Hemodialysis procedure dr. mohamed kamal

1. HD WORKSHOPHD WORKSHOP

2. Vascular Access is The Life
Line for The Patient

5. CENTRAL LINE

8. Temporary dialysis
cath

9. Tunnelled dialysis cath

10. introduction
Without an adequate vascular access, HD efficiency is
reduced, which results in increased morbidity and
mortality
Dialysis access is most common vascular surgery
procedure
Access-related problems are responsible for 50% of the
hospitalizations of HD patients

11. introduction
 Short-term catheters should be used for acute dialysis and for a
limited duration in hospitalized patients.
 Non cuffed femoral catheters should be used in bed-bound patients
only.
 Long-term catheters should be used in conjunction with a plan for
permanent access. Catheters capable of rapid flow rates are
preferred.
 Catheter choice should be based on local experience, goals for use,
and cost.
 Long-term catheters should not be placed on the same side as a
maturing AV access, if possible (RT sided for RT handed).

12. Introduction
 Patients with advanced CKD disease stage 4
CKD (GFR <30), or based on progression of
renal disease) who have elected hemodialysis
as their choice of renal replacement therapy
should be referred to an access surgeon in
order to evaluate and plan construction of AV
access
 If a prosthetic access is to be constructed, this
should be delayed until just before the need for
dialysis.

13. Were it possible to design the ideal catheter, it might
include the following features
 Able to deliver high flow (>400 ml/min)
reliably
 Easy to insert and remove
 Comfortable and acceptable by patient
 Durable
 Free of infection
 Does not cause venous thrombosis or stenosis
 Free of fibrin sheath
 Inexpensive

15. HD catheter

16. Advantages
 Universally applicable
 Multiple access sites
 No maturation time can be used
immediately
 No direct hemodynamic effects on the
circulation
 Allows time for maturation of native AVF
 Thrombotic complications simple to correct

17. disadvantages
The shortest long term patency rates of all
permanent access procedures
Lower blood flow rates obligating longer dialysis
times
External device
Morbidity
Insertion complications
Thrombosis
Infection
> 3 months -morbidity excessive
Risk of central vein stenosis or occlusion
•Limits chronic access options

18. recommendation
These catheters are suitable for immediate use
and should not be inserted before needed .
The subclavian insertion site should not be used
in a patient who may need permanent vascular
access .

20. Alternative placement sites
2nd
left internal jugular
-Higher incidence of flow problems
-Higher risk of stenosis
3rd
inferior vena cava
-Femoral –best alternative
-Translumbar
Subclavian
-High risk of stenosis
-Acceptable only if no further arm access
planned

21. Chest x-ray is mandatory after subclavian and
internal jugular insertion prior to catheter use to
confirm catheter tip position
Femoral catheters should be at least 19-cm long to
minimize recirculation.
 Noncuffed femoral catheters should not be left in
place longer than 5 days and should be left in
place only in bed-bound patients.

29. Optimal Tunneled Hemodialysis catheter
Place in right internal jugular
Use ultrasound for cannulation
Use fluroscopy for placement
Place tip well within atrium

30. The primary determinants of catheter blood flow
(1) are catheter (inner) size dimensions
(2) Tip placement

31. Tip position:
 Blind placement of a relatively stiff device
through the right internal jugular vein has
created the necessity of using a short catheter to
avoid atrial perforation.
 The tip of these catheters comes to be
located in the proximal part of superior vena
cava, and this tip location in smaller blood
vessels does not allow for as great a blood
flow as catheters located in the distal
superior vena cava and the right atrium

32. Catheter length:
NKF-DOQI guidelines recommend placement of a catheter
with the tip adjusted to the level of the caval atrial junction
or into the right atrium to ensure optimal blood flow.
For untunneled catheters, the catheter length and diameter
should be adjusted to the size of the patient.

33. A table was made to help with the selection of the
total catheter length and diameter in relation to the body surface
area and insertion site.
In general, in patients with a body surface
area of 1.5 to 2.0 m2
-A 12-15 cm catheter should be selected for
the jugular vein in the low right position and
-A 15-19 cm catheter for the left jugular
vein.
-A 14 to 17 cm catheter should be used for
the right subclavian vein and
A17 to 22 cm catheter for the left subclavian
vein.

34. Patient comfort
Subclavian catheters are more comfortable for the patient
and provide reliable blood flow if placed in the right atrial
cavity( SVC ostum)
It was shown that in the US 46% of all temporary catheters
used in patients starting hemodialysis treatment were
inserted into the subclavian vein.(may be lower infection)
(against DOQI guidelines)

36. Recirculation
Recirculation:
With the use of catheters, recirculation is
dependent upon two factors:
the location of the catheter tip
the status of the patient's central circulation.

