Item 1 |
- To make sure patients have washed the arm(2). |
- Correct arm washing. |
Infection |
Item 2 |
- To perform AVF inspection and antisepsis and assess the rest of the arm, shoulder, breast, neck and face(8-10). - To record the presence of edema or collateral veins in any of these areas(8-10). - To perform the rapid examination of arteriovenous access through tests such as: pulse increase test and arm lift test. Pulse increase test performed with complete access occlusion several centimeters beyond arterial anastomosis and pulse strength assessment; Arm lift test: performed by arm lift and examination of normal collapse of an AVF(9). |
- If there are dirt or signs of infection. - Presence of edema and collateral veins. - In the pulse increase test, it is considered normal when there is a pulse increase in the upstream (arterial) part of the finger occlusion. - Usually when we occlude the exit of an arteriovenous access, we have two effects: fremitus disappears or the part of the upstream (arterial) access to the finger should become hyperpulsable. If the fremitus persists, suspect an accessory outlet. - Arm lift test is abnormal when the fistula becomes "full" after arm lift and there is no collapse, an indication of downstream (outflow or "venous") stenosis. |
Infection Stenosis |
Item 3 |
- To perform palpation of AVF(2). - To auscultate AVF(2). |
- Perception of fremitus and murmur. - Normality presents with a soft pulse, i.e., the pressure necessary to interrupt the pulsations is small. - Normality of the fremitus resembles a "tinnitus" that can be palpated with the fingers continuously. - Intermittent fremitus suggests arterial stenosis. - Auscultation assesses the quality of the blow. It enables detection and localization of a stenosis by assessing the continuity or intermittence of the murmur. |
Stenosis Thrombosis |
Item 4 |
- To choose needle gauge according to vein size, maturity and volume to be reached(3-4,11). - To start use of AVF (1st use) with smaller needle gauge(8). - 17 G - 250 ml flow(8). - 16 G - 350 ml flow(8). - To access more mature AVF with larger needle gauge(8). - 15 G -> 350 ml flow(8). |
- If the chosen needle matches the prescribed blood flow volume and vessel maturity. - Rule of six: a mature AVF should follow the "rule of 6" - should be 6 mm in diameter, be less than 6 mm below the skin, have a minimum blood flow of 600 ml/min and have a straight cannulation segment minimum 6 cm. Maturation generally should occur around six weeks after surgery. |
|
Item 5 |
- To avoid repeating the previous puncture site(8,12). - To maintain a space of 3 (three) centimeters from the anastomosis site for the arterial puncture and for the venous to maintain a space of 5 (five) centimeters in relation to the arterial(8,12). |
- Vessel dilation, skin thickness and bleeding time after puncture. - Normal bleeding time: approximately 10 to 15 minutes - Excessive bleeding after puncture:> 20 minutes. - If the needles are too close. - If the space between them is being respected. |
Pseudoaneurysm |
Item 6 |
- Do not puncture eroded, reddened or injured areas(8,11-12). |
- If the chosen area shows any of these signs. |
Infection |
Item 7 |
- To turn the needle bevel after puncturing downward, allowing full access channeling and to minimize post-puncture bleeding(3,13). |
- If positioning is in agreement and proper flow. |
Pseudoaneurysm |
Item 8 |
- To ensure needle attachment following unit protocol(14). |
- If the fixing is adequate. - If the needle is too far out. |
Pseudoaneurysm |
Item 9 |
- To check correct channeling and permeability of vascular access with a syringe and saline(2). - To connect patient to cardiopulmonary bypass after verification(2). |
- If there is proper flow. |
Thrombosis |
Item 10 |
- To pay attention to monitoring vital signs, especially blood pressure(2,8,12). |
- Alteration of vital signs. |
Thrombosis |
Item 11 |
- Remove the needle if hematoma or blood leakage occurs at the time of puncture and do not manipulate the puncture site(12,15). - To compress the site to hemostasis(12,15). - To perform cold compress on site(15). |
- Signs of extravasation or local hematoma. |
Pseudoaneurysm Thrombosis |
Item 12 |
- To monitor hemodynamic parameters during dialysis session, such as access flow, blood circuit flow and dynamic pressures; Pre-pumping blood pressure: -80 to -200 mmHg, should not exceed - 250 mmHg(10). - To check circuit venous pressure: always positive value. Ideal is between 50 and 250 mmHg. Increased venous pressure means that access is with problems such as recirculation of the fistula that worsens the quality of dialysis and increases the risk of thrombosis(10). |
- If there is anything outside the parameter. - Normal operation of the dialysis machine. |
Stenosis Thrombosis |
Item 13 |
- To reposition the needle or perform a new puncture in case of (arterial) inflow, characterized by insufficient blood supply to the pump, as the needle may be attached to the vessel wall(2,12,16). |
- Whether the supplied flow is being adequate. - Gauge of the chosen needle compatible with access. |
Thrombosis |
Item 14 |
- To carefully remove the needle at the end of the session(2,8). - To wait for a minimum hemostasis time of 10 to 15 minutes or until a stable clot is formed at the puncture site(2,8,12). |
- If there was blood leakage. - Excessive bleeding (> 20 minutes). - A bleeding for more than twenty minutes may be related to the amount of anticoagulant and antihypertensive. - Emergence of hematoma. |
Thrombosis Pseudoaneurysm |
Item 15 |
- To perform dressing with light compression, with gauze, for approximately five minutes, with tape and gauze after complete hemostasis(12,17). - To advise patients to be removed only six hours after the end of dialysis, guiding them to be kept dry and clean(12,17). |
- Whether the dressing stays clean until the moment patients are in the environment. - In case of extravasation, change the dressing after new hemostasis. |
Infection |