for twenty-one years before having a transplant. I believe the key to living long and well on dialysis is to take charge of your healthcare and learn all you can about dialysis and kidney disease. You take personal responsibility for your wallet or purse, right? Do the same for your healthcare. Seek advice, but always take responsibility for your own healthcare. The fact that you are reading this newsletter shows that you want to learn more, and that is the first step. This newsletter is about fistulas, and yes, a fistula is the gold standard of dialysis access. Access to your blood for dialysis has always been a weak link. If you lose your access, you can t dialyze, so that is why it is so important. Not everyone can have a fistula, but most can. A fistula is the most reliable, trouble free, and longest lasting type of access. Mine is now twenty-eight years old and still going strong. I would advise you to insist with your Nephrologist that you want a fistula if you are a suitable candidate for one. Once you get a fistula, guard it with your life. It is your connection to survival. If at all possible, I would advise you to learn to stick yourself too, because that is the best way to protect your fistula. The payoff is that it will hurt less, and no one can stick it as well as you can. Why does it hurt less to stick yourself? I don t know, but try tickling yourself. You can t, and I think that has something to do with it. Sticking yourself is another step towards taking charge of your treatment. After you have adjusted to dialysis and to sticking your fistula, you may want to try the buttonhole method of sticking. That is where you stick over and over in exactly the same hole for each needle. With this method a scar tunnel develops, and you will find that there is hardly any pain involved in sticking yourself. The Network has a video available for loan demonstrating how to do the Buttonhole technique. It shows me doing my own sticks as well as how the Buttonhole method is done. I hope it will inspire you to go for the gold a fistula. I wish you the very best as you live a happy and healthy life on dialysis, hopefully with the best type of access there is a natural A/V fistula. George Harper is a retired high school counselor and lives in Rome, GA, with his wife Irene who was his home dialysis partner. George has been a long-time volunteer with Network 6, and in 2002 he founded the Georgia Association of Kidney Patients (GAKP), a patient advocacy group. You may contact George at gharper22@comcast.net or 706-232-0793.
Patient and Family Guide to Vascular Access Page 7 You Don t Have a Fistula. WHY? Learn Why AV Fistula is the Best Access for YOU! Q: What is an Arteriovenous Fistula (AVF)? A: It is a surgical joining of an artery and a vein that causes the vein to enlarge to allow cannulation for dialysis. Fistulas require time for the vein to become large enough to cannulate. Q. Why should I get an AVF? A: Fistulas last longer and require fewer interventions, such as declotting. With an AVF, it is also likely that you will experience fewer infections, fewer days in the hospital, and received more adequate dialysis (which will improve the way you feel and improve your quality of life). Q. How do I know if I can get an AVF? A. It is recommended that all patients (including diabetics and elderly) have a vessel mapping performed to see if an AVF is right for you. Q. What is Vessel Mapping? A. This is a study of the blood vessels in the arm to help select the best veins for a fistula and decrease the chance for an unsuccessful surgery. Q. How is an AVF different from a catheter or a graft? A. An AVF is created by connecting one of your own veins and arteries together. A graft requires the surgical placement of a small flexible tube and a catheter requires the placement of a small tube into a large vein in your neck, chest, or groin. The AVF uses your own anatomy and requires no insertion of a foreign substance into your body. Since an AVF uses your own vein and artery, it is less likely to clot or become infected and tends to last longer than a catheter or graft. Remember: The catheter is not the ideal access! Q. What additional care will my AVF require? A. The application of pressure to the site is necessary following the end of your treatment. This will likely add some additional time in the clinic as the access stops bleeding. It will be important that you keep your access clean and wash it thoroughly prior to your dialysis treatment. You will want to make sure anyone caring for your access is wearing clean gloves and observing infection control techniques. You need to be very protective of the arm where your AVF is placed. This includes restricting others from inserting IV s, drawing blood, or taking your blood pressure. You will also want to check your access on a daily basis for changes such as redness or swelling. You might be advised not to lift any heavy objects or put pressure on your access arm because this will limit circulation.
Patient and Family Guide to Vascular Access Page 8 A Patient s View I love being 43 years old! Having been an ESRD patient since the age of 17, and being fortunate to have access to good health care, I have lived, and continue to live a very good life. During these past 26 years I have been on hemodialysis, received a transplant, returned to peritoneal dialysis, and am currently on in unit hemodialysis. I was able to perform dialysis with grafts, with a peritoneal dialysis catheter for and then a catheter for hemodialysis. It was not until I ran out of access options, that my surgeon and I discussed trying to create a natural fistula. You see, my veins did not seem able to support the creation of a fistula, but my surgeon decided to try what they call a BVT (Basal Vein Transposition). It worked, and my fistula is working well. I wished I had known about all my options regarding how the create a fistula. I highly encourage you to find a very good, and experienced surgeon who will discuss all options for the possibility of a fistula. It is worth it! By Celeste C. Lee Chair, NKF Patient and Family Council Chief of Staff, Office of Chancellor for Health Affairs Duke University President and CEO, DUHS HAVE YOU MOVED? If you have recently moved or changed your phone number be sure to tell someone at your facility. Also, when you provide your new information, remind the staff to contact the Southeastern Kidney Council with the changes or call yourself. Southeastern Kidney Council, Inc. 1000 St. Albans Drive, Suite 270 Raleigh, NC 27609 Phone: (919) 855-0882 Toll-Free for Patients Only: (800) 524-7139 Fax: (919) 855-0753 E-mail: info@nw6.esrd.net Web site: www.esrdnetwork6.org