38. Catheter flow problems
Early – malposition
Late - thrombosis

40. Catheter related infection
Local infection
- Exit site infection
- Tunnel infection
Systemic infection
- Catheter related bacteremia( CRB )

41. CRB secondary complications–
Frequent – 20 to 30%
- Septic arthritis
- Endocarditis
- Epidural abscess
- Death – 6 to 18%

47. Nonfunctional non cuffed catheters can be
exchanged over a guide wire as long as the exit
site and tunnel are not infected.
 Exit site, tunnel tract, or systemic infections
should prompt the removal of non cuffed
catheters.

48. The Problem is that we
forget that these
catheters are in the
heart exactly like our
patients who think that
these catheter are in the
neck or chest .

49.  After decades of success in dialysis research and
treatment, prompt availability of a well-functioning
vascular access for dialysis remains a disturbing problem.
(Ravani P et al. Am J Kidney Dis 2002; 40:1264-76)

51. A-V fistula

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60. Fistula assessment

65. Outflow assessment
Arm elevation test
• when the extremity is elevated , the
fistula collapses completely if there is no
outflow obstruction.
• when the extremity is elevated , the
portion of the fistula distal to point of
stenosis remains distended, while the
proximal portion collapses in the normal
fashion.

66. Palpation (Feel(
-Palpation of the thrill along the course of the vein
Assessment of the inflow of the blood
Assessment of the accessory veins

67. Augmentation test

68. Assessment of the accessory
veins

69. Auscultation
Auscultation the bruit along the course
of the vein to the heart

70. Complications of fistulae and
grafts
Clotted: No thrill = thrombosis . seek immediate medical opinion. Swift
intervention (within 48h) either via interventional radiology (local
thrombolysis), or surgery, may be able to salvage the fistula. The longer the
time to intervention, the less likely it is to be successful. There is no clear
evidence for anticoagulation use.
• Infection: fistulae rarely become infected beyond a superficial cellulitis.
PTFE infection is not uncommon. May be occult, causing weight loss, ESA
resistance, and failure to thrive. Antimicrobials rarely successful, and
management usually involves surgical removal.
• Aneurysm or pseudoaneurysm formation: may occur at needling sites,
especially if sites not rotated. Surgery may be necessary.
• Bleeding from an infected or aneurysmal AVF or graft is a much feared
complication (proceeds under arterial pressure!).

71. Distal ischaemia or steal syndrome: flow through the fistula
or graft may compromise distal blood supply. Cold or numb
peripheries are common but may l infarction or ischaemic pain.
Other features include paraesthesia, cyanosis, loss of distal
pulses. Patients often elect to wear a glove on the affected hand.
AVF ligation or graft removal may be necessary in severe cases.
• Excess flow
• Extravasation: blood leakage into the soft tissues. Can cause
rapid limb swelling, haemodynamic compromise, compartment
syndromes, s infection, access thrombosis.

72. Needle

104. Types of AVF
Radio-cephalic
Brachio-cephalic
Brachio-basilic

106. Failure To Mature (FTM(
Incidence: 28 – 53%
Fistula failure can be
divided into
Early: within 1st
3 months of usage.
Late: after 1st
3 months of successful usage.

107. Risk Factors
Pre operative mapping: decrease rate of FTM.
Very small arteries & veins: less than 1.6 mm lead to
increase rate of FTM.
Functional ability of the arteries & veins to dilate.
Age > 65 years, DM, female gender & BMI > 27  increase
rate of FTM.

108. Causes of AVF early failure
Inflow problems:
Poor arterial inflow
Juxta anastomotic venous stenosis (JAVS(
Outflow problems: failure of arterializations of the
vein & presence of large & / or multiple accessory veins.
Technical factors at the time of the surgery e.g. deep
fistula  difficult cannulation.

110. Identification & Management
Of Early AVF Failure
Identification of patient who are at risk of early AVF failure is
critical to perform timely intervention.
Physical examination of the AV access is easy & inexpensive.

111. Specific Interventions
angioplasty: percutaneous transluminal angioplasty (PTA) is
indicated when there is > 50% stenosis of the AVF
Accessory vein ligation:
Superficial accessory vein  Percutanaous ligation
Deep accessory vein  coil insertion
Sequential dilatation: in cases of early failure in a long
segment of the vein which is narrowed or stenosed.

112. Specific Interventions
Surgical techniques:
Patch angioplasty.
Combination of fistula & graft (gaftula(.
New anatomists of (JAVS(.
Superficialization procedures.
Stents in AV access indicated in:
<30%residual stenosis after PTA.
Recurrent stenosis with in 3 months.
Vessel rupture during angioplasty.
Patient not suitable for surgery.
Thrombectomy:
Use of heparin is typically indicated.
Treatment should include detection of the underling anatomic
abnormality, evaluation & management of the out flow including the
central veins.

114. Take Home Message
Evaluation of newly created AVF with in 1st
4-6 weeks to identify early AVF
failure.
Physical examination is simple but efficient.
Once failure identified should be referred to interventionalist for evaluation
& proper intervention.
Delay in intervention lead to:
increase no of tunneled dialysis catheters & its complications.
Risk of thrombosis & permanent loss of access.

115. HD lines

126. Thank
you