Vascular Access In Patients Research Articles

Accessible autogenous vascular access for hemodialysis in obese individuals using lipectomy

Background Arteriovenous fistula are created less frequently in obese individuals, and fewer of these access procedures become functional. The authors review their experience with the excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients. Methods Consecutive vascular access patients undergoing lipectomies for difficult access cannulation due to vein depth were reviewed. Cephalic vein depth was measured by ultrasound at 3 sites before lipectomy and again before the first cannulation. Results Thirty patients were reviewed, with a mean body mass index of 40.2 kg/m 2 (range, 28–57.7 kg/m 2). The mean age was 52 years. Seventeen patients were women, and 19 had diabetes. The mean preoperative vein depth of 15.8 mm (range, 6–30 mm) was reduced to 4.1 mm (range, 3–8 mm) ( P ≤ .01). All fistulas were functional, and only 1 failed during a follow-up period of 2.2 to 53.2 months. Conclusions Lipectomy offers a relatively simple and successful method of extending direct autogenous vascular access to obese individuals.

Overview of Regular Dialysis Treatment in Japan (as of 31 December 2008)

A nationwide statistical survey of 4124 dialysis facilities was conducted at the end of 2008 and 4081 facilities (99.0%) responded. The number of patients undergoing dialysis at the end of 2008 was determined to be 283,421, an increase of 8179 patients (3.0%) compared with that at the end of 2007. The number of dialysis patients per million at the end of 2008 was 2220. The crude death rate of dialysis patients from the end of 2007 to the end of 2008 was 9.8%. The mean age of the new patients begun on dialysis was 67.2 years and the mean age of the entire dialysis patient population was 65.3 years. For the primary diseases of the new patients begun on dialysis, the percentages of patients with diabetic nephropathy and chronic glomerulonephritis were 43.3% and 22.8%, respectively. Among the facilities that measured bacterial count in the dialysate solution in 2008, 52.0% of facilities ensured that a minimum dialysate solution volume of 10 mL was sampled. Among the patients treated by facility dialysis, 95.4% of patients were treated three times a week, and the average time required for one treatment was 3.92 ± 0.53 (SD) h. The average amounts of blood flow and dialysate solution flow were 197 ± 31 and 487 ± 33 mL/min, respectively. The number of patients using a polysulfone membrane dialyzer was the largest (50.7%) and the average membrane area was 1.63 ± 0.35 m(2). According to the classification of dialyzers by function, the number of patients using a type IV dialyzer was the largest (80.3%). The average concentrations of each electrolyte before treatment in patients treated with blood purification by extracorporeal circulation were 138.8 ± 3.3 mEq/L for serum sodium, 4.96 ± 0.81 mEq/L for serum potassium, 102.1 ± 3.1 mEq/L for serum chloride, and 20.7 ± 3.0 mEq/L for HCO(3) (-) ; the average serum pH was 7.35 ± 0.05. Regarding the type of vascular access in patients treated by facility dialysis, in 89.7% of patients an arteriovenous fistula was used and in 7.1% an arteriovenous graft was used. The percentage of hepatitis C virus (HCV)-positive patients who were HCV-negative in 2007 was 1.04%; the percentage is particularly high in patients with a period of dialysis of 20 years or longer. The risk of becoming HCV-positive was high in patients with low serum creatinine, serum albumin, and serum total cholesterol levels, and/or a low body mass index before beginning dialysis.

Recommendations for the Use of Intraosseous Vascular Access for Emergent and Nonemergent Situations in Various Healthcare Settings: A Consensus Paper

In recognition of the value of intraosseous (IO) vascular access in patient resuscitation and stabilization, leading national and international organizations have published position papers that have served to change the standard of care for emergency vascular access. Among them are the American Heart Association (AHA), addressing vascular access in cardiac arrest patients, 1 American Heart Association American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care: management of cardiac arrest. Circulation. 2005; : IV-58–IV-66 Google Scholar the International Committee on Resuscitation (ILCOR), 2 International Liaison Committee on Resuscitation (ILCOR) International consensus of cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: advanced life support. Resuscitation. 2005; 67: 213-247 PubMed Google Scholar the European Resuscitation Council, 3 European Resuscitation Council European resuscitation guidelines. Resuscitation. 2005; 6751 (Accessed July 3, 2010): 51-52http://www.erc.edu/index.php Google Scholar the Infusion Nurses Society (INS), 4 Infusion Nurses Society [position paper] The role of the registered nurse in the insertion of intraosseous access devices. J Infus Nurs. 2009; 32: 187-188 Crossref PubMed Scopus (11) Google Scholar the National Association of EMS Physicians (NAEMSP), 5 Fowler R Gallagher JD Isaacs MS et al. [resource document to the NAEMSP position statement]. The role of intraosseous vascular access in the out-of-hospital environment. Prehosp Emerg Care. 2007; 11: 63-66 Crossref PubMed Scopus (92) Google Scholar with the Emergency Nurses Association (ENA) and the American Association of Critical-Care Nurses (AACN) endorsing the INS position paper. 6 Emergency Nurses Association ENA-supported statements. http://www.ena.org Google Scholar , 7 American Association of Critical-Care Nurses American Association of Critical-Care Nurses endorses nurses’ expanded role in use of IO access devices. http://www.aacn.org/WD/PressRoom Google Scholar These professional societies recognized that IO access may provide significant time savings that could benefit patients in emergent situations by decreasing the time required to achieve access and the time required to administer necessary fluids and medications. The AHA concluded that intravenous (IV) and IO administration have equal, predictable drug delivery and pharmacologic effects. Both AHA and European Resuscitation Council guidelines state that IO access should be the first alternative to failed IV access. 1 American Heart Association American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care: management of cardiac arrest. Circulation. 2005; : IV-58–IV-66 Google Scholar , 2 International Liaison Committee on Resuscitation (ILCOR) International consensus of cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: advanced life support. Resuscitation. 2005; 67: 213-247 PubMed Google Scholar Lynn Phillips, Infusion Nurses Society and Consortium Chair. Lucinda Brown, Society of Pediatric Nurses. Teri Campbell, Air and Transport Nurses Association. Julie Miller, American Association of Critical-Care Nurses. Jean Proehl, Emergency Nurses Association. Barbara Youngberg, Visiting Professor of Health Law and Policy, Beazley Institute for Health Law and Policy, Loyola University Chicago College of Law.

Caring for a patient's vascular access for hemodialysis

Caring for a patient's vascular access for hemodialysis

Reducing the risk of infection in vascular access patients: An in-vitro evaluation of an antimicrobial silver nanotechnology luer activated device

Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Denise Macklin, Charles E. Edmiston, Vea Makina; Reducing the risk of infection in vascular access patients: An in-vitro evaluation of an antimicrobial silver nanotechnology luer activated device. Journal of the Association for Vascular Access 1 September 2010; 15 (3): 108–110. doi: https://doi.org/10.2309/1552-8855-15.3.108b Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest Search

Stent Graft for Nephrologists

The role of the stent graft is emerging in the management of arteriovenous dialysis access. Physicians are incorporating this device in the management of three distinct problems--vein-graft anastomotic stenosis, pseudoaneurysm formation, and cephalic arch stenosis--with varying degrees of success. Indeed, a recent randomized, controlled trial to evaluate the role of angioplasty plus stent graft versus angioplasty alone for the management of stenosis at the vein-graft anastomosis led to the approval of the stent graft by the Food and Drug Administration; however, several elements of the management of stenosis at the vein-graft anastomosis/cephalic arch as well as the repair of pseudoaneurysms by stent graft remain controversial. The situation is further complicated and warrants a cost-to-benefit ratio analysis when the added cost of the device is appended to the procedure. In contrast to the controversies, angioplasty-induced complete vascular rupture is one situation in which a stent graft is indicated beyond any doubt. With recent conditional Food and Drug Administration approval, it is anticipated that the use of stent grafts might increase in our patients. In this context, it is critically important that nephrologists be familiar with the current controversies and consensus that surround the use of stent grafts for dialysis access. Just as therapeutic interventions are analyzed in other disciplines within nephrology, these experts must appraise the use of this device for dialysis access. This report presents an up-to-date synopsis on the use of the stent graft that would assist renal physicians in requesting or rejecting the device for the optimal management of their patient's vascular access dysfunction.

