UNDERSTANDING Understanding YOUR HEMODIALYSIS Your .

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UnderstandingUNDERSTANDINGYourYOUR HEMODIALYSISHemodialysisACCESSOPTIONSAccess Options

What is a vascular access? A vascular accessis a place on your body close to a vein andartery. This place on your body allows “accessto your blood stream.” This place on yourbody allows removal of blood from your body.The kidney machine cleans this blood. Thenthe blood goes back into your body throughyour vascular access. About 15 tablespoons ofblood is removed, cleaned and returned eachminute of treatment. Your vascular access islike a conveyor belt. The machine removes and returns each tablespoon ofblood continuously through your vascular access.This brochure describes common kinds of vascular access. AAKP dividesthis brochure into two sections. The first section describes long-lastingkinds of vascular access. The second section describes short-term vascularaccess. This brochure also tells you how doctors make your vascular access.This brochure includes the pros and cons of each kind of vascular access.AAKP hopes the brochure will help you understand more about the differentkinds of vascular access. After learning about vascular access, you can helpyour doctor decide what kind is best for you.HEMODIALYSIS,Your doctors may recommendto treat yourend-stage kidney disease (ESKD). End stage kidney disease is a medicalterm meaning your kidneys don’t work well enough to keep you healthy.During hemodialysis, the artificial kidney machine pumps your blood fromyour body to the artificial kidney through a flexible, plastic tube which isconnected to your vascular access site. Your blood is cleaned while in thedialysis machine. The dialysis machine returns your cleaned blood to yourbody through a separate tube. When a drop of blood leaves your body,another drop of blood comes back to your body after it is cleaned. Somepeople call the vascular access site “your lifeline.”

YOUR DOCTORS CAN MAKE TWO KINDS OFVASCULAR ACCESS FOR HEMODIALYSISThe first kind is completely COVERED by yourskin. The second type is a plastic tube going fromone of your large veins THROUGH your skin.The Two Kinds “Covered By Your Skin”Arteriovenous FistulaYou and your doctors can choose from two kinds of“under-your-skin” vascular access. The first choice iscalled an “AVF.” AVF means “Arterio-Venous Fistula.”The word “fistula” means a “connection.” Doctorsmake an AVF by sewing one of your arteries to one ofyour veins during a simple medical procedure. Thisis done underneath your skin. Doctors choose whichartery and vein to connect by how fast your bloodflows through the artery and vein.Mayo Clinic Foundation forEducation and ResearchArteriovenous GraftThe other kind of “under-your-skin” vascular access is called a “graft.” Thiskind of vascular access is not a direct connection between your artery andvein. Instead, doctors connect one of your arteries to one of your veins byusing an artificial tube called a “graft.” The graft is an artificial blood vesselmade from soft, rubbery plastic. A graft is like an AVF. Both are “under-theskin.” A graft is different from an AVF because a graft is an artificial bloodvessel. An AVF is made entirely from your own blood vessels. Artificialgrafts are more prone to get plugged with clots or get infected.Both AVFs and grafts require some time to heal before they can be used fordialysis treatments. The healing times vary from days to months. AVFs takelonger to become ready to use for dialysis.Both grafts and AVFs require putting two needles through your skin, into the“Under-the-Skin” vascular access. This is done for every dialysis treatment.One needle takes blood out of your body for cleaning. The other needlereturns cleaned blood back to you. Few people like the thought of havingneedles through their skin for every dialysis treatment. But it turns outthat temporary needles are much, much safer than having a plastic tubethat sticks through your skin 24 hours per day, 7 days per week. Anythingthat sticks through your skin all the time is much more prone to let germs(bacteria) into your blood stream. Infection in the blood stream can requirehospitalization and can even be fatal.American Association of Kidney Patients: Understanding Your Hemodialysis Access Options2

