This document provides an overview of 200-hour training course content on care of arteriovenous (AV) grafts and hemodialysis catheters. The summary covers AV graft placement, maturation, cannulation techniques, and troubleshooting issues like thrombosis. For catheters, topics discussed include insertion sites, ultrasound guidance, dressing changes, infections, and flow issues. Proper handling and decontamination procedures are emphasized to prevent infections.

1. 200 Hours Course for Person In Charge Care of AV Grafts and Hemodialysis Catheters Dr. Yudisthra M. Ganeshadeva MBBS(Mal), MRCP(UK and London), Fellowship in Nephrology (Malaysia)

2. 200 Hours Course for Person In Charge AV Grafts

3. 200 Hours Course for Person In Charge What is an AV Graft? A Synthetic Tube used to connect an artery to a Vein Usually made of PTFE or Dacron Used primarily as access in patients with difficult veins

4. 200 Hours Course for Person In Charge Surgical Placement Can be placed on Forearm (Forearm loop graft) Arm Neck (Necklace graft) Axilary Artery to Femoral Vein The longer the graft – the less likely it is to last.

5. 200 Hours Course for Person In Charge Time to Maturation AV Grafts are usually ready to use within 2-4 weeks from placement May be used earlier if not much soft tissue swelling.

6. 200 Hours Course for Person In Charge Determining the Direction of Flow AV Grafts Compress the graft in the middle with 2 fingers – milk it both ways with pressure Release one finger If the graft fills up again- the limb proximal to that finger is the arterial end.

7. 200 Hours Course for Person In Charge Determining the Direction of Flow AV Grafts Ultrasound technique - can also use doppler to look at flow Most surgeons include a diagram

8. 200 Hours Course for Person In Charge Post Operative Care of AV Graft Patient advice If bleeding – pressure with gauze/kleenex for 10 mins Do not get wound soaked or wet for a week post op Check operation site for redness, swelling, discharge or warmth which may signify infection First week – need to keep arm elevated above level of heart to minimise swelling.

9. 200 Hours Course for Person In Charge Chronic Care of AV Graft Avoid on the side of the graft Taking Blood Pressure Taking Blood tests Thrill should be palpable on working AV Grafts

10. 200 Hours Course for Person In Charge Cannulation of AV Grafts Staff : If hands are visibly soiled, use soap and water. If not visibly soiled, use an alcohol-based hand rub or soap and water. Decontaminate hands before and after patient contact, rubbing hands together vigorously for 15 seconds then rinsing. Staff members who closely follow the policies and procedures of their respective facilities will always use and change gloves when indicated.

11. 200 Hours Course for Person In Charge Cannulation of AV Grafts It is important not to try to cannulate the same site with each treatment as this weakens the access wall – puncture graft in step ladder fashion. Patient: It is recommended that patients wash their site arm carefully with soap and water when arriving at dialysis..

12. 200 Hours Course for Person In Charge Cannulation of AV Graft Skin prep – for grafts, best to wash graft arm with non drying soap and water first before skin prep with povidone/chlorhexidine. Skin pulled taut in opposite direction to needle Needle inserted at 45 degree angle – once in rotated 180 degrees so that cutting edge faces downwards Taped in angle of insertion

13. 200 Hours Course for Person In Charge Removal of needle Needle pulled out – then pressure applied to puncture site. Do not apply pressure before needle removed.

14. 200 Hours Course for Person In Charge Care of Hemodialysis Catheters

16. The Right internal jugular offers a straight path to the atrium.

17. The left internal jugular has a more tortuous path Final Position of the catheter in the right artium

18. 200 Hours Course for Person In Charge Ultrasound Guidance Ultrasound guidance is mandatory cannulation of the internal jugular veins due to markedly variable anatomy. Realtime ultrasound guidance preferred. Lin, BS, Huang, TP, Tang, GJ, et al. Ultrasound-guided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron 1998; 78:423. 190 patients undergoing percutaneous insertion of a temporary catheter into the internal jugular vein compared the complication rates among those using ultrasound-guided placement (104 patients) to those using landmark-guided insertion (86 patients). Significantly superior results were obtained with ultrasound guidance with respect to overall success rate (99 versus 86 percent, P<0.01), success rate of the first attempt (81 versus 35 percent, P<0.01), puncture trials (1.39 versus 2.58, P<0.01), and traumatic complication rate (1.9 versus 11.6 percent, P = 0.015).

20. Higher risk of pneumothorax as well as bleeding and hemothorax as a result of this being a noncompressible site.

22. 200 Hours Course for Person In Charge Care of the Catheter- Patient Info No showers for the first 24 hours. Showers requires catheter and dressing to be wrapped with plastic wrap. If the catheter comes off – compress the insertion point with a finger until bleeding stops.

23. 200 Hours Course for Person In Charge Handling the Catheter Hemodialysis catheter dressing changes and catheter manipulations that access the patient’s bloodstream should only be performed by trained dialysis staff. The catheter exit site should be examined at each hemodialysis treatment for signs of infection. Catheter exit site dressings should be changed at each hemodialysis treatment.

24. 200 Hours Course for Person In Charge Handling the Catheter Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter exit site are recommended after catheter placement and at the end of each dialysis session. Manipulating a catheter and accessing the patient’s bloodstream should be performed in a manner that minimizes contamination.

25. 200 Hours Course for Person In Charge Decontaminating the Catheter Dressing for the catheter at each visit Povidone soak/ Chlorhexidine soak for hubs prior to dialysis procedure.

26. 200 Hours Course for Person In Charge Decontamination procedure Catheter hubs should be soaked for 3-5 mins in povidone iodine and allowed to dry prior to seperation Catheter lumens should be kept sterile. Catheter tips should remain capped or attached to a syringe while maintaining a clean field. Patients should wear a mask for all catheter procedures Dialysis staff should wear a mask and gloves for any procedure related to the catheter. Gloves need to be changed for each patient.

27. 200 Hours Course for Person In Charge Other infection prevention methods Do not recycle blood lines. Keep the dialysis unit clean.

28. 200 Hours Course for Person In Charge Day-to-day management of CVC Advise to patient regarding care of the CVC Very strict aseptic technique Sterile Soak hub with povidone iodine for 5 minutes

29. 200 Hours Course for Person In Charge TroubleshootingAV Grafts and Fistulas

30. 200 Hours Course for Person In Charge When to ReferInfected AV Graft AV Graft Infection May present with following over graft Pus Inflammation New Onset Pain Needs inpatient intravenous antibiotics ± debridement/ removal of part or all of graft.

31. 200 Hours Course for Person In Charge When to referGraft Thrombosis Graft thrombosis is common – no thrill over graft, graft hardened & unable to use for dialysis. Need to refer early to salvage graft- best to return to surgeon who created graft. Graft salvage may be done endovascularly or through surgery

32. 200 Hours Course for Person In Charge When to referGraft Hematoma Graft hematomas can occur due to tears of the graft during needling. Usually resolve spontaneously AV graft different from vessels as tears in material cannot seal off.

33. 200 Hours Course for Person In Charge When to ReferGraft Pseudoaneurysm Present with localised pain and swelling. Pulsatile – external to graft Usually due to poor needling technique. Will require referral for repair of graft – if numerous or large. Avoid areas of pseudoaneurysm for cannulation.

34. 200 Hours Course for Person In Charge When to referInfection of AV Grafts Characterised by Redness Pus Skin Erosion Exposure of the graft Associated with Tenderness over graft Fever ± fluctuance

35. 200 Hours Course for Person In Charge When to referInfection of Grafts Entire graft should be removed in the following conditions: the graft is less than one month old, graft involvement by infection is extensive and graft infection is accompanied by sepsis or hemorrhage.

36. 200 Hours Course for Person In Charge When to referDialysis Associated Steal Syndrome DASS occurs in 2.7-8% of PTFE grafts. Subjectively - coldness, numbness, tingling, and impairment of motor function (not limited by postoperative pain) Objectively – Cold peripheries, decreased sensation.

37. 200 Hours Course for Person In Charge When to referDialysis Associated Steal Syndrome Left untreated – potential of gangrene Usually needs surgical procedure to reduce steal by cutting down arterial inflow. In grafts may occur immediately post surgery when compared to AV fistula where steal may develop over time.

38. 200 Hours Course for Person In Charge TroubleshootingHemodialysis Catheters

39. 200 Hours Course for Person In Charge Immediate Problems

40. 200 Hours Course for Person In Charge Hematoma Hematomas can arise from tears in the jugular vein wall or from punctures into the carotid artery. Hematoma risk is higher in patients with coagulopathies and uraemia.

41. 200 Hours Course for Person In Charge Management Usually conservative Cold compress at site of hematoma may help.

42. 200 Hours Course for Person In Charge Carotid Artery Puncture Carotid artery punctures can result in dissection of the artery and formation of pseudoaneurysms May require placement of covered stent if large or can be filled in with coils

43. 200 Hours Course for Person In Charge Carotid Artery Dissection Carotid artery dissection is as a result of traumatic accidental puncture of the carotid artery and can even result in strokes as well as bleeding.

45. They are usually significant if a dilator or catheter has been passed from the carotid into the jugular or vice versa.

