【Major points】
  1. A well-functioning vascular access is essential for successful hemodialysis treatment.
  2. Arteriovenous fistula(AVF) should be considered as the preferred initial access for patients on hemodialysis if the overall condition is suitable.
  3. The AVG/AVF function should be checked by patient himself/herself every day.
 
What is vascular access for hemodialysis?
Vascular access for hemodialysis is defined as a vascular pathway which is created for uremic patient undergoing hemodialysis. 
A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis procedure. 
 
Types of vascular access:
  1. Central venous catheter(CVC): A central venous catheter (CVC) is placed under the skin and inserted into one of the central veins in the neck or leg near the groin. CVC is designed to stay in for a short period, usually used for patients in urgent dialysis or before the dialysis access is matured. 
  2. Arteriovenous fistula(AVF): AVF is a connection, made via surgical approach, joining an artery and vein so that arterial blood can pulse into the vein achieving venous arterialization for dialysis. The native arteriovenous fistula is considered the best long-term access for hemodialysis.
  3. Arteriovenous graft(AVG): also called artificial vascular grafts, if patients have poor vascular function, the physician will create an arteriovenous graft, where an artificial vessel is used to join the artery and vein, to be used as a future puncture site.
  4. Double-lumen tunnelled dialysis catheters: For patients with bad vascular condition or failure of AVF operation, surgical implantation of a silicone catheter, which has a soft buckle, can be fixed in the subcutaneous tunnel to prevent the invasion of foreign bodies or bacteria, called as double-lumen catheters. The preferred site is the right internal jugular vein. 
 
Caring for vascular access
  1. CVC or Double-lumen tunnelled dialysis catheters
    1. The dressing should be changed every two days (or if necessary), in order to keep the wound clean and dry. Observe the wound for any signs and symptoms of infection, such as purulent discharge, pain, redness/heat, and swelling. 
    2. Pay attention to whether the catheter is clamped.
    3. At the end of each dialysis, the nurse will flush the catheter with saline solution and fill the catheter with an anticoagulant (heparin) to prevent it from becoming blocked.
    4. Use a catheter holder or properly fix the catheter to avoid it sliding out due to pulling.
    5. Avoid kinking or pulling of the catheter, in order to maintain the catheter unobstructed. Ex: Wear loose clothing.
  2. AVF / AVG
    1. Daily observe the fistula for sign of redness, swelling, heat, pain or other signs of infection; palpate the fistula to assess thrill and bruit (swishing sound), if there is no indication, the fistula may be occluded, and notify medical staff as soon as possible.
    2. Home care of arteriovenous fistulas includes arm movements, physical therapy, water and diet control, self-assessment of fistulas, prevention of infections and smoking cessation, etc. In order to maintain the functions of fistulas, extend the service life and reduce the occurrence of obstruction.
    3. Do not let anyone use a blood pressure cuff and draw blood from your access arm.
    4. According to individual conditions and through the professional judgment of the physician, far-infrared adjuvant therapy can be used to maintain the patency of the AVF/ AVG.
    5. It is recommended to regularly receive blood flow examination for AVF every 3 months, and AVG every month.
 
Reference
  1. Chen, F. Y., Ho, Y., & Lin, C. C. (2021). KDOQI Clinical Practice Guidelines for Vascular Access:2019. Kidney and Dialysis, 33(2),97-100. https://doi.org/10.6340/KD.202106_33(2).0009
  2. Hsieh, J. T., & Yang, C., Y. (2020). Hemodialysis Vascular Access Surveillance. Kidney and Dialysis, 32(4), 224-228. https://doi.org/10.6340/KD.202012_32(4).0011
  3. Ou, S. H., & Lee, P. T. (2021). Vascular Access Set-Up and Care. Kidney and Dialysis, 33(2), 63-67.
    https://doi.org/10.6340/KD.202106_33(2).0002
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