Reducing the risk of infection in vascular access patients: An in vitro evaluation of an antimicrobial silver nanotechnology luer activated device

Luer-activated devices (LAD) have been designed to reduce the risk of sharps injury; however, published reports suggest that internal fluid path contamination occurs in selected devices. The present in vitro study compares the antimicrobial property of a silver-nanotechnology LAD to 8 nonantimicrobial LADs. A laboratory reference strain of methicillin-resistant Staphylococcus aureus (MRSA) (ATCC 33592) was used to prepare a standardized microbial challenge, 3.73- to 3.86-log(10) colony-forming units (cfu)/mL, adjusted for fluid path volume for 9 commercially available LAD (1 sliver nanotechnology LAD and 8 non-antimicrobial LADs). Following incubation (15 hours at 30 degrees C), each device was flushed, serially diluted, and plated in triplicate to trypticase soy agar for microbial recovery, expressed as log(10) cfu/mL. Comparison of fluid path volumes documented a wide variation between the 9 commercial devices (range, 0.025-0.359 mL). Log(10) microbial recovery were shown to increase on average 1.5 to 3.0 logs in the 8 non-antimicrobial LADs, whereas S aureus recovery in the silver-nanoparticle LAD demonstrated a 2.6-log decrease following incubation (P < or = .05). These findings suggest that, under in vitro conditions, a silver nanotechnology was effective in reducing the risk of fluid path colonization when the LAD was challenged using a standardized inoculum of a laboratory reference strain of MRSA. Further studies are warranted to assess the clinical efficacy of an antimicrobial LAD technology for reducing the risk of vascular access (catheter associated) infections.

Venous Elastography: Validation of a Novel High‐Resolution Ultrasound Method for Measuring Vein Compliance Using Finite Element Analysis

Ultrasonography for the noninvasive assessment of tissue properties has enjoyed widespread success. With the growing emphasis in recent years on arteriovenous fistulae (AVFs) for dialysis vascular access in patients with end-stage renal disease, and on reducing AVF failures, there is increasing interest in ultrasound for the preoperative evaluation of the mechanical and elastic properties of arteries and veins. This study used high-resolution ultrasound with phase-sensitive speckle tracking to obtain in vivo vein elasticity measurements during dilation. The results of this novel ultrasound technique were then compared to a computer model of venous strain. The computer model and ultrasound analysis of the vessel wall demonstrated internally consistent positive and negative longitudinal strain values as the vein wall underwent dilation. These results support further investigation of the use of phase-sensitive speckle tracking for ultrasound venous mapping for preoperative vascular access evaluation.

Clinical assessment of vascular access: an overview

Clinical assessment of vascular access before cannulation is an integral component of haemodialysis care. Wilfredo Manuel provides renal nurses and technical staff with an overview of the types of vascular access—listing their advantages and disadvantages. He then outlines the basics of assessing, planning, implementing and evaluating a patient's vascular access before, during and after cannulation.

Vascular Access in Patients Treated With Chronic Hemodialysis for 30 Years or More

The aim of our study was to evaluate vascular access in patients treated with chronic hemodialysis for 30 years or more. Patients who had started dialysis in 1978 or earlier were identified from the Slovenian Renal Replacement Therapy Registry. The data on vascular access on April 2008 are presented. Sixteen patients were still alive, seven men and nine women aged 62 +/- 12 years (46-84), and they had been treated for 32 +/- 1.7 years (30-35), mainly with chronic HD. They had started HD at the age of 30 +/- 12 years (13-50), and none had diabetes. The vascular access in nine was a native arteriovenous (AV) fistula, on the forearm in eight patients, and a brachiobasilic fistula in one patient. Four patients had their primary AV fistulas still in use (maximum 35 years). In the remaining five patients, multiple salvage procedures had been performed or new AV fistulas created. The vascular access in four patients was the polytetrafluoroethylene (PTFE) graft, functioning for 1-8 years. In three patients, a non-cuffed, single-lumen hemodialysis catheter (a precurved jugular in two patients and a subclavian in one) locked with 30% citrate, with mupirocin at the exit site, was used for 5-12 years. The catheters were exchanged approximately once every two years over a guide-wire because of mechanical damage. None of these three patients had had catheter-related sepsis or exit-site infection. Before catheters, these patients had had multiple AV fistulas and PTFE grafts. Although native AV fistula is the predominant type of vascular access, a greater than 30-year survival on hemodialysis is possible with the combined use of AV fistula, PTFE graft, and a non-cuffed hemodialysis catheter locked with citrate.

Arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site

Introduction Hemodialysis (HD) for children and adolescents with renal failure is increasingly common in the United States. Consensus opinion views an arteriovenous fistula (AVF) as the best long-term access option, although catheter-based HD remains the most common vascular access in children and has greater risks of complications and higher mortality rates than AVF access. This report reviews our experience with children and adolescents undergoing vascular access operations. Methods We reviewed 721 consecutive vascular access patients who had vascular access surgery by a single surgeon during the previous 5 years. Ten patients 20 years or younger were included in this study. In addition to physical examination, each patient had preoperative vascular ultrasound mapping by the operating surgeon. A radiocephalic AVF (RC-AVF) at the wrist was the first choice for dialysis access when feasible; however, the patients in this report were generally seen after years of intravenous access and venipunctures that necessitated more proximal AVF constructions. A proximal radial artery AVF (PRA-AVF) was our most common choice for vascular access when an RC-AVF was not suitable. Results Patient ages were 9 to 20 years (mean, 16). Seven were male. Renal failure was caused by glomerulnephitis in 4 patients, 3 had a history of obstuctive uropathy, 2 were diabetic and one had congenital nephrotic syndrome. Eight patients had PRA-AVFs created, 1 had an RC-AVF, and 1 patient required a transposition AVF. Follow-up was 4 to 56 months (mean, 32 months). Primary, primary-assisted, and cumulative patencies were 77.8%, 100%, and 100% at 24 months. No prosthetic grafts were used in any vascular access patient during the study period. Conclusion We found HD access in children and adolescents was reliably established through use of a PRA-AVF when an RC-AVF was not feasible. Access sites were often possible through the upper arm cephalic veins and/or with retrograde flow into the forearm. Cumulative (secondary) patency was 100% at 24 months.

Optimizing Arteriovenous Fistula Maturation

Autogenous arteriovenous fistulas are the preferred vascular access in patients undergoing hemodialysis. Increasing fistula prevalence depends on increasing fistula placement, improving the maturation of fistula that fail to mature and enhancing the long-term patency of mature fistula. Percutaneous methods for optimizing arteriovenous fistula maturation will be reviewed.

Transradial coronary intervention using a novel 5‐Fr sheathless guiding catheter

We have recently developed a 5-Fr sheathless guiding catheter system (Virtual 3-Fr, Medikit, Japan), composed of a hydrophilic catheter and a central dilator. This combination of catheter and dilator enables us to introduce the catheter into the artery without the need of an introducer sheath. Because the outer diameter of this 5-Fr sheathless guiding catheter system is approximately 2-Fr sizes smaller than a conventional guiding catheter system, this system provides us with less invasive angioplasty and a puncture site injury equivalent to a conventional 3-Fr introducer sheath. To demonstrate the potential of this 5-Fr sheathless guiding system, we report two cases of chronic total occlusion successfully treated by the transradial approach. This novel 5-Fr sheathless system may become a viable alternative to conventional guiding catheters, and provide a favorable impact upon vascular access complications and patient morbidity.

An overview of vascular access part 1: early history

This is the first of three articles: The first two outline the development of vascular access which dates back hundreds of years; while the third will look at accurate ways to clinically assess a patient's vascular access. Here Sarah Mackie describes the events that led to the development of vascular access.

Therapy outcome in peritoneal dialysis patients transferred from haemodialysis

Haemodialysis (HD) and peritoneal dialysis (PD) should be regarded as complementary methods of renal replacement therapy. Approximately 10-20% of patients on PD are transferred annually to HD due to technique failure. Much smaller proportion of patients changes modality from HD to PD, predominantly due to vascular access problems, cardiac disease or patient preference. The effects of these transfers on therapy outcome, patient and technique survival have not been studied, with research focusing on outcome measures within the single modality and comparisons between the two methods. We have analysed retrospectively a cohort of 264 patients treated with PD in a single PD centre during 1994-2006. Patient characteristics, therapy measures and outcome of patients were compared between patients for whom PD was the initial method of renal replacement therapy (group 1, n = 197) and those transferred to PD from haemodialysis because of complications (group 2, n = 67). The Kaplan-Meier method and Cox proportional hazards multiple regression analysis were used to assess patient and technique survival. In patients transferred from HD, significantly less had diabetes (11.9% versus 38.1%, P < 0.0001) and there were also significantly more females (57% versus 42.2%, P < 0.05). Baseline Kt/V was significantly higher in the primary PD therapy group (2.46 +/- 0.57 versus 2.11 +/- 0.48, P < 0.001), due to lower residual renal function in patients transferred from HD. Group 2 had also significantly higher peritonitis rate (0.86 versus 0.62 episode/year, P < 0.05). During the time of observation, 71 patients have died, in 100 patients kidney transplantation was performed, 56 were transferred to HD, renal function recovered in 5 and 32 were still on PD at the end of the study. No significant differences were observed in unadjusted patient survival, but technique survival was significantly lower in group 2 (P < 0.05). In the Cox multiple regression model, diabetes status, age and albumin level significantly influenced survival. Relative risk of death was not increased significantly in patients transferred from HD. Our data suggest that outcome of patients transferred from HD is similar to that achieved in patients in whom PD is the first choice therapy. Thus, this option should be strongly considered in patients experiencing complications on HD, mainly vascular access problems, heart failure or intradialytic hypotension.