46. Treatment can be conservative if the fistula is small – may seal up spontaneously

47. Covered endovascular stent may be needed in some patients where the fistula is large.

49. 200 Hours Course for Person In Charge Hemothorax Can occur with catheter insertion. Usually accompanied by fall in blood pressure, pallor, tachycardia and difficulty breathing Can occur within hours to days of catheter insertion

52. 200 Hours Course for Person In Charge Troubleshooting HD Catheters Poor flow Red Lumen May be due to sideholes resting against vessel wall – usually in a narrowed vessel May be due to intravascular Sheath formation – this is a fibrinous sock that covers the catheter. Vessel Catheter Sheath

53. 200 Hours Course for Person In Charge Troubleshooting HD Catheters Poor flow Blue Lumen May be due to position of catheter tip May be abutting structure e.g Tricuspid Valve or vessel wall (left sided catheters) Vessel Wall Catheter Tip

54. 200 Hours Course for Person In Charge Can be due to intraluminal thrombus or external thrombus abutting openings No flow both lumens- new catheter May be due to catheter malposition May have dissected through vessel wall during insertion for new catheters. Needs Exchange When To ReferPoor Flow Both or Either Lumen Catheter Blue Lumen Clot Catheter Red Lumen

55. 200 Hours Course for Person In Charge Management Rotate Catheter gently until flow improved. Withdraw catheter 1-2 cm Still no improvement? Refer – may need urokinase or intraluminal brushing if cuffed catheter Cathetogram if new catheter or old catheter failing urokinase/intraluminal brushing.

56. 200 Hours Course for Person In Charge Management Usually involves exchange of catheter or reposition of catheter over guidewire for non cuffed catheters.

57. 200 Hours Course for Person In Charge Other Issues

59. May be due to crack in the Catheter

60. May be due to downstream stenosis

61. May be due to large catheter insertion wound – for new catheters

63. 200 Hours Course for Person In Charge When to referCentral Vein Stenosis Long term HD catheter use can result in central vein stenosis. Difficult to treat – can confound future fistula creation Brachiocephalic Stenosis

64. 200 Hours Course for Person In Charge

65. 200 Hours Course for Person In Charge When to ReferCentral Vein Stenosis May require plasty in the event arm having fistula is swollen and distressing to patient May require plasty if stridor or breathing difficulty in patient.

66. 200 Hours Course for Person In Charge Infections

67. 200 Hours Course for Person In Charge Infections of Catheters

68. 200 Hours Course for Person In Charge Exit Site Infections(ESI) MMWR(CDC) August 9, 2002 / 51(RR10);27-28 Definition: Localized Catheter Colonization Significant growth of a microorganism (>15 CFU) from the catheter tip, subcutaneous segment of the catheter, or catheter hub Exit Site Infection Erythema or induration within 2 cm of the catheter exit site, in the absence of concomitant bloodstream infection (BSI) and without concomitant purulence Clinical Exit Site Infection Tenderness, erythema, or site induration >2 cm from the catheter site along the subcutaneous tract of a tunneled catheter, in the absence of concomitant BSI

69. 200 Hours Course for Person In Charge ESI Prevention:Topical antiobiotic Polysporin triple antibiotic (Lok 2003) 169 patients with TCD, 6 months Mupirocin (Johnson 2002) 50 HD patients with TCD catheters, 20 months

70. 200 Hours Course for Person In Charge Topical antibiotics – meta analysis Topical antibiotics reduced the rate of: Bacteremia rate ratio, 0.22 [95% CI, 0.12 to 0.40]; 0.10 vs. 0.45 case of bacteremia per 100 catheter-days, Exit-site infection rate ratio, 0.17 [CI, 0.08 to 0.38]; 0.06 vs. 0.41 case of infection per 100 catheter-days, Need for catheter removal, and Hospitalization for infection James et al : Ann Intern Med. 2008 Apr 15;148(8):596-605.

71. 200 Hours Course for Person In Charge Tunnel Infections Tunnel Infection Purulent fluid in the subcutaneous tunnel of a totally implanted intravascular catheter that might or might not be associated with spontaneous rupture and drainage or necrosis of the overlaying skin, in the absence of concomitant BSI

72. 200 Hours Course for Person In Charge Blood Stream Infections Infusate-Related BSI Concordant growth of the same organism from the infusate and blood cultures (preferably percutaneously drawn) with no other identifiable source of infection Catheter-Related BSI Bacteremia/fungemia in a patient with an intravascular catheter with at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI except the catheter.

73. 200 Hours Course for Person In Charge Infections

74. 200 Hours Course for Person In Charge The End