THE KIND OF VASCULAR ACCESS THAT“STICKS OUT” THROUGH YOUR SKINCATHETERThis kind of vascular access is a plastictube called a “catheter.” It is insertedthrough your skin into a large vein inthe neck, chest or groin. The tube orcatheter sticks out through your skin,all day, every day. Your doctor willremove the catheter and replaced itif it doesn’t let your blood travel fastenough for good cleaning. It mayalso be removed if the skin aroundthe catheter gets infected. Cathetersare more dangerous. Doctors tend touse catheters for two reasons. First,for people who need dialysis for ashort time (for example, dialysis fora few weeks). Second, for peoplewho are waiting for a fistula or graftto heal and develop. Doctors also usecatheters in patients on long-termdialysis who don’t have big enougharteries and veins to make a fistulaor graft.The following guidelines can helpmake all types of vascular accesswork better and work longer:Wear a Medical Alert bracelet. AMedical Alert bracelet can notifyhealth care providers you are ondialysis and the location and type ofyour vascular access.or AVF. If they don’t listen to yourrequest, you should kindly refuse tolet them take your blood pressureor take your blood. Ask to speak toa supervisor if you need to. Be kind,but be firm.Pay attention to the machine duringdialysis. Your vascular access maynot be working well enough if theblood flow speed is too slow to allowfor good cleaning. If the pressurein the vascular access is too high(like a moving car trying to squeezethrough a tunnel that is too narrow),the blood cleaning may not be goodenough to keep you healthy. Askyour dialysis staff what the flow rateand pressure in the vascular accessshould be for good blood cleaning.Then you can understand why thedialysis machine makes an alarmnoise when these flow rates andpressures are not good enough toallow a good blood cleaning. If thealarms happen too often or can’t beimproved, then you can help makedecisions about how the vascularaccess can be improved to allow forgood blood cleaning.Ask nurses and doctors not to takeblood pressures in the arm with thegraft or AVF. Ask people who takeyour blood not to take blood fromthe veins in the same arm as the graftAmerican Association of Kidney Patients: Understanding Your Hemodialysis Access Options3

SUMMARY OF PROS AND CONS OF THEDIFFERENT KINDS OF VASCULAR ACCESS:AV FISTULAPROSCONS Considered the best vascularaccess Visible under the skin on theforearm Less chance of infection thanother types of access May take weeks to monthsto develop Often lasts many years Fast blood flow, allows thebest blood cleaningAVF placement requires longterm planning, care of armveins, early surgery to beready for use when you needto start long term dialysis May require a graft orcatheter while fistula healsand develops Need to watch for bleedingafter needles are removed Some fistulas may fail tomature. It’s important to get AVFsurgery months before youneed to start dialysisAmerican Association of Kidney Patients: Understanding Your Hemodialysis Access Options4

GRAFTSPROS Can be easily placed Predictable performance Can be used sooner aftersurgery than an AV fistula(within days to 3 or 4 weeks) If a graft stops working well,often it can be converted toan AVF further up the arm(even if an AVF could not beplaced originally).CONS Increased potential forclotting Increased potential forinfection Does not usually last as longas an AV fistula Survival of graft patients islower than fistula patientsAmerican Association of Kidney Patients: Understanding Your Hemodialysis Access Options5

CARE FOR FISTULA AND GRAFTSFind out if your vascular accessis an AVF or a synthetic AV Graft.You need to know the directionthe blood is flowing in your access.You also need to know whicharea the dialysis staff is using forthe arterial and venous needleplacements. The arterial needletakes blood out of you. The venousneedle returns blood to you. Youneed to make sure the dialysis staffperson inserts the needles in theproper direction to the blood flow.The staff person must also connectthe bloodlines red to red and blueto blue.Learn how to properly hold thepatches after the staff personremoves the dialysis needle. Also,learn how to put pressure on aneedle site in case it bleeds afterdialysis. Keep an emergency supplyof gauze dressings and tape in yourpocket or purse. Reapply a cleandressing if the needle sites bleed onthe way home from dialysis.If blood leaks out of a needle siteat home, apply pressure on the sitewith a dressing below the bleedingsite. Call 911 immediately.Wash the skin over the access withsoap and water daily and beforedialysis.6Ask how your skin should becleaned before the needles areinserted. Make certain the staff isusing proper ways to prepare yourskin before inserting the needlesinto the access. Ask if you canlearn to wash and clean your ownskin and then follow what youare taught. Ask if you can learnto clean your skin AND put yourown needles into your vascularaccess. Thousands of people placeand remove their own needles.It might sound difficult or scarynow. It won’t be difficult or scaryonce you learn how and practicewith a nurse or technician helpingyou. Medical studies show it isbetter to put in and take out yourown needles than having otherpeople do it. If you learn to placeand remove your own needles, youwill always have the person whoknows your vascular access thebest doing the job YOU!Watch for signs of infection. Thesemay include redness, tendernessor pus, or you might feel a feveror chill. Cleanliness is one of themost important ways to preventinfection. Dialysis staff will teachhow to do this. Report any signs ofinfection to your doctor or nurseimmediately.American Association of Kidney Patients: Understanding Your Hemodialysis Access Options

FEEL — LISTEN— LOOKYour dialysis staff will teach you thefollowing tricks for monitoring yourvascular access. Feel your access with your finger tipsand check for a “thrill” (vibration)every day. Check also after youexperience low blood pressure,dizziness or light-headedness. Ifyou cannot feel a ”thrill”, listen toyour access for a “bruit” (swishingsound – pronounced “bru-eee”)with a stethoscope if you have one.Some people can hear the “bruit”just by holding the arm to theirear. If you do not think your accessis working, contact your dialysisunit or doctor immediately. Theywill arrange to have the surgeonor radiology specialist look at you. Try not to carry heavy items drapedover the access arm or wear tightfitting clothing over the access armor leg. It is important to try not tosleep on top of the access arm orleg. In other words, the arm withthe vascular access should not beunder your body when you sleep.staff should change the needle siteeach dialysis treatment to preventan aneurysm from forming orenlarging. Do not allow putting aneedle through an aneurysm, dueto danger of bleeding. Develop a close relationship withyour patient care technician andnurse. Don’t be afraid to remindthem to change needle sites foreach treatment. Be kind, but ifnecessary, be firm. If there is adisagreement, ask kindly tospeak to the nurse in charge, thedirector of nursing, or the dialysisadministrator. (“Kindly” meanssaying something like, “I needto speak to so and so about this,please.”) A good way to rememberhow to talk kindly is simply to talkto the other person as you wouldwant the other person to talk toyou. You can also learn a lot aboutcaring for your access from them.You may even want to learn toput your own needles in for eachtreatment. If your fistula or graft developsan aneurysm (looks like a smallballoon like you might see on anold bicycle tire), tell your doctor ornurse immediately. You may needsurgery or simply to be closelywatched for a while. Your dialysisAmerican Association of Kidney Patients: Understanding Your Hemodialysis Access Options7

CATHETERSCATHETERSPROSCONS Dialysis can be performedimmediately Not ideal as a long-termblood access Easily inserted as anoutpatient procedure High infection rates May not provide enoughblood flow to allow foradequate blood cleaning May cause narrowed veinsthat can prevent futureplacement of AVFs orgrafts Swimming andtaking baths are notrecommended because ofinfection risks Can usually be removedand replaced Avoids the need for needlesticksCARE OF CATHETERSYour dialysis staff will teach youall of the following ways to care foryour catheter. Your catheter exit site shouldbe cleaned with each dialysistreatment. Place clean dry gauzeon it. You must wear a surgicalmask over your mouth and nosefor the dressing change. The rightkind of mask will be given to youby your dialysis staff every timeyou need to wear a mask. Also,wear the mask when connecting or8disconnecting the catheter to themachine tubing. You should weara mask any time your dialysiscatheter’s screw cap is removed.Ask your dialysis staff what thecatheter cleansing and dressingprocedure is for your unit. Also,ask how you should care for thecatheter at home. Some catheters have “cuffs”. Othersdon’t. For non-cuffed catheters,the sutures (stitches) must remainin place for as long as you have theAmerican Association of Kidney Patients: Understanding Your Hemodialysis Access Options

catheter. For tunneled (tunneledunder your skin for several inchesbefore sticking out of your skin)and cuffed catheters, your doctorshould remove the stiches oncethe catheter is in place and healed.This will help decrease the risk of askin infection around the catheter.Pictured above is a catheter cap.Pictured above is a catheter clamp.Your catheter caps must remainon your catheter. The dialysis staffare the only ones to remove them.The clamps must remain closedat all times, unless the catheteri

American Association of Kidney Patients: Understanding Your Hemodialysis Access Options 3 CATHETER This kind of vascular access is a plastic tube called a “catheter.” It is inserted through your skin into a large vein in the neck, chest or groin. The tube or catheter sticks out through your skin, all day, every day. Your doctor will