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. This study seeks to determine which initial approach by EPs would lead to greater success. This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

THE CLINICAL APPLICATION OF CRRT—CURRENT STATUS: Clinical Nursing for the Application of Continuous Renal Replacement Therapy in the Intensive Care Unit

Treatment of critically ill patients with continuous renal replacement therapy (CRRT) requires a set of new skills and knowledge base for the intensive care unit (ICU) nurse. After a decision to treat is made, nurses effectively manage the technique by following a series of steps in sequence. These sequential steps include patient and machine circuit preparation, connection of the extracorporeal circuit (EC) to the patient's vascular access, and nursing management of a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine "vital signs," and, when necessary, diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential for a successful CRRT nursing policy or protocol. This chapter provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians

Purpose We evaluated the efficacy and safety of emergency department technicians' (EDT) use of ultrasound (US) guided peripheral intravenous (PIV) access compared to the traditional approach on a subset of patients with difficult IV access. Methods We enrolled a convenience sample of 75 ED patients with difficult IV access (at least 2 failed PIV attempts). During phase I, EDTs used the standard technique. EDTs then attended a didactic session on ultrasound guided PIV access of the upper extremity. In phase II, the EDTs used US guidance for PIV access. Outcome measures were successful PIV cannulation by an EDT, time to cannulation, medical doctor (MD) or registered nurseRN intervention, complications, patient satisfaction, and number of skin punctures. Results Successful cannulation rates were similar (US: 33/41, 80.5%; traditional technique: 24/34, 70.6%) (difference: 9.9%; 95% confidence interval (CI): -9.3%, 29.1%). US was 2.0 times faster (CI 1.3, 3.1), required less MD/RN intervention (7.3% vs. 20.6%) (difference: 13.3%; CI: -2.5, 30.2%), had fewer complications (41.5% vs. 64.7%, difference: 23.3%; CI 0.6%, 42.7%) and skin punctures (1.6 vs. 3.6; difference: 2.0; CI: 1.6, 2.7), and improved patient satisfaction from 4.4 to 7.7 cm ( P-value = .0001). Conclusions Following a brief US training for PIV access, EDTs showed similar success rates but US had significantly improved speed and patient satisfaction with fewer skin punctures and complications.

Brachial Artery-To-Brachial Vein Arterio-Venous Fistula in a Pediatric Patient

The National Kidney Foundation's Disease Outcome Quality Initiative (NKF-DOQI) guidelines, produced in 1997, emphasized the superiority of arterio-venous fistulae (AVF) as vascular access in patients on chronic hemodialysis. Challenges in pediatric hemodialysis patients include poor superficial venous vasculature. We describe an approach to brachial artery to brachial vein AVF creation in a pediatric dialysis patient. The fistula is patent for greater than one year after creation. A great deal of passion and enthusiasm is a prerequisite for successful and technically challenging cases such as the one described.

Percutaneous coronary intervention using a novel 4‐French coronary accessor

Percutaneous coronary intervention (PCI) using a guiding catheter with small diameters may have a favorable impact on vascular access complications and patient morbidity. Here, we report the initial results of PCI using a 4-Fr coronary accessor. A total of 31 patients underwent 4-Fr PCI. Exclusion criteria for 4-Fr PCI were (1) lesions associated with large side branches requiring wire protection or kissing balloon technique and (2) planned use of angioplasty devices which were not compatible with 4-Fr catheter. A total of 36 lesions, including 4 chronic total occlusions (CTO), were treated. Access sites included radial artery in 19 patients (61%), brachial artery in 8 (26%), and femoral artery in 4 (13%). Four-Fr PCI was successful in 34 of 36 lesions (94%) in 29 of 31 patients (94%). One of the two unsuccessful patients was a case of CTO, and the other a case of tortuous right coronary artery. In both, crossover to a 6-Fr PCI was necessary. Among successfully treated 34 lesions of the 29 patients, coronary stents were deployed in 30 lesions (88%). There were no stent dislodgements or inadequate contrast opacification. No access-site related complications including radial artery occlusion were observed. PCI with a 4-Fr coronary accessor is a viable alternative to the use of larger guide catheters. The advent of 4-Fr stent delivery system may afford a less invasive approach for the treatment of patients with coronary artery disease.