V25-S1 Vascular Access Guidelines

CASE 1
Ms. Best is a 60-year-old female who arrived in the dialysis unit for her first hemodialysis treatment. The team in the Chronic Kidney Disease Clinic has followed her for the past few years and her vascular access is a left arm radio-cephalic arterio-venous (AV) fistula, which was created three months ago.

Questions 1–4 refer to this case

1. After introducing yourself to Ms. Best and orienting
her to the dialysis treatment, the nephrology nurse’s
first step towards cannulation of Ms. Best’s new AV
fistula should be to:

In order to maximize the longevity of the fistula, the
nephrology nurse cannulating Ms. Best’s fistula should:

The nephrology nurse should teach Ms. Best to examine her fistula:

Buttonhole cannulation (BH) technique has been described as a method that may prolong the use of the fistula and result in less painful cannulation. BH cannulation involves placement of the fistula needles in the exact same site until the tunnel tracks are developed. An important component of tunnel track creation that the nephrology nurse needs to be aware of is that:

CASE 2
Mr. Jones is a 65-year-old male with diabetic nephropathy who has missed several appointments at the Chronic Kidney Disease Clinic. Three months ago, Mr. Jones needed to start on hemodialysis urgently and a central venous catheter was inserted by interventional radiologist. Mr. Jones had an arterio-venous fistula created in his left forearm four weeks ago and the Nephrologist has orders for initiation of cannulation. Today, the nephrology nurse is planning on cannulating the fistula of Mr.
Jones for the first time.

Questions 5–7 refer to this case

5. When a new arteriovenous (AV) fistula is cannulated
in the presence of an existing central venous catheter,
the approach to cannulation should include:

Four weeks later, the nephrology nurse has been able to cannulate the fistula of Mr. Jones with two needles on a regular basis and obtain prescribed blood flow rates. The recommended fistula flow rates for Mr. Jones, as measured by access flow technology are:

The risk of bacteremia is highest for patients on hemodialysis who have:

CASE 3
Mr. Smith is a 25-year-old male with end stage renal disease secondary to focal segmental glomerulosclerosis (FSGS), and had a deceased donor renal transplant two years ago. Recently, his original kidney disease has recurred in the transplanted kidney and he is now requiring dialysis thrice weekly. His vascular access is a right tunneled central venous HD catheter (CVC).

Questions 8–15 refer to this case

8. After the CVC insertion, a small amount of fresh blood
was noted by the nurse on the dressing material. The
nephrology nurse should first:

Mr. Smith’s CVC should be considered:

Mr. Smith’s catheter usually delivers blood flow (Qb) of 400 ml/min and his urea reduction ratio (URR) or per cent reduction of urea (PRU) is >70%. The nephrology
nurse should be first concerned about Mr. Smith’s CVC performance when:

Mr. Smith’s CVC is functioning poorly with a maximum achievable Qb of <250 ml/min and frequent arterial and venous pressure alarms. The Nephrologist/ NP orders instillation of alteplase (Cathflo®) to restore line patency using a push protocol. Prior to initiating the algorithm, the Nephrolgist/NP should:

If a thrombolytic agent, for example alteplase (Cathflo®), is ordered by the physician to “lock” or “cap” the catheter, the nephrology nurse would instill alteplase to fill the catheter lumens:

To assist in maintenance of CVC patency, the Canadian Vascular Access Association (CVAA) recommends:

In order to identify catheter dysfunction, the nephrology nurse should document arterial and venous pressures at the beginning of every dialysis treatment with the blood pump speed set at:

Trends in dynamic venous pressure monitoring should be reviewed for Mr. Smith by the nephrology team at
least: